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Bill

A 5195

Requires health insurance coverage for coronary artery calcium screening under certain circumstances.

2026-2027 Regular Session

The bill requires broad health insurance plans to cover coronary artery calcium screening for adults 45+ or at intermediate risk every five years, with more frequent coverage if me

Introduced, Referred to Assembly Financial Institutions and Insurance Committee
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Bill Summary · A 5195

Bill overview

A 5195, 222nd Legislature (New Jersey) requires health insurance coverage for coronary artery calcium (CAC) screening under specified circumstances. The measure applies across a broad range of health coverage categories (commercial plans, state employee programs, school employee programs, small employers, etc.) and mandates CAC screening benefits for eligible individuals every five years (with medical justification for more frequent screening).

Purpose and intent

  • Expand health insurance coverage to include coronary artery calcium screening as a covered benefit.
  • Ensure individuals at least 45 years old or those at intermediate risk for coronary heart disease have access to CAC screening without cost barriers under a wide set of health plans.
  • Align coverage with evidence-based practices for cardiovascular risk assessment, using widely used algorithms (including pooled cohort equations) to determine intermediate risk.

Key provisions and changes

  • Coverage mandates by plan type:
    • Hospital Service Corporations (commercial insurers with hospital/medical coverage)
    • Medical Service Corporations
    • Health Service Corporations
    • Individual Policies
    • Group Policies
    • Enrollee Agreements (e.g., HMOs)
    • Health Benefits Plans (including state risk pools)
    • Small Employer Health Benefits Plans
    • State Health Benefits Commission contracts
    • School Employees’ Health Benefits Commission
  • Eligibility for CAC screening coverage:
    • Aged 45 years or older, or
    • At intermediate risk of coronary heart disease as determined by a health care provider using an evidence-based risk score (including pooled cohort equations).
  • Frequency:
    • Benefits must be provided every five years.
    • If a health care provider determines more frequent screening is beneficial due to an underlying condition, coverage must be provided more frequently.
  • Scope of benefits:
    • CAC screening expenses must be covered to the same extent as any other medical condition under the relevant contract.
  • Applicability:
    • In contracts where the insurer or administrator reserves the right to change premiums, the CAC coverage requirement applies.
    • The act explicitly covers multiple state-regulated and private plan types, including those administered for state programs (State Health Benefits, School Employees’ Health Benefits) and enrollment-based plans (enrollee agreements, health maintenance organizations).
  • Effective date:
    • Immediate effect; applies to policies and contracts delivered, issued, executed, or renewed on or after the act’s effective date.

Who would be affected

  • Insurance carriers and health service organizations offering plans in New Jersey (including commercial insurers, medical/hospital service, and health maintenance organizations).
  • Policyholders, enrollees, and subscribers aged 45+ or those with intermediate cardiovascular risk.
  • State programs and school employee health benefit programs purchasing contracts after the act’s effective date.
  • State Health Benefits Commission and School Employees’ Health Benefits Commission in contracting for coverage.

Procedural and timeline aspects

  • The act is effective immediately and applies to policies/contracts delivered, issued, executed, or renewed on or after the effective date.
  • Introduced June 4, 2026; referred to Assembly Financial Institutions and Insurance Committee.
  • No phase-in period specified; coverage appears required for applicable contracts moving forward from the effective date.

Potential impact

  • Improved access to CAC screening for adults at risk, potentially enabling earlier detection and risk stratification for coronary disease.
  • Increased insurance spending on preventive cardiovascular screening, with a defined five-year cadence (potentially higher costs if more frequent screening is medically indicated).
  • Reduced variability in CAC screening coverage across different plan types, promoting uniform application of a preventive service aligned with evidence-based risk assessment.

Compiled from official sources — confirm details with the bill’s official record.

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