ASSEMBLY, No. 1977

STATE OF NEW JERSEY

217th LEGISLATURE

PRE-FILED FOR INTRODUCTION IN THE 2016 SESSION

 


 

Sponsored by:

Assemblyman† VINCENT PRIETO

District 32 (Bergen and Hudson)

Assemblyman† RAJ MUKHERJI

District 33 (Hudson)

Assemblyman† DANIEL R. BENSON

District 14 (Mercer and Middlesex)

Assemblywoman† VALERIE VAINIERI HUTTLE

District 37 (Bergen)

 

Co-Sponsored by:

Assemblymen Wolfe, C.A.Brown, Johnson, Diegnan, Wimberly and Chiaravalloti

 

 

 

 

SYNOPSIS

†††† Requires health benefits coverage for mammograms for women under 40 who lack access to family medical history due to their or their parentís adoption.

 

CURRENT VERSION OF TEXT

†††† Introduced Pending Technical Review by Legislative Counsel.

††


An Act requiring health benefits coverage for mammograms for adopted women and daughters of adopted parents, 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, or was adopted or whose parent was adopted, 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.

†††† 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, or was adopted or whose parent was adopted, 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.

†††† 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, or was adopted or whose parent was adopted, 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.

†††† 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 (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 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, or was adopted or whose parent was adopted, 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.

†††† 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, or was adopted or whose parent was adopted, 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.

†††† 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 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, or was adopted or whose parent was adopted, 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.

†††† 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 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, or was adopted or whose parent was adopted, 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.

†††† 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 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, or was adopted or whose parent was adopted, 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.

†††† 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, or was adopted or whose parent was adopted, 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.

†††† 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 on the 90th day after enactment and shall apply to all contracts and policies that are delivered, issued, executed, or renewed or approved for issuance or renewal in this State on or after the effective date.

 

 

STATEMENT

 

†††† This bill requires health insurers, including health, hospital, and medical service corporations; commercial individual, small employer, and larger group health insurers; health maintenance organizations; and the State Health Benefits Program (SHBP) to provide health benefits coverage for expenses incurred in conducting an annual mammogram for women under 40 years of age who may be at risk for breast cancer but may not have access to their family medical histories because they were adopted, beginning when the woman's physician deems the mammogram to be medically necessary.

†††† For women with a family history of breast cancer, many physicians recommend they begin annual mammograms 10 years prior to the age at which their family member was first diagnosed; for some women, this means that they should start having annual mammograms as early as age 25.† Currently, most insurers are required to provide benefits for expenses incurred in conducting mammograms for women with a family history of breast cancer at an age and interval deemed to be medically necessary by a womanís health care provider.† Adopted women and daughters of adopted parents may not have access to their familyís medical history, and thus may not be able to prove their family history to receive insurance coverage for this potentially life-saving screening.

†††† According to the Centers for Disease Control and Prevention, breast cancer is the second most fatal cancer among American women.† Women with a close relative who has been diagnosed with breast cancer face twice the risk of being diagnosed themselves.† Although an estimated 40,000 women died from breast cancer in 2010, earlier detection through screening has helped to steadily decrease this number since 1990.

†††† Thus, in order to ensure that younger women without knowledge of their family history, but still at great risk for breast cancer, have access to this potentially life-saving test, this bill extends the annual mammogram requirement to cover adopted women and daughters of adopted parents under the age of 40, as recommended by their physicians.