Sponsored by:
Assemblywoman ELIANA PINTOR MARIN
District 29 (Essex)
Assemblywoman SADAF F. JAFFER
District 16 (Hunterdon, Mercer, Middlesex and Somerset)
Assemblywoman ANGELA V. MCKNIGHT
District 31 (Hudson)
Co-Sponsored by:
Assemblyman Benson
SYNOPSIS
Requires health insurers to provide coverage for certain imaging related to breast cancer detection.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning mammograms and amending P.L.1991, c.279 and P.L.2004, c.86.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L. 1991, c.279 (C.17:48-6g) is amended to read as follows:
1. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be 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 this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.1)
2. Section 2 of P.L.1991, c.279 (C.17:48A-7f) is amended to read as follows:
2. a. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be 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 this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the medical service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.2)
3. Section 3 of P.L.1991, c.279 (C.17:48E-35.4) is amended to read as follows:
3. a. No group or individual health service corporation contract providing hospital or medical expense benefits shall be 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 this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the health service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.3)
4. Section 4 of P.L.1991, c.279 (C.17B:26-2.1e) is amended to read as follows:
4. a. No individual health insurance policy providing hospital or medical expense benefits shall be 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 this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.4.
5. Section 5 of P.L.1991, c.279 (C.17B:27-46.1f) is amended to read as follows:
5. a. No group health insurance policy providing hospital or medical expense benefits shall be 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 this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.5)
6. Section 7 of P.L.2004, c.86 (C.17B:27A-7.10) is amended to read as follows:
7. a. Every individual health benefits plan that 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, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.6)
7. Section 8 of P.L.2004, c.86 (C.17B:27A-19.13) is amended to read as follows:
8. a. Every small employer health benefits plan that 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, on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) any physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.7)
8. Section 6 of P.L.1991, c.279 (C.26:2J-4.4) is amended to read as follows:
6. a. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee for the conduct of:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the health maintenance organization of the medical necessity of the additional screening and diagnostic testing.
b. These health care services shall be provided to the same extent as for any other sickness under the enrollee agreement.
c. 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.
d. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.8)
9. Section 9 of P.L.2004, c.86 (C.52:14-17.29i) is amended to read as follows:
9. a. The State Health Benefits Commission shall provide benefits to each person covered under the State Health Benefits Program for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are [40] 18 years of age; a mammogram examination every year for women age [40] 18 and over; and, in the case of a woman who is under [40] 18 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) physician-directed imaging, including, but not limited to, an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination or high risk assessment, if the mammogram or high risk assessment demonstrates extremely dense breast tissue, if the mammogram or high risk assessment is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the contract.
c. As used in this section, “high risk assessment” means an annual assessment consisting of both a mammogram examination and a magnetic resonance imaging scan provided to a woman that is determined by the woman’s physician to be at high risk of breast cancer.
(cf: P.L.2013, c.196, s.9)
10. This act shall take effect immediately and shall apply to all health benefits plans currently in effect in the State, or that are 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 this act.
STATEMENT
This bill requires 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, and the State Health Benefits Program) to provide coverage for mammograms for women age 18 or older, rather than age 40 and older as is required under current law. In addition, the bill also requires health insurers to provide coverage for physician-directed imaging under certain circumstances.