[Passed Both Houses]

 

[First Reprint]

 

ASSEMBLY SUBSTITUTE FOR

SENATE, No. 1704 and

ASSEMBLY, Nos. 10, 2551, 2524 and 2575 ACS

 

STATE OF NEW JERSEY

 

 

 

ADOPTED FEBRUARY 20, 1997

 

 

Sponsored by Senators INVERSO, SINAGRA, Assemblymen AZZOLINA, CORODEMUS, Assemblywomen HECK, VANDERVALK, TURNER, MURPHY, Assemblymen O'TOOLE, WEINGARTEN, BLEE, Senators McGreevey, Matheussen, Rice, Codey, Bubba, LaRossa, Bark, Sacco, Baer, Assemblymen Augustine, Barnes, Bucco, Assemblywoman Buono, Assemblymen Dalton, DiGaetano, Felice, Gibson, Assemblywomen Gill, Quigley, Assemblyman Rocco, Assemblywoman Weinberg, Assemblyman Wolfe, Senators Kosco, McNamara and Scott

 

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 a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The contract shall not require a health care provider to obtain authorization from the hospital service corporation for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

      The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the hospital service corporation under the contract.

      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 a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The contract shall not require a health care provider to obtain authorization from the medical service corporation for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

       The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the medical service corporation under the contract.

      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 a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The contract shall not require a health care provider to obtain authorization from the health service corporation for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

       The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the health service corporation under the contract.

      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 a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The policy shall not require a health care provider to obtain authorization from the insurer for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

      The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the insurer under the policy. 

      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 a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The policy shall not require a health care provider to obtain authorization from the insurer for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

       The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the insurer under the policy.

      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 of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 or 48 hours as appropriate, of inpatient care as provided for in this section.

      The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the carrier under the health benefits plan.                 

      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 of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The health benefits plan shall not require a health care provider to obtain authorization from the carrier for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

       The provisions of this section 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: or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the carrier under the health benefits plan.

      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 a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The enrollee agreement shall not require a health care provider to obtain authorization from the health maintenance organization for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.

      The provisions of this section 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; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the health maintenance organization under the enrollee agreement.    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 a mastectomy.

 

      1[10. The attending physician of a patient who will undergo a mastectomy or 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 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 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.]1

 

      1[11.] 10.1 This act shall take effect immediately.

 

 

                             

 

Requires health insurers to provide minimum hospital care for certain breast cancer surgeries and requires employers and physicians to notify insured if health insurance coverage is not subject to requirements of bill.