P.L. 1999, c.0339 (A1653 2R)

CHAPTER 339

An Act concerning health insurance benefits for health wellness examinations and counselling,amending P.L.1993, c.327 and making an appropriation.

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

1. Section 3 of P.L.1993, c.327 (C.17:48-6i) is amended to read as follows:

C.17:48-6i Hospital service corporation, benefits or health promotion.

3. a. Every hospital service corporation contract that provides hospital and 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 P.L.1999, c.339, shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin; blood pressure; blood glucose level; and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level;

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 2 of P.L.1995, c.415 (C.17:48-6o);

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 1 of P.L.1991, c.279 (C.17:48-6g);

(7) For all adults, recommended immunizations; and

(8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles.

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the hospital service corporation shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every individual or group health care contract offered for sale in this State by a hospital service corporation pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no hospital service corporation shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

c. The Commissioner of Banking and Insurance, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which the adjustment is made.

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.).

2. Section 4 of P.L.1993, c.327 (C.17:48A-7h)is amended to read as follows:

C.17:48A-7h Medical service corporation, benefits for health promotion.

4. a. Every medical service corporation contract that provides hospital and 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 P.L.1999, c.339, shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level;

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 3 of P.L.1995, c.415 (C.17:48A-7m);

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 2 of P.L.1991, c.279 (C.17:48A-7f);

(7) For all adults, recommended immunizations; and

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the medical service corporation shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every individual or group basic health care contract offered for sale in this State by a medical service corporation pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no medical service corporation shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

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. Section 5 of P.L.1993, c.327 (C.17:48E-35.6) is amended to read as follows:

C.17:48E-35.6 Health service corporation, benefits for health promotion.

5. a. Every health service corporation contract that provides hospital and 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 P.L.1999, c.339, shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 1 of P.L.1995, c.415 (C.17:48E-35.12);

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 3 of P.L.1991, c.279 (C.17:48E-35.4);

(7) For all adults, recommended immunizations; and

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the health service corporation shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every individual or group health care contract offered for sale in this State by a health service corporation pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no health service corporation shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

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. Section 6 of P.L.1993, c.327 (C.17B:26-2.1h) is amended to read as follows:

C.17B:26-2.1h Individual health insurer, benefits for health promotion.

6. a. Every individual policy that provides hospital and 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 P.L.1999, c.339, shall provide benefits to each person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear every two years;

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 4 of P.L.1991, c.279 (C.17B:26-2.1e);

(7) For all adults, recommended immunizations; and

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the insurer shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every individual health care policy offered for sale in this State by an insurer pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no insurer shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

d. The requirements of this section shall apply only to health insurers which issue or deliver primary health insurance coverage in this State providing hospital or medical expense benefits. Primary health insurance coverage shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, Medicare supplement coverage, CHAMPUS supplement coverage, coverage for Medicare services pursuant to a contract with the United States government, coverage for Medicaid services pursuant to a contract with the State, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage.

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

f. 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. Section 7 of P.L.1993, c.327 (C.17B:27-46.1h) is amended to read as follows:

C.17B:27-46.1h Group health insurer, benefits for health promotion.

7. a. Every group policy that provides hospital and 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 P.L.1999, c.339, shall provide benefits to each person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 4 of P.L.1995, c.415 (C.17B:27-46.1n);

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 5 of P.L.1991, c.279 (C.17B:27-46.1f);

(7) For all adults, recommended immunizations; and

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the insurer shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. Every group health care policy offered for sale in this State by an insurer pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no insurer shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.

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

f. 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. Section 8 of P.L.1993, c.327 (C.26:2J-4.6) is amended to read as follows:

C.26:2J-4.6 Health maintenance organization, benefits for health promotion.

