ASSEMBLY, No. 10

 

STATE OF NEW JERSEY

 

INTRODUCED DECEMBER 9, 1996

 

 

By Assemblymen AZZOLINA and CORODEMUS

 

 

An Act concerning coverage for inpatient care following a mastectomy and supplementing P.L.1938, c.366 (C.17:48-1 et seq.), P.L.1940, c.74 (C.17:48A-1 et seq.), P.L.1985, c.236 (C.17:48E-1 et seq.), Chapters 26 and 27 of Title 17B of the New Jersey Statutes, P.L.1992, c.161 (C.17B:27A-2 et seq.), P.L.1992, c.162 (C.17B:27A-17 et seq.), P.L.1973, c.337 (C.26:2J-1 et seq.) and Titles 34 and 45 of the Revised Statutes.

 

    Be It Enacted by the Senate and General Assembly of the State of New Jersey:

 

    1. a. Every individual or group hospital service corporation contract that provides hospital or 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 a minimum of 72 hours of inpatient care following surgery for a mastectomy. The contract shall not require a health care provider to obtain authorization from the hospital service corporation for prescribing 72 hours of inpatient care as provided for in this section.     The benefits shall be provided to the same extent as for any other sickness under the contract.

     The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.

    b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    2. a. Every individual or group medical service corporation contract that provides hospital or 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 a minimum of 72 hours of inpatient care following surgery for a mastectomy. The contract shall not require a health care provider to obtain authorization from the medical service corporation for prescribing 72 hours of inpatient care as provided for in this section.

    The benefits shall be provided to the same extent as for any other sickness under the contract.

    The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.

    b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    3. a. Every individual or group health service corporation contract that provides hospital or 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 a minimum of 72 hours of inpatient care following surgery for a mastectomy. The contract shall not require a health care provider to obtain authorization from the health service corporation for prescribing 72 hours of inpatient care as provided for in this section.

    The benefits shall be provided to the same extent as for any other sickness under the contract.

    The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.

    b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    4. a. Every individual policy that provides hospital or 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 a minimum of 72 hours of inpatient care following surgery for a mastectomy. The policy shall not require a health care provider to obtain authorization from the insurer for prescribing 72 hours of inpatient care as provided for in this section.

    The benefits shall be provided to the same extent as for any other sickness under the policy.

    The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

    b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    5. a. Every group policy that provides hospital or 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 benefits for a minimum of 72 hours of inpatient care following surgery for a mastectomy. The policy shall not require a health care provider to obtain authorization from the insurer for prescribing 72 hours of inpatient care as provided for in this section.

    The benefits shall be provided to the same extent as for any other sickness under the policy.

    The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

    b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    6. a. Every individual health benefits plan that provides hospital or 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 on or after the effective date of this act shall provide benefits for a minimum of 72 hours inpatient care following surgery for a mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 hours of inpatient care as provided for in this section.

    The benefits shall be provided to the same extent as for any other sickness under the health benefits plan.

    The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

    b. The New Jersey Individual Health Coverage Program Board shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    7. a. Every small employer health benefits plan that provides hospital or 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 on or after the effective date of this act shall provide benefits for a minimum of 72 hours inpatient care following surgery for a mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 hours of inpatient care as provided for in this section.

    The benefits shall be provided to the same extent as for any other sickness under the health benefits plan.

    The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.

    b. The New Jersey Small Employer Health Benefits Program Board shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    8. a. Every enrollee agreement that provides hospital or medical expense benefits and 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 Health and Senior Services on or after the effective date of this act shall provide health care services for a minimum of 72 hours of inpatient care following surgery for a mastectomy. The enrollee agreement shall not require a health care provider to obtain authorization from the health maintenance organization for prescribing 72 hours of inpatient care as provided for in this section.

    The health care services shall be provided to the same extent as for any other sickness under the enrollee agreement.

    The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.

    b. The Commissioner of Health and Senior Services shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.

 

    9. An employer in this State who provides coverage to his employees or their dependents for treatment of breast cancer shall annually and upon request of an employee at other times during the year, notify his employees whether the employees' coverage for treatment of breast cancer is subject to the requirements of P.L. , c. (pending before the Legislature as this bill) concerning the minimum time a patient shall be permitted to remain at an inpatient care facility following surgery for a mastectomy.

 

    10. The attending physician of a patient who will undergo a mastectomy who has health care insurance coverage for the treatment of breast cancer, shall, prior to the surgery, determine if the coverage is subject to the requirements of P.L. , c. (pending before the Legislature as this bill) concerning the minimum time a patient shall be permitted to remain at an inpatient care facility following surgery for a mastectomy. If the physician determines that the patient's coverage is not subject to the requirements of P.L. , c. , (pending before the Legislature as this bill), the physician shall promptly notify the patient of that fact and, if known, the duration of inpatient care to which the patient is entitled under the patient's insurance coverage.

 

    11. This act shall take effect immediately.

 

 

STATEMENT

 

    This bill requires hospital, medical and health service corporations, individual and small and large group commercial insurers, and health maintenance organizations to provide a minimum of 72 hours inpatient care following surgery for a mastectomy. The bill also provides that the insurer or health maintenance organization shall not require a health care provider to obtain authorization from the insurer or health maintenance organization for prescribing the 72 hours of inpatient care as provided for in this bill.

    The requirements of this bill affect health, hospital and medical service corporation contracts, individual, small employer and group health insurance policies and health maintenance organization coverage issued in this State. The requirements, however, do not extend to coverage issued by an out-of-State carrier or to self-insured health benefits plans that are not subject to State regulation. This gap in coverage, which can only be corrected by federal legislation, may result in cancer patients who believe that they are covered under this bill being denied 72 hours of inpatient care following a mastectomy by their insurance carrier.

    Therefore, to ensure that the patient is promptly notified about any such limitations in that person's health insurance coverage, this bill also provides that an employer in this State who provides coverage to his employees or their dependents for treatment of breast cancer shall annually and upon request of an employee at other times during the year, notify his employees whether the employees' coverage for treatment of breast cancer is subject to the requirements of this bill. Also, the attending physician of a patient who will undergo a mastectomy who has health care insurance coverage for the treatment of breast cancer, shall, prior to the surgery, determine if the coverage is subject to the requirements of this bill. If the physician determines that the patient's coverage is not subject to the requirements of this bill, the physician shall promptly notify the patient of that fact and, if known, the duration of inpatient care to which the patient is entitled under the insurance coverage.


                             

Requires health insurers to provide minimum of 72 hours inpatient care following a mastectomy and requires providers and employers to notify insured if their health insurance coverage is not subject to 72-hour mastectomy law.