N.J. Stat. § 17B:27A-7.25

Current through L. 2024, c. 87.

Section 17B:27A-7.25 - Individual health benefits plan to provide coverage for breastfeeding support

a. An individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L. 2019, c. 343(C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing.

b. Coverage of breastfeeding equipment shall include:

(1) Purchase of a single-user breast pump, subject to the following conditions:

(a) A plan shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump.

(b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding.

(c) A plan shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph.

(d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee.

(e) Coverage for breast pumps shall include repair or replacement if necessary.

(2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions:

(a) When recommended by a licensed health care provider, a plan shall provide coverage for a multi-user breast pump.

(b) An individual health benefits plan may determine whether a rental or purchase is covered.

(c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump.

(d) An individual health benefits plan may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump.

(3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider.

(4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the individual health benefits plan cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts.

(5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the individual health benefits plan shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment.

c. Coverage of comprehensive lactation counseling and lactation consultation shall include:

(1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions:

(a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits.

(b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need.

(2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need.

(3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups.

(4) A plan shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting.

(5) An individual health benefits plan shall not impose medical management techniques not described in this section.

d. Except as otherwise authorized pursuant to this section, an individual health benefits plan shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided.

e. As used in this section:

"Cost-sharing" means deductible, co-insurance or co-payments, or similar charges.

"Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump.

"Lactation consultant" means an individual who is an International Board Certified Lactation Consultant.

"Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services.

Lactation care and services shall include, but not be limited to:

(1) lactation assessment through the systematic collection of subjective and objective data;

(2) analysis of data and creation of a plan of care;

(3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider;

(4) evaluation of outcomes;

(5) provision of lactation education to parents and health care providers; and

(6) the recommendation and use of assistive devices.

"Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as:

(1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding;

(2) acting as an advocate for breastfeeding as the norm for feeding infants and young children;

(3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals;

(4) using principles of adult education when teaching clients, health care providers, and others in the community; and

(5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately.

"Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is:

(1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or

(2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice.

"Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication.

f. This section shall apply to those plans in which the individual health benefits plan has reserved the right to change the premium.

N.J.S. § 17B:27A-7.25

Added by L. 2019, c. 343, s. 6, eff. 7/11/2020.