S719

An Act requiring health insurance coverage for certain expenses incurred in connection with mastectomies, 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.1983, c.50 (C.17:48-6b) is amended to read as follows:

1. Every subscription certificate and group and individual contract providing hospital service benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of [this act] P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the cost of prostheses , and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any contract providing outpatient x-ray or radiation therapy, benefits for outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. [Such] These benefits shall be provided to the same extent as for any other sickness under the contract.

(cf: P.L.1997, c.75, s.1)

2. Section 1 of P.L.1983, c.51 (C.17:48A-7b) is amended to read as follows:

1. Every subscription certificate and group and individual contract providing medical service benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of [this act] P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses , and additionally, in the case of a mastectomy on one
breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any contract providing out-of-hospital x-ray or radiation therapy, benefits for out-of-hospital chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the out-of-hospital x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium. [Such] These benefits shall be provided to the same extent as for any other sickness under the contract.

(cf: P.L.1997, c.75, s.2)

3. Section 35 of P.L.1985, c.236 (C.17:48E-35) is amended to read as follows:

35. Every subscription certificate and group and individual contract providing health service coverage, delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the commissioner on or after the effective date of [this act] P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the cost of prostheses , and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any contract providing outpatient x-ray or radiation therapy, benefits for outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer, which shall be included as a part of the outpatient x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium. These benefits shall be provided to the same extent as for any other sickness under the contract.

(cf: P.L.1997, c.75, s.3)

4. Section 1 of P.L.1983, c.53 (C.17B:26-2.1a) is amended to read as follows:

1. Every health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of [this act] P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. [Such] These benefits shall be provided to the same extent as for any other sickness under the policy.

(cf: P.L.1997, c.75, s.4)

5. Section 1 of P.L.1983, c.52 (C.17B:27-46.1a) is amended to read as follows:

1. Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of [this act] P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses , and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any policy providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. [Such] These benefits shall be provided to the same extent as for any other sickness under the policy.

(cf: P.L.1997, c.75, s.5)

6. (New section) 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 by the Commissioner of Banking and Insurance on or after the effective date of P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any plan providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. These benefits shall be provided to the same extent as for any other sickness under the health benefits plan. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

7. (New section) 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 by the Commissioner of Banking and Insurance on or after the effective date of P.L. , c. (C. ) (pending before the Legislature as this bill), shall provide benefits, following a mastectomy on one or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any plan providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage. These benefits shall be provided to the same extent as for any other sickness under the health benefits plan. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

8. Section 6 of P.L.1997, c.75 (C.26:2J-4.14) is amended to read as follows:

6. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of [Health and Senior Services] Banking and Insurance on or after the effective date of [P.L.1997, c.75] P.L. , c. (C. ) (pending before the Legislature as this bill) unless the health maintenance organization provides health care services to any enrollee, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and prostheses , and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any contract for health care services providing outpatient x-ray or radiation therapy, outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy. The health care services shall be provided to the same extent as for any other medical condition under the contract for health care services. The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.

(cf: P.L.1997, c.75, s.6)

9. (New section) The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of P.L. , c. (C. ) (pending before the Legislature as this bill) that provides hospital or medical expense benefits, shall provide benefits, following a mastectomy on one or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any contract providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage.

10. (New section) The School Employees’ Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of P.L. , c. (C. ) (pending before the Legislature as this bill) that provides hospital or medical expense benefits, shall provide benefits, following a mastectomy on one or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses, and additionally, in the case of a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast when recommended by the health care provider to reduce any future occurrence of breast cancer; and, under any contract providing outpatient x-ray or radiation therapy, the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy coverage.

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

STATEMENT

This bill requires health insurers, including hospital, medical, and health service corporations, and individual and group commercial health insurers, health maintenance organizations, and health benefits plans or contracts which are issued or purchased pursuant to the New Jersey Individual Health Coverage Program, New Jersey Small Employer Health Benefits Program, State Health Benefits Program, and School Employees’ Health Benefits Program to provide coverage, following a mastectomy on one breast to treat breast cancer, for a prophylactic mastectomy on the remaining breast. This preventive procedure would only be covered when recommended by the health care provider to reduce any future occurrence of breast cancer.

In addition to the new coverage for prophylactic mastectomies, existing statutory coverage by health insurers and health maintenance organizations for certain other procedures related to mastectomies, including costs associated with all stages of breast reconstructive surgery following a mastectomy on one or both breasts, symmetry operations on the opposite breast, and the cost of prostheses, would also apply to health benefits plans or contracts which are issued or purchased pursuant to the New Jersey Individual Health Coverage Program, New Jersey Small Employer Health Benefits Program, State Health Benefits Program, and School Employees’ Health Benefits Program. Implementing such existing coverage with respect to these health benefits programs makes all statutorily mandated coverage for mastectomies and breast cancer treatment uniform across every applicable insurance coverage source.