8. a. Notwithstanding any provision of this act or any other 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 Health and Senior Services on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee which include a health promotion program providing 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 5 of P.L.1995, c.415 (C.26:2J-4.12);
(6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 6 of P.L.1991, c.279 (C.26:2J-4.4);
(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 an enrollee to receive a different schedule of tests and services than that provided for under this subsection, the health maintenance organization shall provide coverage for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section.
b. A health maintenance organization shall not be required to offer services to enrollees set forth in subsection a. of this section for which the value exceeds: $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 value of a left-sided colon examination shall not be included in the above amount; however, no health maintenance organization shall be required to provide services to enrollees for a left-sided colon examination with a value in excess of $150.
c. The Commissioner of Health and Senior Services, 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 it is reported.
d. Nothing in this act shall be construed to require that a health maintenance organization take any actions which conflict with the health benefits, underwriting and rating standards established by the federal government pursuant to subchapter XI of Pub.L.93-222 (42 U.S.C. s.300e et seq.).
e. This section shall apply to all health maintenance organization contracts in which the right to change the enrollee charge has been reserved.
f. 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.8; amended 1999, c.339, s.6.
We hope you find our tools helpful, please visit www.thelegalassistant.com for further information on our other free legal tools and products including LPO compliant legal case management software.