Bill Text: NJ A4801 | 2020-2021 | Regular Session | Introduced
Bill Title: "Michelle's Law"; requires health benefit plans to cover mammogram for an individual if recommended by health care provider.
Spectrum: Partisan Bill (Republican 3-0)
Status: (Introduced - Dead) 2020-10-19 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A4801 Detail]
Download: New_Jersey-2020-A4801-Introduced.html
Sponsored by:
Assemblyman ANTWAN L. MCCLELLAN
District 1 (Atlantic, Cape May and Cumberland)
Assemblyman ERIK K. SIMONSEN
District 1 (Atlantic, Cape May and Cumberland)
SYNOPSIS
"Michelle's Law"; requires health benefit plans to cover mammogram for an individual if recommended by health care provider.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health benefits for mammograms, designated as Michelle's Law, 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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(cf: P.L.2013, c.196, s.3)
4. Section 4 of P.L.1991, c.279 (C17B: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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(cf: P.L.2013, c.196, s.5)
6. 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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(cf: P.L.2013, c.196, s.8)
7. 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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(cf: P.L.2013, c.196, s.6)
8. 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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(cf: P.L.2013, c.196, s.7)
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 years of age; a mammogram examination every year for women age 40 and over; and[, in the case of a woman who is under 40 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] recommended by [the woman's] a covered person's health care provider; and
(2) 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, if the mammogram demonstrates extremely dense breast tissue, if the mammogram 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.
(cf: P.L.2013, c.196, s.9)
10. This act shall take effect immediately.
STATEMENT
This bill requires health benefit plans to cover the cost of a mammogram if a health care provider recommends the examination.
Presently, health benefit plans are only required to cover mammograms for women who are 40 and over or women under the age of 40 if they have a family history of breast cancer or other breast cancer related risk factor. Health benefit plans must also cover additional testing of an entire breast or breasts after a baseline mammogram examination. Under this bill, health benefit plans will be required to cover the cost of a mammogram examination, and any additional testing after the examination, if the health care provider of the subscriber or other person covered under the plan recommends it. Mammograms for women 40 and over will still be covered under this bill.
This bill, named "Michelle's Law," is in response to the tragic death of Michelle DeVita. Michelle was a 38-year-old woman who lost her battle to breast cancer. Under the requirements of the current law, insurance was not required to provide her coverage for a mammogram
