A2613

ASSEMBLY, No. 2613

STATE OF NEW JERSEY

INTRODUCED DECEMBER 16, 1996

By Assemblyman FELICE and Assemblywoman ALLEN

An Act concerning health insurance coverage for treatment of asthma and supplementing various parts of the statutory law.

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 providing hospital or medical expense benefits that 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 benefits to any subscriber or other person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of asthma, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist, including, but not limited to: peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

b. That individual or group hospital service corporation contract shall also provide benefits for expenses incurred for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Benefits provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the subscriber's or other covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacist in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the contract.

d. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

f. The Commissioner of Banking and Insurance may, in consultation with the Commissioner of Health and Senior Services, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate and periodically update a list of additional asthma equipment and related supplies that are medically necessary for the treatment of asthma and for which benefits shall be provided according to the provisions of this section.

2. a. Every individual or group medical service corporation contract providing hospital or medical expense benefits that 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 benefits to any subscriber or other person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of asthma, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist, including, but not limited to: peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

b. That individual or group medical service corporation contract shall also provide benefits for expenses incurred for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Benefits provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the subscriber's or other covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacist in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the contract.

d. This section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

3. a. Every individual or group health service corporation contract providing hospital or medical expense benefits that 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 benefits to any subscriber or other person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of asthma, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist, including, but not limited to: peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

b. That individual or group health service corporation contract shall also provide benefits for expenses incurred for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Benefits provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma; upon the diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the subscriber's or other covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacist in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the contract.

d. This section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

4. a. Every individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes 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 to any person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of asthma, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist, including, but not limited to: peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

b. That individual health insurance policy shall also provide benefits for expenses incurred for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Benefits provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacist in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the policy.

d. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

5. a. Every group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes 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 to any person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of asthma, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist, including, but not limited to: peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

b. That group health insurance policy shall also provide benefits for expenses incurred for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Benefits provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacist in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The benefits required by this section shall be provided to the same extent as for any other sickness under the policy.

d. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

6. a. Every contract for health care services that 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 on or after the effective date of this act shall provide health care services to any enrollee or other person covered thereunder for the following equipment and supplies for the treatment of asthma, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist, including, but not limited to: peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

b. That contract shall also provide health care services for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Health care services provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma; upon diagnosis by a participating physician or participating nurse practitioner/clinical nurse specialist of a significant change in the enrollee's or other covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a participating physician or participating nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacist in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

c. The health care services required by this section shall be provided to the same extent as for any other sickness under the contract.

d. This section shall apply to all contracts in which the health maintenance organization has reserved the right to change the schedule of charges.

e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).

7. This act shall take effect immediately.

STATEMENT

This bill requires hospital, medical and health service corporations, commercial individual and group health insurers and health maintenance organizations to provide benefits for expenses incurred for equipment and supplies for the treatment of asthma, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist. The list of supplies and equipment includes, but is not limited to, peak flow meters; sodium chloride for respiratory use; spacing devices; mini nebulizers; and ultrasonic nebulizers.

The bill also requires health insurers to provide benefits for expenses incurred for asthma self-management education to ensure that a person with asthma is educated as to the proper self-management and treatment of their asthmatic condition. Benefits provided for self-management education shall be limited to visits medically necessary upon the diagnosis of asthma, upon significant change in a covered person's symptoms or conditions which necessitate changes in that person's self-management, and upon the need for reeducation or refresher education.

Asthma self-management education shall be provided by a physician, nurse practitioner/clinical nurse specialist, or a registered pharmacists in the State qualified with regard to management education for asthma by any institution recognized by the board of pharmacy of the State of New Jersey.

Nationwide studies indicate that access to self-management education, equipment and supplies can result in cost savings for hospitalization and treatment of asthma. Studies also indicate that inadequate reimbursement creates a major impediment to high quality care for persons with asthma. Despite recent advances in the treatment and monitoring of this disease which allow a person with asthma to live a near normal and productive life, many persons are often unable to comply with optimal programs of treatment because they cannot afford the cost of supplies, equipment, education or treatment.

Requires health insurers to provide coverage for asthma self-management education, equipment and supplies.