Bill Text: NJ A4161 | 2012-2013 | Regular Session | Introduced
Bill Title: Requires health insurers, SHBP and SEHBP to provide coverage for diagnosis, evaluation and treatment of lymphedema.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2013-07-19 - Reviewed by the Pension and Health Benefits Commission Recommend to not enact [A4161 Detail]
Download: New_Jersey-2012-A4161-Introduced.html
Sponsored by:
Assemblyman DAVID P. RIBLE
District 30 (Monmouth and Ocean)
Assemblywoman GABRIELA M. MOSQUERA
District 4 (Camden and Gloucester)
SYNOPSIS
Requires health insurers, SHBP and SEHBP to provide coverage for diagnosis, evaluation and treatment of lymphedema.
CURRENT VERSION OF TEXT
As introduced.
An Act requiring health insurance coverage for lymphedema and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), 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, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract.
c. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
2. a. A medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), 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, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract.
c. This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
3. a. A health service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), 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, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract.
c. This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.
4. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., 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, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the insured's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the policy.
c. This section shall apply to those individual health insurance policies in which the insurer has reserved the right to change the premium.
5. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., 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, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the insured's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the policy.
c. This section shall apply to those group health insurance policies in which the insurer has reserved the right to change the premium.
6. a. An individual health benefits plan that provides hospital and medical expense benefits and 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 by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the health benefits plan.
c. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
7. a. A small employer health benefits plan that provides hospital and medical expense benefits and 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 by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the health benefits plan.
c. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
8. a. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), 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, shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the enrollee's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract for services.
c. This section shall apply to those contracts for health care services under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract.
10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the covered person's physician.
b. The benefits provided by this section shall be provided to the same extent and with the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract.
11. This act shall take effect on the first day of the seventh month next following enactment.
STATEMENT
This bill requires health insurers and health maintenance organizations, as well as health benefits plans or contracts which are issued or purchased pursuant to the New Jersey Individual Health Coverage Program, New Jersey Small Employer Health Benefits Program, State Health Benefits Program, and School Employees' Health Benefits Program, to provide coverage for expenses incurred in the diagnosis, evaluation, and treatment of lymphedema that is determined to be medically necessary by the treating physician.
Lymphedema is caused by an abnormality of the lymphatic system leading to excessive build-up of tissue fluid that forms lymph, known as interstitial fluid. Interstitial fluid can build up in any area of the body that has inadequate lymph drainage and cause lymphedema. Left untreated, lymphedema leads to chronic inflammation, infection and hardening of the skin that, in turn results in further lymph vessel damage and distortion of the shape of affected body parts. Lymphedema is a condition that develops slowly and once present is usually progressive.
Although some people are born with abnormalities in the lymphatic system, a condition known as Primary Lymphedema, most lymphedema in the United States is Secondary Lymphedema. This type of lymphedema occurs from damage to the lymphatic system, commonly from cancer and its treatment, but also from trauma to the skin such as from burns or infections. Lymphedema can occur as a result of breast cancer, melanoma, gynecologic cancer, head and neck cancer, and sarcoma.
Early diagnosis of lymphedema is important since treatment is most effective when commenced at the earliest stage of the disease. Lymphedema has no cure, but can be successfully managed when properly diagnosed and treated. Every patient diagnosed with lymphedema should have access to established effective treatment.
