Requires health insurance coverage for coronary artery calcium screening under certain circumstances.
Assembly Bill 5195 requires a broad range of New Jersey health coverage arrangements to pay for coronary artery calcium (CAC) screening under specified conditions. The mandate applies to hospital service corporations, medical service corporations, health service corporations, individual and group health insurance policies, individual and small employer health benefits plans, health maintenance organization enrollee agreements, and the State Health Benefits Program and School Employees’ Health Benefits Program. Coverage must be provided for a person who is at least 45 years old, or who is determined by a health care provider to have an intermediate risk of coronary heart disease based on an evidence-based cardiovascular risk algorithm, including the pooled cohort equation.
The bill requires the screening benefit to be available every five years, unless a provider determines more frequent screening is medically necessary because of an underlying condition. The screening must be covered to the same extent as other medical conditions under the applicable contract or plan. The bill applies to policies, contracts, and plans issued, renewed, or otherwise in effect on or after the effective date, and it takes effect immediately.
This bill would add a new mandated health insurance benefit in New Jersey for coronary artery calcium screening, expanding coverage obligations across the commercial market and state employee health plans. It would affect insurers, health service corporations, hospital service corporations, medical service corporations, HMOs, and entities administering public employee benefits, requiring them to reimburse the cost of CAC screening for eligible enrollees and subscribers. The practical effect is to make preventive cardiovascular risk assessment more accessible for middle-aged adults and those with intermediate heart disease risk, while potentially increasing premium and plan costs for carriers and public benefit programs.
Based on the bill text and the absence of recorded committee testimony or votes in the provided materials, the overall sentiment appears supportive and preventive in nature. The legislation is framed as a health coverage expansion aimed at earlier detection of coronary disease risk, and its structure suggests a policy preference for standardized access to screening rather than discretionary coverage. No formal opposition, amendments, or recorded roll-call concerns are included in the available context.
The main potential points of contention are likely to be cost and mandate scope. Insurers and public benefit administrators may be concerned about the financial impact of requiring coverage for a screening test across multiple plan types, especially because the bill applies broadly and includes state employee programs. Another possible issue is medical-necessity standards: the bill relies on a provider’s determination of intermediate risk using an evidence-based algorithm, which could raise questions about utilization, consistency, and whether the five-year interval is appropriate in all cases. No specific opposing stakeholders or objections are identified in the provided record.