Sponsored by:
Assemblyman TROY SINGLETON
District 7 (Burlington)
SYNOPSIS
Requires insurers to cover comprehensive ultrasound breast screening or other screening services if a mammogram demonstrates certain dense breast tissue, and requires certain mammogram reports to contain information on breast density.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning breast cancer screening, amending P.L.1991, c.279 and P.L.2004, c.86, and supplementing Title 26 of the Revised Statutes.
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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the hospital service corporation, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the hospital service corporation to have overutilized the coverage required under this paragraph.
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.2004, c.86, 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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the medical service corporation, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the medical service corporation of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the medical service corporation to have overutilized the coverage required under this paragraph.
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.2004, c.86, 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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the health service corporation, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the health service corporation of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the health service corporation to have overutilized the coverage required under this paragraph.
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.2004, c.86, 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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the insurer, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the insurer to have overutilized the coverage required under this paragraph.
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.2004, c.86, 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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the insurer, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the insurer to have overutilized the coverage required under this paragraph.
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.2004, c.86, s.5)
6. 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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the health maintenance organization, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the health maintenance organization of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the health maintenance organization to have overutilized the coverage required under this paragraph.
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.2012, c.17, s.263)
7. 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 woman covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the carrier, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the carrier to have overutilized the coverage required under this paragraph.
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.2004, c.86, s.7)
8. 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 woman covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the carrier, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the carrier to have overutilized the coverage required under this paragraph.
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.2004, c.86, 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 at least 35 but less than 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has 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; and
(2) comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the carrier, of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the carrier of the medical necessity of the comprehensive ultrasound screenings if the provider has been determined by the carrier to have overutilized the coverage required under this paragraph.
b. The benefits shall be provided to the same extent as for any other medical condition under the contract.
(cf: P.L.2004, c.86, s.9)
10. (New section) Every provider of mammography services shall, if a patient's mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, include the following information, at a minimum, in any mammography report sent, pursuant to the federal Mammography Quality Standards Act, 42 U.S.C. s.263b, to the patient and the patient's physician: "Your mammogram shows that your breast tissue is dense as determined by the Breast Imaging Reporting and Data System established by the American College of Radiology. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram, and may also be associated with a risk factor for breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician."
11. The Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-14 1 et seq.), shall adopt such rules and regulations as are necessary to effectuate the purposes of section 10 of P.L. , c. (C. ) (pending before the Legislature as this bill).
12. This act shall take effect on the first day of the fourth month next following the date of enactment. Sections 1 through 9 of this act 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. The Commissioner of Banking and Insurance and the Commissioner of Health take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.
STATEMENT
This bill requires health insurers to cover comprehensive ultrasound breast screening if a mammogram demonstrates dense breast tissue, and also requires mammogram reports to contain information on breast density.
Specifically, the bill provides that, in addition to the existing health benefits coverage requirement for mammograms under State law, health insurers are to provide health benefits coverage for comprehensive ultrasound screening, or other screening services deemed to be medically acceptable by the American Cancer Society and ordered by the treating physician or advanced practice nurse and approved by the insurer, of an entire breast or breasts if a mammogram demonstrates heterogeneously or extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by a woman's physician or advanced practice nurse. This coverage may be subject to review of the medical necessity of the comprehensive ultrasound screening if the provider has been determined by the insurer to have overutilized the service.
The insurance provisions of the bill apply to: health, hospital, and medical service corporations; commercial, individual, and group health insurers; health maintenance organizations; health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs; and the State Health Benefits Program (which by law requires coverage under the School Employees' Health Benefits Program as well).
In addition, the bill requires that providers of mammography services must, if a patient's mammogram demonstrates heterogeneously or extremely dense breast tissue, include the following information, at a minimum, in the mammography report sent to the patient and the patient's physician (required by federal law): "Your mammogram shows that your breast tissue is dense as determined by the Breast Imaging Reporting and Data System established by the American College of Radiology. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram, and may also be associated with a risk factor for breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician."
The bill takes effect on the first day of the fourth month following enactment of the bill. The insurance provisions apply to all health insurance 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.
The need for this bill is predicated on the following facts:
· Two-thirds of pre-menopausal and one fourth of post-menopausal women have dense breast tissue, and many do not even know it;
· Cancer is five times more likely in women with extremely dense breasts;
· A mammogram will detect only about 48 percent of tumors in women with dense breast tissue, and so the rest will elude early detection;
· Breast density is one of the strongest predictors of the failure of mammography screening to detect cancer;
· Cancer recurrence is four times more likely in women with dense breasts; and
· A May 2010 national survey conducted by Harris Interactive found that 95 percent of women ages 40 and older did not know their breast density, and nearly 90 percent did not know that breast density increases the risk of developing breast cancer.