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A1462
ASSEMBLY, No. 1462
STATE OF NEW JERSEY
222nd LEGISLATURE
�
PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION
Sponsored by:
Assemblyman ANTWAN L. MCCLELLAN
District 1 (Atlantic, Cape May and Cumberland)
Assemblywoman CAROL A. MURPHY
District 7 (Burlington)
Assemblyman BRIAN BERGEN
District 26 (Morris and Passaic)
Co-Sponsored by:
Assemblyman Simonsen, Assemblywoman Flynn and Assemblyman
Scharfenberger
SYNOPSIS
���� "Michelle's Law"; requires health benefit
plans to cover mammogram for an individual if recommended by health care
provider.
CURRENT VERSION OF TEXT
���� Introduced Pending Technical Review by Legislative
Counsel.
��
An Act
concerning health benefits for mammograms,
designated as Michelle�s Law, and amending P.L.1991, c.279 and P.L.2004, c.86.
����
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.� N
o group or individual hospital service corporation contract
providing hospital or medical expense benefits shall be delivered, issued,
executed, or renewed in this State or approved for issuance or renewal in this
State by the Commissioner of Banking and Insurance, on or after the effective
date of this act, unless the contract provides benefits to any subscriber or
other person covered thereunder for expenses incurred in conducting:
���� (1)��
one baseline
mammogram examination for women who are 40 years of age; 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
]
recommended
by
[
the woman's
]
a covered
person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.
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 additional screening and diagnostic testing.
���� b.��� These
benefits shall be provided to the same extent as for any other sickness under
the contract.
���� c.���� The
provisions of this section shall apply to all contracts in which the hospital
service corporation has reserved the right to change the premium.
(cf:
P.L.2013, c.196, s.1)
���� 2.��� Section 2 of P.L.1991,
c.279 (C.17:48A-7f) is amended to read as follows:
���� 2.��� a.� No group or
individual medical service corporation contract providing hospital or medical
expense benefits shall be delivered, issued, executed, or renewed in this State
or approved for issuance or renewal in this State by the Commissioner of
Banking and Insurance, on or after the effective date of this act, unless the
contract provides benefits to any subscriber or other person covered thereunder
for expenses incurred in conducting:
���� (1)��
one baseline mammogram examination for women who are
40 years of age; 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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider.
� 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
additional screening and diagnostic testing.
���� b.��� These benefits shall be
provided to the same extent as for any other sickness under the contract.
���� c.���� The provisions of this
section shall apply to all contracts in which the medical service corporation
has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.2)
���� 3.��� Section 3 of P.L.1991,
c.279 (C.17:48E-35.4) is amended to read as follows:
���� 3.��� a.� No group or
individual health service corporation contract providing hospital or medical
expense benefits shall be delivered, issued, executed, or renewed in this State
or approved for issuance or renewal in this State by the Commissioner of
Banking and Insurance, on or after the effective date of this act, unless the
contract provides benefits to any subscriber or other person covered thereunder
for expenses incurred in conducting:
���� (1)��
one baseline mammogram examination for women who are
40 years of age; 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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.� 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
additional screening and diagnostic testing.
���� b.��� These benefits shall be
provided to the same extent as for any other sickness under the contract.
���� c.���� The provisions of this
section shall apply to all contracts in which the health service corporation
has reserved the right to change the premium.
(cf: P.L.2013, c.196, s.3)
���� 4.��� Section 4 of P.L.1991,
c.279 (C17B:26-2.1e) is amended to read as follows:
���� 4.� a. �No individual health
insurance policy providing hospital or medical expense benefits shall be
delivered, issued, executed, or renewed in this State or approved for issuance
or renewal in this State by the Commissioner of Banking and Insurance, on or
after the effective date of this act, unless the policy provides benefits to
any named insured or other person covered thereunder for expenses incurred in
conducting:
���� (1)��
one baseline mammogram examination for women who are
40 years of age; 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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.� The coverage required
under this paragraph may be subject to utilization review, including periodic
review, by the insurer of the medical necessity of the additional screening and
diagnostic testing.
���� b.��� These benefits shall be
provided to the same extent as for any other sickness under the policy.�
���� c.���� The provisions of this
section shall apply to all policies in which the insurer has reserved the right
to change the premium.
(cf: P.L.2013, c.196, s.4)
���� 5.��� Section 5 of P.L.1991,
c.279 (C.17B:27:46.1f) is amended to read as follows:
���� 5.� a. �No group health
insurance policy providing hospital or medical expense benefits shall be
delivered, issued, executed, or renewed in this State or approved for issuance
or renewal in this State by the Commissioner of Banking and Insurance, on or
after the effective date of this act, unless the policy provides benefits to
any named insured or other person covered thereunder for expenses incurred in
conducting:
���� (1)��
one baseline mammogram examination for women who are
40 years of age; 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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.� The coverage required
under this paragraph may be subject to utilization review, including periodic
review, by the insurer of the medical necessity of the additional screening and
diagnostic testing.
