ASSEMBLY, No. 4738
STATE OF NEW JERSEY
218th LEGISLATURE
INTRODUCED NOVEMBER 26, 2018
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
As reported by the Assembly Health and Senior Services Committee on May 13, 2019, with amendments.
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, 1the breast cancer gene, or other breast abnormality,1 including, but not limited to, mastectomy surgery, lymph node dissection, or lumpectomy, shall 1[provide information to] ensure that1 each patient receiving treatment for breast cancer 1[concerning the option of reconstructive surgery following the provision of surgical services, including] 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)1 the availability of coverage 1under a health benefits plan1 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 1[information] written notice1 shall be provided to the patient 1[in writing] upon the general hospital’s notification of the patient’s breast cancer diagnosis1 and in advance of obtaining consent to the surgical procedure1[, and shall include, at a minimum:
(1) a description of the various reconstructive options and the advantages and disadvantages of each;
(2) a description of the provisions of State and federal law that require health benefits carriers to provide coverage for reconstructive surgery;
(3) a description of how a patient may access reconstructive care, including the potential of transferring care to a facility that provides reconstructive care or choosing to pursue reconstruction after completing breast cancer surgery, chemotherapy, and radiotherapy; and
(4) such other information as shall be required by the Commissioner of Health.
b. The Commissioner of Health 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]1.
2. a. A contract between a carrier and a health care provider for 1[a managed care plan] network participation1 shall not contain any provision that1:
(1)1 prohibits a health care provider from 1[referring] making recommendations to1 a covered person to 1[an out-of-network] a board-certified or board-eligible1 plastic surgeon 1[for], 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 subsection1.
1b. 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 to1 reconstructive breast surgery or surgery to restore and achieve symmetry between two breasts following 1[a] treatment or surgery for breast cancer, the breast cancer gene, or other breast abnormality, including, but not limited to,1 mastectomy 1[, if there is no reasonable access to an in-network plastic surgeon capable of performing those services within 10 miles of the location where the mastectomy was performed. For purposes of] surgery, lumpectomy, or radiation.
d. As used in1 this section, “carrier” 1[shall include] means a “carrier” as defined in section 2 of P.L.1997, c.192 (C.26:2S-2),1 the State Health Benefits Program, and the School Employees’ Health Benefits Program.
1[b.] e.1 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.