STATE OF NEW JERSEY
220th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2022 SESSION
Sponsored by:
Assemblywoman LISA SWAIN
District 38 (Bergen and Passaic)
Assemblyman P. CHRISTOPHER TULLY
District 38 (Bergen and Passaic)
SYNOPSIS
Requires hospitals to provide breast cancer patients with information concerning reconstructive surgery; prohibits certain provisions in managed care plan contracts.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel.
An Act concerning breast cancer and supplementing Title 26 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. Each general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) that provides surgical services for the treatment of breast cancer, the breast cancer gene, or other breast abnormality, including, but not limited to, mastectomy surgery, lymph node dissection, or lumpectomy, shall ensure that each patient receiving treatment for breast cancer is provided with written notice of: (1) the patient's right to seek a consultation with a board-certified or board-eligible plastic surgeon of the patient's choosing who provides breast reconstructive services, regardless of whether the plastic surgeon is affiliated with the general hospital or a health care provider network, concerning the patient's treatment options during and after the provision of surgical services, including the use of a prosthesis and the option of undergoing reconstructive surgery during or after the provision of surgical services for the treatment of breast cancer, the breast cancer gene, or other breast abnormality; (2) the patient's right to obtain reconstructive surgery from a board-certified or board-eligible plastic surgeon who provides breast reconstructive services, regardless of whether the plastic surgeon is affiliated with the general hospital or a health care provider network; and (3) the availability of coverage under a health benefits plan for reconstructive surgery pursuant to section 1 of P.L.1983, c.50 (C.17:48-6b), section 1 of P.L.1983, c.51 (C.17:48A-7b), section 35 of P.L.1985, c.236 (C.17:48E-35), section 1 of P.L.1983, c.53 (C.17B:26-2.1a), section 1 of P.L.1983, c.52 (C.17B:27-46.1a), section 6 of P.L.1997, c.75 (C.26:6J-4.14), and federal law. The written notice shall be provided to the patient upon the general hospital's notification of the patient's breast cancer diagnosis and in advance of obtaining consent to the surgical procedure.
2. a. A contract between a carrier and a health care provider for network participation shall not contain any provision that:
(1) prohibits a health care provider from making recommendations to a covered person to a board-certified or board-eligible plastic surgeon, regardless of network affiliation, who provides the full scope of breast reconstructive services necessary and appropriate to the patient's treatment, provided that the primary consideration when making such recommendations shall be the patient's clinical needs, as determined by the patient's treating physician. Other considerations may include the plastic surgeon's training, expertise, availability, and accessibility to the patient; or
(2) seeks to limit the ability of a health care provider to make recommendations as described in paragraph (1) of this subsection.
b. In no case shall a carrier deny requests to approve the medical necessity for reconstructive surgery or related services based solely on the network status or hospital affiliation of the plastic surgeon who will perform the reconstructive surgery and related services.
c. The provisions of this section shall apply to reconstructive breast surgery or surgery to restore and achieve symmetry between two breasts following treatment or surgery for breast cancer, the breast cancer gene, or other breast abnormality, including, but not limited to, mastectomy surgery, lumpectomy, or radiation.
d. As used in this section, "carrier" means a "carrier" as defined in section 2 of P.L.1997, c.192 (C.26:2S-2), the State Health Benefits Program, and the School Employees' Health Benefits Program.
e. The Commissioner of Banking and Insurance shall, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), adopt rules and regulations as shall be necessary to effectuate the provisions of this section.
3. This act shall take effect on the 90th day after the date of enactment.
STATEMENT
This bill requires general hospitals that provide surgical services for the treatment of breast cancer, the breast cancer gene, or other breast abnormality, including, but not limited to, mastectomy surgery, lymph node dissection, or lumpectomy, to ensure that breast cancer patients are provided written notice of the patient's right to seek a consultation with a board-certified plastic surgeon of the patient's choosing who provides reconstructive services concerning the patient's treatment options during and after the provision of surgical services, including the use of a prosthesis and the option of undergoing reconstructive surgery either during, or after receiving, surgical treatment for breast cancer, the breast cancer gene, or other breast abnormality, as well as the patient's right to obtain such services, regardless of the plastic surgeon's hospital affiliation or network participation. Patients are also to be provided with written notice concerning the availability of coverage under a health benefits plan for reconstructive surgery pursuant to State and federal law. The written information is to be provided to the patient when the hospital is notified of the patient's breast cancer diagnosis and in advance of obtaining consent to the surgical procedure.
The bill also supplements the "Health Care Quality Act" to provide that a contract between a carrier and a health care provider for network participation will not contain any provision that prohibits or limits a health care provider in making recommendations or referrals for a covered person to a board-certified plastic surgeon, regardless of network affiliation, who provides the full scope of breast reconstructive services necessary and appropriate to the patient's treatment needs, as determined by the patient's treating physician based on the plastic surgeon's training, experience, and location in relation to the patient's primary residence, provided that the primary consideration in making such recommendations and referrals is the patient's treatment needs. Carriers will not be permitted to deny authorization for reconstructive surgery and related services based on the plastic surgeon's network status or hospital affiliation. The provision applies to reconstructive breast surgery or surgery to restore and achieve symmetry between two breasts following treatment or surgery for breast cancer, the breast cancer gene, or other breast abnormality, including, but not limited to, mastectomy surgery, lumpectomy, or radiation. For purposes of the bill, the term "carrier" means a carrier as used in the "Health Care Quality Act," P.L.1997, c.192 (C.26:2S-1 et seq.), as well as the State Health Benefits Program and the School Employees' Health Benefits Program.