S T A T E O F N E W Y O R K ________________________________________________________________________ 8319 2013-2014 Regular Sessions I N A S S E M B L Y December 18, 2013 ___________ Introduced by M. of A. JAFFEE -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to authorizing coverage for mammography and other imaging screening for occult breast cancer and to provide notification of dense breast tissue results to the patient's physician THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. Subparagraphs (A), (C) and (D) of paragraph 11 of 2 subsection (i) of section 3216 of the insurance law, as amended by chap- 3 ter 219 of the laws of 2011, are amended to read as follows: 4 (A) Every policy that provides coverage for hospital, surgical or 5 medical care shall provide the following coverage for mammography AND 6 OTHER IMAGING screening for occult breast cancer: 7 (i) upon the recommendation of a physician, a mammogram at any age for 8 covered persons having a prior history of breast cancer or who have a 9 first degree relative with a prior history of breast cancer; 10 (ii) a single baseline mammogram for covered persons aged thirty-five 11 through thirty-nine, inclusive; [and] 12 (iii) an annual mammogram for covered persons aged forty and older[.]; 13 AND 14 (IV) UPON RECOMMENDATION OF A PHYSICIAN, SUPPLEMENTAL SCREENING FOR A 15 COVERED PERSON USING OTHER IMAGING MODALITIES AS DEEMED APPROPRIATE BY 16 THE AMERICAN COLLEGE OF RADIOLOGY OR THE AMERICAN CANCER SOCIETY OF AN 17 ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS IF: 18 (A) A MAMMOGRAM PERFORMED PURSUANT TO THIS SUBPARAGRAPH DEMONSTRATES 19 THAT THE COVERED PERSON HAS DENSE BREAST TISSUE; OR 20 (B) A COVERED PERSON IS BELIEVED TO BE AT INCREASED RISK FOR BREAST 21 CANCER DUE TO FAMILY HISTORY OR PRIOR PERSONAL HISTORY OF BREAST CANCER, 22 POSITIVE GENETIC TESTING OR OTHER INDICATIONS AS DETERMINED BY A PHYSI- 23 CIAN. EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD13128-01-3 A. 8319 2 1 FOR THE PURPOSES OF THIS SUBPARAGRAPH DENSE BREAST TISSUE SHALL MEAN 2 HETEROGENEOUSLY DENSE OR EXTREMELY DENSE TISSUE AS DEFINED IN NATIONALLY 3 RECOGNIZED GUIDELINES OR SYSTEMS FOR BREAST IMAGING REPORTING OF MAMMOG- 4 RAPHY SCREENING, INCLUDING, BUT NOT LIMITED TO, THE BREAST IMAGING 5 REPORTING AND DATA SYSTEM OF THE AMERICAN COLLEGE OF RADIOLOGY, AND ANY 6 EQUIVALENT NEW TERMS, AS SUCH GUIDELINES OR SYSTEMS ARE UPDATED. 7 (C) (I) For purposes of subparagraphs (A) and (B) of this paragraph, 8 mammography screening means an X-ray examination of the breast using 9 dedicated equipment, including X-ray tube, filter, compression device, 10 screens, films and cassettes, with an average glandular radiation dose 11 less than 0.5 rem per view per breast. 12 (II) FOR PURPOSES OF SUBPARAGRAPHS (A) AND (B) OF THIS PARAGRAPH, 13 IMAGING MODALITIES ARE MODALITIES USED TO SCREEN FOR, OR DIAGNOSE, 14 OCCULT BREAST CANCER. 15 (D) In addition to subparagraph (A), (B) or (C) of this paragraph, 16 every policy that provides coverage for hospital, surgical or medical 17 care, except for a grandfathered health plan under subparagraph (E) of 18 this paragraph, shall provide coverage for the following mammography 19 screening services AND FOR THE FOLLOWING COMPREHENSIVE ULTRASOUND 20 SCREENINGS OF AN ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS, and such 21 coverage shall not be subject to annual deductibles or coinsurance: 22 (i) evidence-based items or services for mammography that have in 23 effect a rating of 'A' or 'B' in the current recommendations of the 24 United States preventive services task force; [and] 