ASSEMBLY HEALTH COMMITTEE

STATEMENT TO

ASSEMBLY COMMITTEE SUBSTITUTE FOR

ASSEMBLY, Nos. 10, 2551, 2524 and 2575

STATE OF NEW JERSEY

DATED: DECEMBER 16, 1996

      The Assembly Health Committee reports favorably an Assembly Committee Substitute for Assembly Bill Nos. 10, 2551, 2524 and 2575.

      This committee substitute 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 a mastectomy and a minimum of 48 hours of inpatient care following a lymph node dissection for the treatment of breast cancer. The substitute 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 or 48 hours, as appropriate, of inpatient care as provided for in this substitute. The provisions of the substitute shall not be construed to require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate.

      The requirements of this substitute 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 substitute being denied 72 or 48 hours, as appropriate, of inpatient care following a mastectomy or a lymph node dissection 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 substitute 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 substitute. Also, the attending physician of a patient who will undergo a mastectomy or a lymph node dissection 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 substitute. If the physician determines that the patient's coverage is not subject to the requirements of this substitute, 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.