8. a. Notwithstanding any provision of this act or any other law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health and Senior Services on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee which include a health promotion program providing health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:

(2) For all persons 35 years of age or older, a glaucoma eye test every five years;

(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;

(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;

(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 5 of P.L.1995, c.415 (C.26:2J-4.12);

(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 6 of P.L.1991, c.279 (C.26:2J-4.4);

(7) For all adults, recommended immunizations; and

Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for an enrollee to receive a different schedule of tests and services than that provided for under this subsection, the health maintenance organization shall provide coverage for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.

b. A health maintenance organization shall not be required to offer services to enrollees set forth in subsection a. of this section for which the value exceeds: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the value of a left-sided colon examination shall not be included in the above amount; however, no health maintenance organization shall be required to provide services to enrollees for a left-sided colon examination with a value in excess of $150.

c. The Commissioner of Health and Senior Services, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which it is reported.

d. Nothing in this act shall be construed to require that a health maintenance organization take any actions which conflict with the health benefits, underwriting and rating standards established by the federal government pursuant to subchapter XI of Pub.L.93-222 (42 U.S.C. s.300e et seq.).

e. This section shall apply to all health maintenance organization contracts in which the right to change the enrollee charge has been reserved.

f. 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. Section 9 of P.L.1993, c.327 (C.26:1A-36.13) is amended to read as follows:

C.26:1A-36.13 Health Wellness Promotion Advisory Board.

9. a. There is created a Health Wellness Promotion Advisory Board which shall consist of three members, each of whom has a background in epidemiology and a demonstrated professional expertise in services, issues or programs relating to health wellness promotion, who are residents of the State, one of whom shall be appointed by the Governor, one by the President of the Senate and one by the Speaker of the General Assembly.

b. The terms of office of the members of the board shall be three years. Vacancies shall be filled for an unexpired term only in the manner provided for the original appointment.

c. Members of the board shall serve without compensation but shall be reimbursed for their reasonable and necessary traveling and other expenses incurred in the performance of their official duties.

d. The Commissioner of Health and Senior Services shall designate an officer or employee of the Department of Health and Senior Services to act as secretary of the board who shall not be a member of the board.

e. The board, for the purpose of transacting its business, shall meet at least once every six months at times and places fixed by the board. At its first meeting each year it shall organize and elect a chair from its members. Special meetings may also be held at times as the board may fix, or at the call of the chair or the Commissioner of Health and Senior Services. A timely written notice of the time, place and purpose of any special meeting shall be mailed by the secretary to all members of the board.

f. A majority of the members of the board shall constitute a quorum for the transaction of business at any meeting.

g. The board shall advise and make recommendations to the Legislature pertaining to any revisions of medical testing and services that are deemed by the board to be appropriate for health promotion and that will encourage health care consumers to engage in healthy lifestyle behaviors which will result in a reduction of the long-term costs of providing health care. In deciding whether a recommendation should be made to add an additional medical test or service to those currently required by this act, the board shall consider the benefits as well as the cost to provide such a medical test or service. To assist the board in its consideration, the board shall select two organizations which have established expertise in the areas of epidemiology, sensitivity, specificity and predictive value of screening, disease protection, and health promotion tests. No additional test or service shall be added to those required under this act unless: (1) both organizations selected by the board agree that the medical test or counselling service will improve the quality of life, prolong good quality life, or reduce mortality; and (2) the board, subsequent to the agreement of both organizations, recommends that such additional test or service be made.

h. The board shall also appoint a committee which includes representatives of health care professions, including, but not limited to, physicians, nurses, chiropractors, dentists, dietitians, physician assistants, pharmacists and optometrists, and other interested persons to advise the board regarding medical testing and services that are deemed to be appropriate for health promotion and that will encourage health care consumers to engage in healthy lifestyle behaviors. The board shall determine the number, composition and terms of office of the committee members, and may establish such procedural and administrative requirements as it deems appropriate for the committee.

i. The board shall report annually to the Governor and the Legislature its findings and recommendations concerning the issues enumerated in subsection g. of this section.

8. Section 10 of P.L.1993, c.327 (C.26:1A-36.14) is amended to read as follows:

C.26:1A-36.14 Regulations.

10. The Commissioner of Banking and Insurance, after consultation with the Health Wellness Promotion Advisory Board, established pursuant to section 9 of P.L.1993, c.327 (C.26:1A-36.13), shall, within 180 days of the effective date of P.L.1999, c.339, promulgate regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to effectuate the purposes of P.L.1999, c.339.

9. There is appropriated $95,000 to the Department of Health and Senior Services for allocation to the Health Wellness Promotion Advisory Board established pursuant to section 9 of P.L.1993, c.327 (C.26:1A-36.13), to evaluate implementation of the provisions of this act and to ensure awareness and utilization of the health promotion program by covered persons and health care providers.

10. This act shall take effect on the 90th day after enactment.

Approved January 10. 2000.