���� b.��� These benefits shall be
provided to the same extent as for any other sickness under the policy.
���� c.���� The provisions of this
section shall apply to all policies in which the insurer has reserved the right
to change the premium.
(cf: P.L.2013, c.196, s.5)
���� 6.��� Section 6 of P.L.1991,
c.279 (C.26:2J-4.4) is amended to read as follows:
���� 6.� a. �Notwithstanding any
provision of law to the contrary, a certificate of authority to establish and
operate a health maintenance organization in this State shall not be issued or
continued by the Commissioner of Banking and Insurance on or after the effective
date of this act unless the health maintenance organization provides health
care services to any enrollee for the conduct of:
���� (1)��
one baseline mammogram examination for women who are
40 years of age; 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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.� 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
additional screening and diagnostic testing.
���� b.��� These health care
services shall be provided to the same extent as for any other sickness under
the enrollee agreement.
���� c.���� The provisions of this
section shall apply to all enrollee agreements in which the health maintenance
organization has reserved the right to change the schedule of charges.
(cf: P.L.2013, c.196, s.8)
���� 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 person covered thereunder for expenses incurred
in conducting:
���� (1)��
one baseline mammogram examination for women who are
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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.� The coverage required
under this paragraph may be subject to utilization review, including periodic
review, by the carrier of the medical necessity of the additional screening and
diagnostic testing.
���� b.��� The benefits shall be
provided to the same extent as for any other medical condition under the health
benefits plan.
���� c.���� The provisions of this
section shall apply to all health benefit plans in which the carrier has
reserved the right to change the premium.
(cf: P.L.2013, c.196, s.6)
���� 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 person covered thereunder for expenses incurred
in conducting:
���� (1)��
one baseline mammogram examination for women who are
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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider.
� The coverage required
under this paragraph may be subject to utilization review, including periodic
review, by the carrier of the medical necessity of the additional screening and
diagnostic testing.
���� b.��� The benefits shall be
provided to the same extent as for any other medical condition under the health
benefits plan.
���� c.���� The provisions of this
section shall apply to all health benefit plans in which the carrier has
reserved the right to change the premium.
(cf: P.L.2013, c.196, s.7)
���� 9.��� Section 9 of P.L.2004,
c.86 (C.52:14-17.29i) is amended to read as follows:
���� 9.��� a. �The State Health
Benefits Commission shall provide benefits to each person covered under the
State Health Benefits Program for expenses incurred in conducting:
���� (1)��
one baseline mammogram examination for women who are
40 years of age; 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
]
recommended
by
[
the woman's
]
a covered person�s
health care provider;
and
���� (2)�� an
ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional
mammography, or other additional testing of an entire breast or breasts, after
a
[
baseline
]
mammogram examination, if the mammogram demonstrates
extremely dense breast tissue, if the mammogram is abnormal within any degree
of breast density including not dense, moderately dense, heterogeneously dense,
or extremely dense breast tissue, or if the patient has additional risk factors
for breast cancer including but not limited to family history of breast cancer,
prior personal history of breast cancer, positive genetic testing, extremely
dense breast tissue based on the Breast Imaging Reporting and Data System
established by the American College of Radiology, or other indications as
determined by the patient's health care provider
.� The coverage required
under this paragraph may be subject to utilization review, including periodic
review, by the carrier of the medical necessity of the additional screening and
diagnostic testing.
���� b.��� The benefits shall be
provided to the same extent as for any other medical condition under the
contract.
(cf: P.L.2013, c.196, s.9)
���� 10.� This act shall take
effect immediately.
STATEMENT
���� This bill requires health
benefit plans to cover the cost of a mammogram if a health care provider
recommends the examination.�
���� Presently, health benefit
plans are only required to cover mammograms for women who are 40 and over or
women under the age of 40 if they have a family history of breast cancer or
other breast cancer related risk factor.� Health benefit plans must also cover
additional testing of an entire breast or breasts after a baseline mammogram
examination.� Under this bill, health benefit plans will be required to cover
the cost of a mammogram examination, and any additional testing after the
examination, if the health care provider of the subscriber or other person
covered under the plan recommends it.� Mammograms for women 40 and over will
still be covered under this bill.
���� This bill, named �Michelle�s
Law,� is in response to the tragic death of Michelle DeVita.� Michelle was a
38-year-old woman who lost her battle to breast cancer.� Under the requirements
of the current law, insurance was not required to provide her coverage for a
mammogram.