New Jersey Proposes New Statute on PBMs, CMS Expands Coverage for COVID-19 Testing and More

For more information about this blog post, please contact Khaled J. KleleRyan M. MageeLabinot Alexander Berlajolli, or Brianna J. Santolli.

New Jersey’s Proposed Pharmacy Benefits Manager Licensure and Regulation Act

This bill, A5410, first introduced to the New Jersey Assembly on March 1, 2021, provides for the licensure of pharmacy benefits managers ("PBM"). Under the bill, the Commissioner of Banking and Insurance is to create the application for a license to operate in New Jersey as a PBM and establish the accompanying licensing, fees, application, financial standards, and reporting requirements of PBMs.

The bill also prohibits PBMs from imposing penalties on pharmacies that disclose to any covered person any health care information that the pharmacy or pharmacist deems appropriate regarding the nature of treatment, risks, or alternatives thereto, the availability of alternate therapies, consultations, or tests, the decision of utilization reviewers or similar persons to authorize or deny services, the process that is used to authorize or deny health care services or benefits, or information on financial incentives and structures used by the insurer.  Specifically, a pharmacy or pharmacist may provide to an insured information regarding the insured's total cost for pharmacist services for a prescription drug and offer more affordable alternatives.

If passed, the bill will apply to contracts or health benefit plans that are delivered, issued, executed, or renewed in New Jersey on or after January 1, 2022. 

New Jersey Board of Medical Examiners Expands Role of Midwives

The Board of Medical Examiners has adopted a rule, 52 N.J.R. 366(a), to allow licensed midwives to administer nitrous oxide as a labor analgesia in licensed health care facilities. Specifically, the rule amends N.J.A.C. 13:35-2A.10 and 2A.12, so that licensed midwives may administer or facilitate the administration of nitrous oxide for pain relief during the intrapartum and postpartum stages when they are providing services in a health care facility licensed by the Department of Health. Although licensed midwives practice in a variety of settings other than health care facilities licensed by the Department of Health, including patients' homes, the rule acknowledges that many of these outpatient settings lack similar policies and procedures to ensure that nitrous oxide is safely stored and administered. Accordingly, the rule limits licensed midwives' ability to administer nitrous oxide as labor analgesia to licensed health care facilities only.                    

Health Insurers Now Required to Cover COVID-19 Testing for Asymptomatic People

In accordance with President Biden’s January 21, 2021 Executive Order, the Centers for Medicare & Medicaid Services (“CMS”), with the Department of Labor and the Department of the Treasury, issued new guidance increasing insurance coverage for COVID‑19 diagnostic testing without cost sharing. Under the guidance, private group health plans cannot use medical screening criteria to deny coverage for COVID‑19 tests for asymptomatic people or those without a known exposure to the virus. Tests must be covered without cost-sharing, prior authorization, or other medical management requirements imposed by the plan or issuer. Health plans also must cover point‑of‑care COVID‑19 tests and tests that are administered at a state or local testing site. For example, covered individuals wanting to ensure they are COVID-19 negative prior to visiting a family member would be able to be tested without paying cost sharing. Plans, however, may deny coverage for testing for public health surveillance or employment purposes if the individual is asymptomatic and does not have a suspected exposure to COVID‑19.   More information is available in CMS’s press release.

CMS Revises Nursing Home COVID-19 Visitation Recommendations

CMS, with the Centers for Disease Control and Prevention (“CDC”), issued updated guidance for nursing homes to safely expand visitation options during the COVID‑19 public health emergency. Per the guidance, facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident or visitor, unless certain scenarios arise that would limit visitation for:

  • Unvaccinated residents if: (1) the COVID-19 county positivity rate is greater than 10 percent; and (2) less than 70 percent of residents in the facility are fully vaccinated;
  • Residents with confirmed COVID‑19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue transmission‑based precautions; or
  • Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.

For more information regarding the visitation guidelines, review CMS’s fact sheet and press release.