An Act concerning health benefits coverage for certain treatments of sickle cell anemia 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 hospital service corporation contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the covered person's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the hospital service corporation contract provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the hospital service corporation contract provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the contract.

This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.

2. A medical service corporation contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the covered person's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the medical service corporation contract provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the medical service corporation contract provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the contract.

This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.

3. A health service corporation contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the covered person's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the health service corporation contract provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the health service corporation contract provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the contract.

This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.

4. A prepaid prescription service organization contract for prescription drug benefits that is delivered, issued, executed or renewed in this State pursuant to P.L.1997, c.380 (C.17:48F-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for any prescription drug expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the enrollee's physician.

The benefits shall be provided to the same extent as for any other prescription drug under the contract.

This section shall apply to those prepaid prescription contracts in which the prepaid prescription service organization has reserved the right to change the premium.

5. An individual health insurance policy that is delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the insured's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the policy provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the policy provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the policy.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

6. A group health insurance policy that is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the insured's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the policy provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the policy provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the policy.

This section shall apply to those policies in which the insurer has reserved the right to change the premium.

7. An 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 by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the covered person's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the health benefits plan provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the health benefits plan provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

8. A 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 by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the covered person's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the health benefits plan provides hospital and medical expense benefits; and

b. any prescription drug treatment of sickle cell anemia, if the health benefits plan provides prescription drug benefits.

The benefits shall be provided to the same extent as for any other condition under the health benefits plan.

This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.

9. A health maintenance organization contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the treatment of sickle cell anemia that is determined to be medically necessary by the enrollee's physician by:

a. dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when performed by an institution approved by the National Heart, Lung, and Blood Institute or pursuant to protocols consistent with the guidelines of any nationally recognized professional medical specialty academy or organization, if the health maintenance organization contract provides health care services; and

b. any prescription drug treatment of sickle cell anemia, if the health maintenance organization contract provides health care services for prescription drugs.

The health care services shall be provided to the same extent as for any other condition under the contract.

This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved.

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

STATEMENT

This bill requires hospital, medical and health service corporations, individual, small employer and large group insurers, health maintenance organizations and prepaid prescription service organizations to cover certain medically necessary treatments for sickle cell anemia.

Under the bill, insurers that provide prescription drug benefits must cover any prescription drug expenses incurred in the treatment of sickle cell anemia. In addition, insurers, other than prepaid prescription organizations, must cover any expenses for treatments using dose-intensive chemotherapy/bone marrow transplantation and umbilical cord blood transplantation when those treatments are performed by certain health care facilities or performed pursuant to guidelines approved by certain medical organizations.