Bill Text: NJ A5477 | 2020-2021 | Regular Session | Introduced
Bill Title: Requires health care professionals to order bi-lateral ultrasounds concurrently when ordering mammograms; requires insurers to cover concurrent mammograms and bi-lateral ultrasounds.
Spectrum: Partisan Bill (Democrat 4-0)
Status: (Introduced - Dead) 2021-03-15 - Introduced, Referred to Assembly Health Committee [A5477 Detail]
Download: New_Jersey-2020-A5477-Introduced.html
Sponsored by:
Assemblywoman ANNETTE QUIJANO
District 20 (Union)
SYNOPSIS
Requires health care professionals to order bi-lateral ultrasounds concurrently when ordering mammograms; requires insurers to cover concurrent mammograms and bi-lateral ultrasounds.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning mammograms and other diagnostic testing for breast cancer, amending P.L.1991, c.279 and P.L.2004, c.86, and supplementing Title 26 of the Revised Statues.
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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts conducted pursuant to paragraph concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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, s.4 (C.17B:26-2.1) 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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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 7 of P.L.2004, c.86 (C.17B:27A-7.10) is amended to read as follow:
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 by the woman'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; and.
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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)
7. Section 8 of 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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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)
8. Section 6 of 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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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)
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 by the woman'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; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts concurrently ordered with a mammogram examination by a health care provider pursuant to section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
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. (New section) Any health care provider engaged in the diagnosis or treatment of breast cancer shall concurrently order an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts when ordering a mammogram examination if a woman has additional risk factors for breast cancer or other indications as determined by the provider.
11. The Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt such rules and regulations as are necessary to effectuate the purposes of section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
12. This act shall take effect on the first day of the fourth month next following the date of enactment. Sections 1 through 9 of this act shall apply to all contracts and policies 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. The Commissioner of Health may take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of section 10 of this act.
STATEMENT
This bill requires any health care provider engaged in the diagnosis or treatment of breast cancer to concurrently order an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts when ordering a mammogram examination if a woman has additional risk factors for breast cancer or other indications as determined by the provider.
The bill also requires health insurers to cover the ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts when concurrently ordered with a mammogram examination.
The bill provides that the health benefits coverage requirements apply to: health, hospital, and medical service corporations; commercial, individual, and group health insurers; health maintenance organizations; and health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs. The bill provides the requirements for coverage also apply to the State Health Benefits Program, which by law requires similar health benefits coverage under the School Employees' Health Benefits Program.
