ASSEMBLY, No. 5542 STATE OF NEW JERSEY 221st LEGISLATURE INTRODUCED APRIL 10, 2025
ASSEMBLY, No. 5542
STATE OF NEW JERSEY
221st LEGISLATURE
INTRODUCED APRIL 10, 2025
Sponsored by: Assemblywoman LISA SWAIN District 38 (Bergen) SYNOPSIS Requires health insurance coverage of diagnostic and supplemental breast examinations without cost-sharing. CURRENT VERSION OF TEXT As introduced.
Sponsored by:
Assemblywoman LISA SWAIN
District 38 (Bergen)
SYNOPSIS
Requires health insurance coverage of diagnostic and supplemental breast examinations without cost-sharing.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning breast examinations and insurance coverage and supplementing various parts of the statutory law. Be It Enacted by the Senate and General Assembly of the State of New Jersey: 1. a. 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 a diagnostic breast examination and supplemental breast examination. b. These benefits shall be provided to the same extent as for any other sickness under the contract, except that the contract shall not impose a cost-sharing requirement. 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. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 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 a diagnostic breast examination and supplemental breast examination. b. These benefits shall be provided to the same extent as for any other sickness under the contract, except that the contract shall not impose a cost-sharing requirement. 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. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 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 a diagnostic breast examination and supplemental breast examination. b. These benefits shall be provided to the same extent as for any other sickness under the contract, except that the contract shall not impose a cost-sharing requirement. 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. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 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 a diagnostic breast examination and supplemental breast examination. b. These benefits shall be provided to the same extent as for any other sickness under the policy, except that the policy shall not impose a cost-sharing requirement. c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 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 a diagnostic breast examination and supplemental breast examination. b. These benefits shall be provided to the same extent as for any other sickness under the policy, except that the policy shall not impose a cost-sharing requirement. c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 6. 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 a diagnostic breast examination and supplemental breast examination. b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan, except that the plan shall not impose a cost-sharing requirement. 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. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 7. 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 a diagnostic breast examination and supplemental breast examination. b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan, except that the plan shall not impose a cost-sharing requirement. 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. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 8. 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 a diagnostic breast examination and supplemental breast examination. b. These health care services shall be provided to the same extent as for any other sickness under the enrollee agreement, except that the agreement shall not impose a cost-sharing requirement. 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. d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. e. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 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 a diagnostic breast examination and supplemental breast examination. b. The benefits shall be provided to the same extent as for any other medical condition under the contract, except that the contract shall not impose a cost-sharing requirement. c. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 10. a. The School Employees' Health Benefits Commission shall provide benefits to each person covered under the School Employees' Health Benefits Program for expenses incurred in conducting a diagnostic breast examination and supplemental breast examination. b. The benefits shall be provided to the same extent as for any other medical condition under the contract, except that the contract shall not impose a cost-sharing requirement. c. As used in this section: "Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. "Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts. 11. This act shall take effect on the first day of the fourth month next following the date of enactment and shall apply to all contracts and policies that are delivered, issued, executed, or renewed or approved for issuance or renewal in this State on or after the effective date. STATEMENT This bill requires health insurance carriers (insurance companies, health, hospital, and medical service corporations, health maintenance organizations, and State and School Employees' Health Benefits Program contracts) to provide coverage for diagnostic and supplemental breast examinations without cost-sharing. Under the bill, "diagnostic breast examination" means a medically necessary and appropriate, in accordance with National Comprehensive Cancer Network Guidelines, examination of the breast (including, but not limited to, such an examination using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging) that is used to evaluate an abnormality: (1) seen or suspected from a screening examination for breast cancer; or (2) detected by another means of examination. Under the bill, "supplemental breast examination" means a medically necessary and appropriate, in accordance with National Comprehensive Cancer Network Guidelines, examination of the breast (including, but not limited to, such an examination using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging) that is: (1) used to screen for breast cancer when there is no abnormality seen or suspected; and (2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer (including heterogeneously or extremely dense breasts).
An Act concerning breast examinations and insurance coverage and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. 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 a diagnostic breast examination and supplemental breast examination.
b. These benefits shall be provided to the same extent as for any other sickness under the contract, except that the contract shall not impose a cost-sharing requirement.
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.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
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 a diagnostic breast examination and supplemental breast examination.
b. These benefits shall be provided to the same extent as for any other sickness under the contract, except that the contract shall not impose a cost-sharing requirement.
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.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
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 a diagnostic breast examination and supplemental breast examination.
b. These benefits shall be provided to the same extent as for any other sickness under the contract, except that the contract shall not impose a cost-sharing requirement.
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.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
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 a diagnostic breast examination and supplemental breast examination.
b. These benefits shall be provided to the same extent as for any other sickness under the policy, except that the policy shall not impose a cost-sharing requirement.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
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 a diagnostic breast examination and supplemental breast examination.
b. These benefits shall be provided to the same extent as for any other sickness under the policy, except that the policy shall not impose a cost-sharing requirement.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
6. 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 a diagnostic breast examination and supplemental breast examination.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan, except that the plan shall not impose a cost-sharing requirement.
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.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
7. 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 a diagnostic breast examination and supplemental breast examination.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan, except that the plan shall not impose a cost-sharing requirement.
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.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
8. 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 a diagnostic breast examination and supplemental breast examination.
b. These health care services shall be provided to the same extent as for any other sickness under the enrollee agreement, except that the agreement shall not impose a cost-sharing requirement.
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.
d. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
e. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
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 a diagnostic breast examination and supplemental breast examination.
b. The benefits shall be provided to the same extent as for any other medical condition under the contract, except that the contract shall not impose a cost-sharing requirement.
c. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
10. a. The School Employees' Health Benefits Commission shall provide benefits to each person covered under the School Employees' Health Benefits Program for expenses incurred in conducting a diagnostic breast examination and supplemental breast examination.
b. The benefits shall be provided to the same extent as for any other medical condition under the contract, except that the contract shall not impose a cost-sharing requirement.
c. As used in this section:
"Cost-sharing requirement" means a deductible, coinsurance, copayment, or any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.
"Diagnostic breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
"Supplemental breast examination" means a medically necessary and appropriate examination of the breast, in accordance with National Comprehensive Cancer Network Guidelines, including, but not limited to, examinations using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.
11. This act shall take effect on the first day of the fourth month next following the date of enactment and shall apply to all contracts and policies that are delivered, issued, executed, or renewed or approved for issuance or renewal in this State on or after the effective date.
STATEMENT
This bill requires health insurance carriers (insurance companies, health, hospital, and medical service corporations, health maintenance organizations, and State and School Employees' Health Benefits Program contracts) to provide coverage for diagnostic and supplemental breast examinations without cost-sharing.
Under the bill, "diagnostic breast examination" means a medically necessary and appropriate, in accordance with National Comprehensive Cancer Network Guidelines, examination of the breast (including, but not limited to, such an examination using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging) that is used to evaluate an abnormality:
(1) seen or suspected from a screening examination for breast cancer; or
(2) detected by another means of examination.
Under the bill, "supplemental breast examination" means a medically necessary and appropriate, in accordance with National Comprehensive Cancer Network Guidelines, examination of the breast (including, but not limited to, such an examination using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging) that is:
(1) used to screen for breast cancer when there is no abnormality seen or suspected; and
(2) based on personal or family medical history or additional factors that increase the individual's risk of breast cancer (including heterogeneously or extremely dense breasts).