17:48E-35.6. Health service corporation, benefits for health promotion
5. a. Every health service corporation contract that provides hospital and medical expense benefits and 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 P.L.1999, c.339, shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services:
(1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level;
(2) For all persons 35 years of age or older, a glaucoma eye test every five years;
(3) For all persons 40 years of age or older, an annual stool examination for presence of blood;
(4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;
(5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 1 of P.L.1995, c.415 (C.17:48E-35.12);
(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 3 of P.L.1991, c.279 (C.17:48E-35.4);
(7) For all adults, recommended immunizations; and
(8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles.
Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the health service corporation shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.
b.Every individual or group health care contract offered for sale in this State by a health service corporation pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no health service corporation shall be required to provide payment for benefits for a left-sided colon examination in excess of $150.
c.The Commissioner of Banking and Insurance, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which the adjustment is made.
d.This section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the premium.
e.The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).
L.1993,c.327,s.5; amended 1999, c.339, s.3.
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Last modified: October 11, 2016