Sponsored by:
Assemblywoman SADAF F. JAFFER
District 16 (Hunterdon, Mercer, Middlesex and Somerset)
Assemblyman REGINALD W. ATKINS
District 20 (Union)
Assemblywoman ANGELA V. MCKNIGHT
District 31 (Hudson)
Co-Sponsored by:
Assemblywoman Carter
SYNOPSIS
Requires health insurers to cover additional mammogram examinations and genetic testing and counseling under certain circumstances.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance coverage for mammogram examinations, genetic testing, and genetic counseling, and amending and supplementing various 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.1991, c.279 (C.17:48-6g) is amended to read as follows:
1. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(f) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.1)
2. Section 2 of P.L.1991, c.279 (C.17:48A-7f) is amended to read as follows:
2. a. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.2)
3. Section 3 of P.L.1991, c.279 (C.17:48E-35.4) is amended to read as follows:
3. a. No group or individual health service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)]
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.3)
4. Section 4 of P.L.1991, c.279 (C.17B:26-2.1e) is amended to read as follows:
4. a. No individual health insurance policy providing hospital or medical expense benefits shall be 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, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20%, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.4)
5. Section 5 of P.L.1991, c.279 (C.17B:27-46.1f) is amended to read as follows:
5. a. No group health insurance policy providing hospital or medical expense benefits shall be 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, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) genemutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.5)
6. Section 7 of P.L.2004, c.86 (C.17B:27A-7.10) is amended to read as follows:
7. a. Every individual health benefits plan that 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 to any person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.6)
7. Section 8 of P.L.2004, c.86 (C.17B:27A-19.13) is amended to read as follows:
8. a. Every small employer health benefits plan that 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 to any person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.7)
8. Section 6 of P.L.1991, c.279 (C.26:2J-4.4) is amended to read as follows:
6. a. Notwithstanding any provision of 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 Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee for the conduct of:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These health care services shall be provided to the same extent as for any other sickness under the enrollee agreement.
c. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
(cf: P.L.2013, c.196, s.8)
9. Section 9 of P.L.2004, c.86 (C.52:14-17.29i) is amended to read as follows:
9. a. The State Health Benefits Commission shall provide benefits to each person covered under the State Health Benefits Program for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over; [and,]
(2) in the case of a woman who is under 40 years of age [and has a] , a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors[, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider];
(b) personal history of atypical breast histologies;
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) gene mutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
[(2)] (3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a [baseline] mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the contract.
(cf: P.L.2013, c.196, s.9)
10. (New section) a. The School Employees’ Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred in:
(1) one baseline mammogram examination for women who are 40 years of age and a mammogram examination every year for women age 40 and over;
(2) in the case of a woman who is under 40 years of age, a yearly mammogram examination if the woman is believed to be at an increased risk of breast cancer due to:
(a) family history of breast cancer or other breast cancer risk factors;
(b) personal history of atypical breast histologies
(c) genetic predisposition for breast cancer;
(d) prior therapeutic thoracic radiation therapy;
(e) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20 percent, according to risk assessment tools based on family history;
(ii) personal history of breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) genemutations;
(iii) a first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these symptoms; or
(b) extremely dense breast tissue based on breast composition categories; and
(3) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a mammogram examination provided pursuant to paragraphs (1) and (2) of this subsection, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, genetic predisposition for breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications, including any additional factors under paragraph (2) of this subsection, as determined by the patient's health care provider. The coverage required under this paragraph and paragraph (2) of this subsection may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the contract.
11. (New section) a. A 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 benefits to any named subscriber or other person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 1 of P.L.1991, c.279 (C.17:48-6g).
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. The provisions of 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. As used in this section, “genetic counseling” means the same as defined pursuant to Section 3 of P.L.2009, c.41 (C.45:9-37.113).
12. (New section) a. Every 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 benefits to any named subscriber or other person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 2 of P.L.1991, c.279 (C.17:48A-7f).
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. The provisions of 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. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
13. (New section) a. Every 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 benefits to any named subscriber or other person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 3 of P.L.1991, c.279 (C.17:48E-35.4).
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. The provisions of 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. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
14. (New section) 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 benefits to any named insured or other person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 4 of P.L.1991, c.279 (C.17:26-2.1e).
c. The benefits shall be provided to the same extent as for any other medical condition under the policy.
d. The provisions of this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium.
e. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
15. (New section) 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 to any named insured or other person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 5 of P.L.1991, c.279 (C.17B:27-46.1f).
c. The benefits shall be provided to the same extent as for any other medical condition under the policy.
d. The provisions of this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium.
e. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
16. (New section) 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 Banking and Insurance on or after the effective date of this act, shall provide health care services to any enrollee or other person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 6 of P.L.1991, c.279 (C.26:2J-4.4).
c. The health care services shall be provided to the same extent as for any other medical condition under the enrollee agreement.
d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
e. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
17. (New section) 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 to any person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 7 of P.L.2004, c.86 (C.17B:27A-7.10).
c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
d. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
e. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
18. (New section) 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 to any person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 8 of P.L.2004, c.86 (C.17B:27A-19.13).
c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
d. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
e. As used in this
section, “genetic counseling” means the same as defined in Section 3 of
P.L.2009, c.41 (C.45:9-37.113).
19. (New section) a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act, that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 9 of P.L.2004, c.86 (C.52:14-17.29i).
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
20. (New section) a. The School Employees’ Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred in providing genetic counseling and testing for the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes by an individual licensed, certified, or otherwise regulated to provide genetic counseling and genetic testing. The benefits provided shall include all costs associated with genetic counseling and, if indicated after genetic counseling, a genetic laboratory test of the BRCA1 or BRCA2 genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.
b. A test with a positive result for the existence of BRCA1 or BRCA2 shall qualify as “positive genetic testing” for breast cancer for purposes of additional testing authorized pursuant to paragraph (3) of subsection a. of section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. As used in this section, “genetic counseling” means the same as defined in Section 3 of P.L.2009, c.41 (C.45:9-37.113).
21. This act shall take effect on the 90th day next following enactment and shall apply to policies and contracts that are delivered, issued, executed, or renewed on or after that date.
STATEMENT
This bill requires health insurance coverage of additional mammogram examinations and genetic testing and counseling under certain circumstances.
Under the bill, health insurance carriers (including health service corporations, hospital service corporations, medical service corporations, commercial individual and group health insurers, health maintenance organizations authorized to issue health benefits plans in New Jersey, and entities contracted to administer health benefits in connection with the State Health Benefits Program and School Employees’ Health Benefits Program) will be required to cover a yearly mammogram examination for a woman under the age of 40 if the woman is believed to be at an increased risk of breast cancer due to a variety of factors that include family history, genetic predisposition, or experiences with certain hereditary genetic conditions.
The bill also provides for health insurance coverage for genetic counseling and testing. Under the bill, health insurance carriers will be required to cover all costs associated with genetic counseling and, if indicated after genetic counseling, genetic laboratory testing of the breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) genes for individuals assessed to be at an increased risk, based on a clinical risk assessment tool, of potentially harmful mutations in the BRCA1 or BRCA2 genes due to a personal or family history of breast or ovarian cancer.