26:2J-4.31 HMOs to provide benefits for orthotic and prosthetic appliances.
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/nj/title-26/chapter-2j/26-2j-4-31·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
8. a. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Health and Senior Services on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.) unless the health maintenance organization provides health care services for any person covered thereunder for expenses incurred in obtaining:
(1)an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and
(2)an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.
As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).
b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), a health maintenance organization shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.
c. The benefits shall be provided to the same extent as for any other medical condition under the enrollee agreement.
d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2007, c.345, s.8; amended 2012, c.17, s.276; 2025, c.89, s.8.