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A 5790

Relates to the qualifications of voters and civic education of students

2025 Regular Session Introduced by Rodneyse Bichotte Hermelyn and 15 co-sponsors

Requires health insurers in New Jersey to cover medically indicated lipedema treatments, including lipectomy when necessary, with equivalent cost-sharing to similar services.

REFERRED TO ELECTION LAW
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Bill Summary · A 5790

Summary — A.5790 (1R): Health insurance coverage for treatment of lipedema

Overview / Purpose

A.5790 requires health insurers doing business in New Jersey — including hospital, medical, and health service corporations, commercial individual and group insurers, HMOs, plans under the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP), and plans under the Individual and Small Employer Programs — to provide coverage for treatment of lipedema. The bill aims to ensure that medically indicated therapies and surgeries for this chronic, progressive fat-distribution disorder are covered consistent with current standards of care.

Key provisions

  • Insurers must cover expenses incurred for treatment of lipedema, including:
    • Compression garments for all affected extremities
    • Manual lymphatic drainage (MLD)
    • Medical nutrition therapy
    • Mental health care
    • Lipectomy(s) determined to be medically necessary by the patient’s surgeon
    • Pre- and post-lipectomy physician and surgeon appointments
  • Carriers must provide coverage for the total number of lipectomies the surgeon deems medically necessary and may not require the surgeon to remove less fat than medically necessary to obtain coverage.
  • Coverage must be provided to the same extent and with the same deductibles, coinsurance, and other cost-sharing as apply to similar services and be consistent with the current standard of care for lipedema.
  • Prior authorization for lipectomy must comply with prior-authorization requirements established under the Ensuring Transparency in Prior Authorization Act (P.L.2023, c.296).
  • If coverage is denied, carriers must provide a detailed explanation. Carriers may not deny coverage solely on the basis of photographs submitted under the bill.
  • Documentation required: physician diagnosis of lipedema; if applicable, surgeon documentation including supporting photographs and the number of lipectomies deemed medically necessary.

Fiscal impact (Office of Legislative Services)

  • Estimated combined annual expenditure increase to SHBP/SEHBP: approximately $36.5 million
    • State (SHBP) increase: ~$13.7 million annually
    • Local (SHBP/SEHBP) increase: ~$22.8 million annually
  • OLS estimates expanded coverage costs roughly $2,000 per woman; estimated ~17,700 women covered under SHBP/SEHBP may seek treatment based on prevalence and diagnosis rates.
  • Some services (lipectomies, nutrition therapy, mental health care) are already covered with precertification; the bill expands coverage chiefly for compression garments and manual lymphatic drainage. Local employers purchasing private-market coverage could experience indeterminate cost increases.

Who is affected

  • Covered persons (insured New Jersey residents under the enumerated plans)
  • All insurers and health plans issued, renewed, or approved in New Jersey as listed above
  • State and local employers participating in SHBP/SEHBP (budgetary impact)
  • Providers delivering MLD, nutrition therapy, mental health care, and surgeons performing lipectomies

Legislative status & timeline

  • Introduced in Assembly: 6/12/2025; referred to Assembly Financial Institutions and Insurance Committee
  • Reported out with amendments and to Assembly Appropriations Committee: 6/19/2025
  • Passed Assembly (68–2–9): 6/30/2025
  • Received in Senate and referred to Senate Commerce Committee: 10/20/2025
  • Committee amendment aligned prior-authorization language with the Ensuring Transparency in Prior Authorization Act.

Sponsors and related bills

  • Primary sponsor: Rep. Robert C. Carroll; multiple cosponsors (see bill text)
  • Companion / related: S.4495, S.1016; prior-session bills: A.6839, A.3339, A.635, A.274

Notes: The bill directs coverage consistent with clinical standards; specifics such as numeric limits on sessions or monetary caps (which would affect cost) would depend on plan design decisions by carriers or benefit commissions.

Compiled from official sources — confirm details with the bill’s official record.

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