Bill Text: IN SB0195 | 2012 | Regular Session | Introduced
Bill Title: Insurance coverage for diagnostic mammograms.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2012-01-19 - Committee report: do pass, reassigned to Committee on Appropriations [SB0195 Detail]
Download: Indiana-2012-SB0195-Introduced.html
Citations Affected: IC 5-10-8-7.2; IC 27-8-14; IC 27-13-7-15.3.
Synopsis: Insurance coverage for diagnostic mammograms. Prohibits
dollar limits, deductibles, copayments, or coinsurance for certain
diagnostic mammograms under a state employee health plan, a policy
of accident and sickness insurance, or a health maintenance
organization contract, that are less favorable than those allowed for
breast cancer screening mammography. Requires the department of
state personnel to request written guidance from the federal Internal
Revenue Service concerning the status of an annual diagnostic
mammogram as "preventive care" under Section 223(c)(2) of the
Internal Revenue Code (for purposes of determining whether a
deductible under a high deductible health plan is not required).
Effective: Upon passage; July 1, 2012.
January 4, 2012, read first time and referred to Committee on Health and Provider
Services.
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana Constitution) is being amended, the text of the existing provision will appear in this style type, additions will appear in this style type, and deletions will appear in
Additions: Whenever a new statutory provision is being enacted (or a new constitutional provision adopted), the text of the new provision will appear in this style type. Also, the word NEW will appear in that style type in the introductory clause of each SECTION that adds a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
(1) Breast cancer screening mammography.
(2) Surgical breast biopsy.
(3) Pathologic examination and interpretation.
(b) As used in this section, "breast cancer outpatient treatment services" means procedures that are intended to treat cancer of the human breast and that are delivered on an outpatient basis. The term includes the following:
(1) Chemotherapy.
(2) Hormonal therapy.
(3) Radiation therapy.
(4) Surgery.
(5) Other outpatient cancer treatment services prescribed by a physician.
(6) Medical follow-up services related to the procedures set forth in subdivisions (1) through (5).
(c) As used in this section, "breast cancer rehabilitative services" means procedures that are intended to improve the results of or to ameliorate the debilitating consequences of the treatment of breast cancer and that are delivered on an inpatient or outpatient basis. The term includes the following:
(1) Physical therapy.
(2) Psychological and social support services.
(3) Reconstructive plastic surgery.
(d) As used in this section, "breast cancer screening mammography" means a standard, two (2) view per breast, low-dose radiographic examination of the breasts that is:
(1) furnished to an asymptomatic woman; and
(2) performed by a mammography services provider using equipment designed by the manufacturer for and dedicated specifically to mammography in order to detect unsuspected breast cancer.
The term includes the interpretation of the results of a breast cancer screening mammography by a physician.
(e) As used in this section, "covered individual" means a female individual who is:
(1) covered under a self-insurance program established under section 7(b) of this chapter to provide group health coverage; or
(2) entitled to services under a contract with a health maintenance organization (as defined in IC 27-13-1-19) that is entered into or renewed under section 7(c) of this chapter.
(f) As used in this section, "diagnostic mammogram" means a mammogram furnished to a covered individual who has a:
(1) personal history of breast cancer; or
(2) breast abnormality that is suspicious for breast cancer and requires mammography for diagnostic evaluation.
The term includes the interpretation of the results of a diagnostic mammogram by a physician.
(1) has been accredited by the American College of Radiology;
(2) meets equivalent guidelines established by the state department of health; or
(3) is certified by the federal Department of Health and Human
Services for participation in the Medicare program (42 U.S.C.
1395 et seq.).
(g) (h) As used in this section, "woman at risk" means a woman who
meets at least one (1) of the following descriptions:
(1) A woman who has a personal history of breast cancer.
(2) A woman who has a personal history of breast disease that
was proven benign by biopsy.
(3) A woman whose mother, sister, or daughter has had breast
cancer.
(4) A woman who is at least thirty (30) years of age and has not
given birth.
(h) (i) A self-insurance program established under section 7(b) of
this chapter to provide health care coverage must provide covered
individuals with coverage for breast cancer diagnostic services, breast
cancer outpatient treatment services, and breast cancer rehabilitative
services. The coverage must provide reimbursement for breast cancer
screening mammography at a level at least as high as:
(1) the limitation on payment for screening mammography
services established in 42 CFR 405.534(b)(3) according to the
Medicare Economic Index at the time the breast cancer screening
mammography is performed; or
(2) the rate negotiated by a contract provider according to the
provisions of the insurance policy;
whichever is lower. The costs of the coverage required by this
subsection may be paid by the state or by the employee or by a
combination of the state and the employee.
(i) (j) A contract with a health maintenance organization that is
entered into or renewed under section 7(c) of this chapter must provide
covered individuals with breast cancer diagnostic services, breast
cancer outpatient treatment services, and breast cancer rehabilitative
services.
(j) (k) The coverage required by subsection (h) (i) and services
required by subsection (i) (j) may not be subject to dollar limits,
deductibles, or coinsurance provisions that are less favorable to
covered individuals than the dollar limits, deductibles, or coinsurance
provisions applying to physical illness generally under the
self-insurance program or contract with a health maintenance
organization.
