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A5181
ASSEMBLY, No. 5181
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED JUNE 1, 2026
Sponsored by:
Assemblywoman� HEATHER SIMMONS
District 3 (Cumberland, Gloucester and Salem)
SYNOPSIS
���� Mandates insurance coverage for pain management
services related to outpatient gynecological procedures.
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act
concerning insurance coverage for pain management
services related to outpatient gynecological procedures and supplementing
various parts of the statutory law.
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� a. �A hospital service
corporation contract that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to P.L.1938,
c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance, on or after the effective date of
this act, shall provide coverage for pain management services related to
outpatient gynecological procedures and shall not label or categorize pain
management for these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� c.���� This section shall
apply to those hospital service corporation contracts in which the hospital
service corporation has reserved the right to change the premium.
���� 2.��� a. �A medical service
corporation contract that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to P.L.1940,
c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance, on or after the effective date of
this act, shall provide coverage for pain management services related to
outpatient gynecological procedures and shall not label or categorize pain
management for these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� c.���� This section shall
apply to those medical service corporation contracts in which the medical
service corporation has reserved the right to change the premium.
���� 3.��� a. A health service
corporation contract that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to P.L.1985,
c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State
by the Commissioner of Banking and Insurance, on or after the effective date of
this act, shall provide coverage for pain management services related to
outpatient gynecological procedures and shall not label or categorize pain
management for these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� c.���� This section shall
apply to those health service corporation contracts in which the health service
corporation has reserved the right to change the premium.
���� 4.��� a. �An individual health
insurance policy that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to
N.J.S.17B-26-1 et seq., or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance, on or after the effective date of
this act, shall provide coverage for pain management services related to
outpatient gynecological procedures and shall not label or categorize pain
management for these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the policy.
���� c.���� This section shall
apply to those policies in which the insurer has reserved the right to change
the premium.
���� 5.��� a. �A group health
insurance policy that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B-27-26
et seq., or approved for issuance or renewal in this State by the Commissioner
of Banking and Insurance, on or after the effective date of this act, shall
provide coverage for pain management services related to outpatient�
gynecological procedures and shall not label or categorize pain management for
these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the policy.
���� c.���� This section shall
apply to those policies in which the insurer has reserved the right to change
the premium.
���� 6.��� a. �An individual health
benefits plan that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to P.L.1992,
c.161 (C.17B-27A-2 et seq.), or approved for issuance or renewal in this State
by the Commissioner of Banking and Insurance, on or after the effective date of
this act, shall provide coverage for pain management services related to
outpatient gynecological procedures and shall not label or categorize pain
management for these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� c.���� This section shall
apply to those health benefits plans in which the carrier has reserved the
right to change the premium.
���� 7.��� a. �A small employer
health benefits plan that provides hospital or medical expense benefits and is
delivered, issued, executed, or renewed in this State pursuant to P.L.1992,
c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State
by the Commissioner of Banking and Insurance, on or after the effective date of
this act, shall provide coverage for pain management services related to
outpatient gynecological procedures and shall not label or categorize pain
management for these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� c.���� This section shall
apply to those health benefits plans in which the carrier has reserved the
right to change the premium.
���� 8.��� a. �A health maintenance
organization contract for health care services that is delivered, issued,
executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et
seq.), or approved for issuance or renewal in this State by the Commissioner of
Banking and Insurance, on or after the effective date of this act, shall
provide coverage for pain management services related to outpatient
gynecological procedures and shall not label or categorize pain management for
these procedures as elective or medically unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� c.���� This section shall
apply to those contracts for health care services under which the health
maintenance organization has reserved the right to change the schedule of
charges for enrollee coverage.
���� 9.��� a. �The State Health
Benefits Commission shall ensure that every contract purchased by the
commission on or after the effective date of this act that provides hospital or
medical expense benefits shall provide coverage for pain management services
related to outpatient gynecological procedures and shall not label or
categorize pain management for these procedures as elective or medically
unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� 10.� a. �The School Employees�
Health Benefits Commission shall ensure that every contract purchased by the
commission on or after the effective date of this act that provides hospital or
medical expense benefits shall provide coverage for pain management services
related to outpatient gynecological procedures and shall not label or
categorize pain management for these procedures as elective or medically
unnecessary.
���� b.��� The benefits shall be
provided to the same extent as for any other condition under the contract.
���� 11.� a. �Notwithstanding any
State law or regulation to the contrary, the Division of Medical Assistance and
Health Services in the Department of Human Services shall ensure that expenses
incurred, by an eligible enrollee, for pain management services provided for
outpatient gynecological procedures are covered with no cost-sharing under the
Medicaid and NJ FamilyCare programs.� No prior authorization or utilization
management requirements shall be imposed on services provided pursuant to this
section.
���� b.��� The Commissioner of
Human Services shall apply for such State plan amendments or waivers as may be
necessary to implement the provisions of this section and to secure federal
financial participation for State Medicaid expenditures under the federal
Medicaid program.
���� c.���� As used in this
section, �Medicaid program� means the program established pursuant to P.L.1968,
c.413 (C.30:4D-1 et seq.).
���� 12.� This act shall take
effect 90 days from the effective date of this act, except that the
Commissioner of Human Services may take any anticipatory administrative action
in advance as necessary for the implementation of this act.
STATEMENT
���� This bill would require health
insurers (health, hospital and medical service corporations, commercial
individual and group health insurers, health maintenance organizations, health
benefits plans issued pursuant to the New Jersey Individual Health Coverage and
Small Employer Health Benefits programs, the State Health Benefits Commission,
the School Employees� Health Benefits Commission, and the State Medicaid and NJ
FamilyCare programs) to cover pain management services related to outpatient
gynecological procedures and such insurers would not be allowed to label such
services as medically unnecessary or elective.