§6
C. 26:2J-4.14
§7
Note To §§1-6
P.L. 1997, CHAPTER 75, approved April 17, 1997
Senate, No. 1783
An Act requiring health insurance coverage for reconstructive breast surgery to restore symmetry, and amending and supplementing parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L.1983, c.50 (C.17:48-6b) is amended to read as follows:
1. Every subscription certificate and group and individual contract providing hospital service benefits 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, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, [including but not limited to] surgery to restore and achieve symmetry between the two breasts, and the cost of prostheses and, under any contract providing outpatient x-ray or radiation therapy, benefits for outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the contract.
(cf: P.L.1983, c.50, s.1)
2. Section 1 of P.L.1983, c.51 (C.17:48A-7b) is amended to read as follows:
1. Every subscription certificate and group and individual contract providing medical service benefits 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, shall provide benefits, following a
mastectomy on one breast or both breasts, for reconstructive breast surgery, [including but not limited to] surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses and, under any contract providing out-of-hospital x-ray or radiation therapy, benefits for out-of-hospital chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the out-of-hospital x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the contract.
(cf: P.L.1983, c.51, s.1)
3. Section 35 of P.L.1985, c.236 (C.17:48E-35) is amended to read as follows:
35. Every subscription certificate and group and individual contract providing health service coverage, delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the commissioner on or after the effective date of this act, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, [including, but not limited to:] surgery to restore and achieve symmetry between the two breasts, and the cost of prostheses and, under any contract providing outpatient x-ray or radiation therapy, benefits for outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer, which shall be included as a part of the outpatient x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium. These benefits shall be provided to the same extent as for any other sickness under the contract.
(cf: P.L. 1985, c.236, s.35)
4. Section 1 of P.L. 1983, c.53 (C.17B:26-2.1a) is amended to read as follows:
1. Every health insurance policy providing hospital or medical expense benefits 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, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, [including but not limited to] surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the policy.
(cf: P.L.1983, c.53, s.1)
5. Section 1 of P.L.1983, c.52 (C.17B:27-46.1a) is amended to read as follows:
1. Every group health insurance policy providing hospital or medical expense benefits 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, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, [including but not limited to:] surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the policy.
(cf: P.L.1983, c.52, s.1)
6. (New section) A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Health and Senior Services on or after the effective date of P.L. ...., c. .... (now before the Legislature as this bill) unless the health maintenance organization provides health care services to any enrollee, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and prostheses and, under any contract for health care services providing outpatient x-ray or radiation therapy, outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy.
The health care services shall be provided to the same extent as for any other medical condition under the contract for health care services.
The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
7. This act shall take effect on the 90th day after enactment.
STATEMENT
This bill requires health insurers, including hospital service corporations, medical service corporations, health service corporations, commercial insurers and health maintenance organizations, to provide insurance coverage for the costs associated with all stages of the reconstruction that may be necessary following breast cancer surgery, including symmetry operations on the opposite breast, in order to restore a woman's body to wholeness. Insurers and health maintenance organizations are required under current law to provide prostheses and, under any contract for health care services providing outpatient x-ray or radiation therapy, outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer as a part of the outpatient x-ray or radiation therapy.
Breast cancer is the most common cancer in American women, afflicting 182,000 women per year, striking one out of nine and causing the death of 46,000 women a year. Coping with this disease is a medical and emotional struggle since it carries with it the fear of disfigurement in a society that places great value on physical appearance. Breast reconstruction is extremely important to restore a sense of wholeness and well being in society, family, and interpersonal relationships. There is no known cause or cure for this epidemic.
Requires health insurance coverage for reconstructive breast surgery to restore symmetry.