(k) (l) The coverage for breast cancer diagnostic services required
by subsection (h) (i) and the breast cancer diagnostic services required
by subsection (i) (j) must include the following:
(1) In the case of a covered individual who is at least thirty-five
(35) years of age but less than forty (40) years of age, at least one
(1) baseline breast cancer screening mammography performed
upon the individual before she becomes forty (40) years of age.
(2) In the case of a covered individual who is:
(A) less than forty (40) years of age; and
(B) a woman at risk;
at least one (1) breast cancer screening mammography performed
upon the covered individual every year.
(3) In the case of a covered individual who is at least forty (40)
years of age, at least one (1) breast cancer screening
mammography performed upon the individual every year.
(4) Any additional mammography views that are required for
proper evaluation.
(5) Ultrasound services, if determined medically necessary by the
physician treating the covered individual.
(l) (m) The coverage for breast cancer diagnostic services required
by subsection (h) (i) and the breast cancer diagnostic services required
by subsection (i) (j) shall be provided in addition to any benefits
specifically provided for x-rays, laboratory testing, or wellness
examinations.
(n) Except as provided in subsection (o), the coverage provided
by a:
(1) self-insurance program established under section 7(b) of
this chapter to provide health care coverage; or
(2) contract with a health maintenance organization that is
entered into or renewed under section 7(c) of this chapter;
for a diagnostic mammogram that is ordered one (1) time per year
in conjunction with an annual physical examination may not be
subject to dollar limits, deductibles, copayments, or coinsurance
provisions that are less favorable to a covered individual than the
dollar limits, deductibles, copayments, or coinsurance provisions
that apply to breast cancer screening mammography under the
self-insurance program or contract with a health maintenance
organization.
(o) Subsection (n) does not apply to a:
(1) self-insurance program established under section 7(b) of
this chapter to provide health care coverage; or
(2) contract with a health maintenance organization that is
entered into or renewed under section 7(c) of this chapter;
that is a high deductible health plan if the federal Internal Revenue
Service does not determine that a diagnostic mammogram that is
ordered one (1) time per year in conjunction with an annual
physical examination is considered to be preventive care for which
a deductible under a high deductible health plan is not required by
26 U.S.C. 223(c)(2).
(1) personal history of breast cancer; or
(2) breast abnormality that is suspicious for breast cancer and requires mammography for diagnostic evaluation.
(b) The term includes the interpretation of the results of a diagnostic mammogram by a physician.
(b) Subsection (a) does not apply to an accident and sickness policy that is a high deductible health plan if the federal Internal Revenue Service does not determine that a diagnostic mammogram that is ordered one (1) time per year in conjunction with an annual physical examination is considered to be preventive care for which a deductible under a high deductible health plan is not required by 26 U.S.C. 223(c)(2).
(b) As used in this section, "diagnostic mammogram" means a mammogram furnished to an enrollee who has a:
(1) personal history of breast cancer; or
(2) breast abnormality that is suspicious for breast cancer and requires mammography for diagnostic evaluation.
The term includes the interpretation of the results of a diagnostic mammogram by a physician.
forth in IC 27-8-14-5.
(c) (d) Except as provided in subsection (g), (h), a health
maintenance organization issued a certificate of authority in Indiana
shall provide breast cancer screening mammography as a covered
service under every group contract that provides coverage for basic
health care services.
(d) (e) Except as provided in subsection (g), (h), the coverage that
a health maintenance organization must provide under this section must
include the following:
(1) If the enrollee is at least thirty-five (35) years of age but less
than forty (40) years of age and a female, coverage for at least one
(1) baseline breast cancer screening mammography performed
upon the enrollee before the enrollee becomes forty (40) years of
age.
(2) If the enrollee is less than forty (40) years of age and a woman
at risk, one (1) breast cancer screening mammography performed
upon the enrollee every year.
(3) If the enrollee is at least forty (40) years of age and a female,
one (1) breast cancer screening mammography performed upon
the enrollee every year.
(4) Any additional mammography views that are required for
proper evaluation.
(5) Ultrasound services, if determined medically necessary by the
physician treating the enrollee.
(e) (f) Except as provided in subsection (g), (h), the coverage that
a health maintenance organization must provide under this section may
not be subject to a contract provision that is less favorable to an
enrollee or a subscriber than contract provisions applying to physical
illness generally under the health maintenance organization contract.
(f) (g) Except as provided in subsection (g), (h), the coverage that
a health maintenance organization must provide under this section is
in addition to services specifically provided for x-rays, laboratory
testing, or wellness examinations.
(g) (h) In the case of coverage that is not employer based, the health
maintenance organization must offer to provide the coverage described
in subsections (c) (d) through (f). (g).
(i) To the extent allowed by federal law, the coverage provided
under an individual contract or a group contract for a diagnostic
mammogram that is ordered one (1) time per year in conjunction
with an annual physical examination may not be subject to a
contract provision that is less favorable to an enrollee than the
contract provisions that apply to breast cancer screening
mammography under the individual contract or group contract.
(b) This SECTION expires December 31, 2012.
(b) IC 27-8-14, as amended by this act, applies to an accident and sickness insurance policy that is issued, delivered, amended, or renewed after June 30, 2012.
(c) IC 27-13-7-15.3, as amended by this act, applies to an individual contract or a group contract that is entered into, delivered, amended, or renewed after June 30, 2012.
(d) This SECTION expires July 1, 2014.