25 (ii) with respect to women, such additional preventive care and 26 screenings for mammography not described in item (i) of this subpara- 27 graph and as provided for in comprehensive guidelines supported by the 28 health resources and services administration[.]; AND 29 (III) COMPREHENSIVE ULTRASOUND SCREENINGS AS LONG AS DEEMED APPROPRI- 30 ATE BY THE AMERICAN COLLEGE OF RADIOLOGY OR THE AMERICAN CANCER SOCIETY 31 OF AN ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS IF: 32 (A) A MAMMOGRAM DEMONSTRATES THAT A WOMAN HAS DENSE BREAST TISSUE; OR 33 (B) A WOMAN IS BELIEVED TO BE AT INCREASED RISK FOR BREAST CANCER DUE 34 TO FAMILY HISTORY OR PRIOR PERSONAL HISTORY OF BREAST CANCER, POSITIVE 35 GENETIC TESTING OR OTHER INDICATIONS AS DETERMINED BY A PHYSICIAN. 36 FOR THE PURPOSES OF THIS SUBPARAGRAPH DENSE BREAST TISSUE SHALL MEAN 37 HETEROGENEOUSLY DENSE OR EXTREMELY DENSE TISSUE AS DEFINED IN NATIONALLY 38 RECOGNIZED GUIDELINES OR SYSTEMS FOR BREAST IMAGING REPORTING OF MAMMOG- 39 RAPHY SCREENING, INCLUDING, BUT NOT LIMITED TO, THE BREAST IMAGING 40 REPORTING AND DATA SYSTEM OF THE AMERICAN COLLEGE OF RADIOLOGY, AND ANY 41 EQUIVALENT NEW TERMS, AS SUCH GUIDELINES OR SYSTEMS ARE UPDATED. 42 S 2. Subparagraphs (A), (C) and (D) of paragraph 11 of subsection (1) 43 of section 3221 of the insurance law, as amended by chapter 219 of the 44 laws of 2011, are amended to read as follows: 45 (A) Every insurer delivering a group or blanket policy or issuing a 46 group or blanket policy for delivery in this state that provides cover- 47 age for hospital, surgical or medical care shall provide the following 48 coverage for mammography AND OTHER IMAGING screening for occult breast 49 cancer: 50 (i) upon the recommendation of a physician, a mammogram at any age for 51 covered persons having a prior history of breast cancer or who have a 52 first degree relative with a prior history of breast cancer; 53 (ii) a single baseline mammogram for covered persons aged thirty-five 54 through thirty-nine, inclusive; [and] 55 (iii) an annual mammogram for covered persons aged forty and older[.]; 56 AND A. 8319 3 1 (IV) UPON RECOMMENDATION OF A PHYSICIAN, SUPPLEMENTAL SCREENING FOR A 2 COVERED PERSON USING OTHER IMAGING MODALITIES AS DEEMED APPROPRIATE BY 3 THE AMERICAN COLLEGE OF RADIOLOGY OR THE AMERICAN CANCER SOCIETY OF AN 4 ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS IF: 5 (A) A MAMMOGRAM PERFORMED PURSUANT TO THIS SUBPARAGRAPH DEMONSTRATES 6 THAT THE COVERED PERSON HAS DENSE BREAST TISSUE; OR, 7 (B) A COVERED PERSON IS BELIEVED TO BE AT INCREASED RISK FOR BREAST 8 CANCER DUE TO FAMILY HISTORY OR PRIOR PERSONAL HISTORY OF BREAST CANCER, 9 POSITIVE GENETIC TESTING OR OTHER INDICATIONS AS DETERMINED BY A PHYSI- 10 CIAN. 11 FOR THE PURPOSES OF THIS SUBPARAGRAPH DENSE BREAST TISSUE SHALL MEAN 12 HETEROGENEOUSLY DENSE OR EXTREMELY DENSE TISSUE AS DEFINED IN NATIONALLY 13 RECOGNIZED GUIDELINES OR SYSTEMS FOR BREAST IMAGING REPORTING OF MAMMOG- 14 RAPHY SCREENING, INCLUDING, BUT NOT LIMITED TO, THE BREAST IMAGING 15 REPORTING AND DATA SYSTEM OF THE AMERICAN COLLEGE OF RADIOLOGY, AND ANY 16 EQUIVALENT NEW TERMS, AS SUCH GUIDELINES OR SYSTEMS ARE UPDATED. 17 (C) (I) For purposes of subparagraphs (A) and (B) of this paragraph, 18 mammography screening means an X-ray examination of the breast using 19 dedicated equipment, including X-ray tube, filter, compression device, 20 screens, films and cassettes, with an average glandular radiation dose 21 less than 0.5 rem per view per breast. 22 (II) FOR PURPOSES OF SUBPARAGRAPHS (A) AND (B) OF THIS PARAGRAPH, 23 IMAGING MODALITIES ARE MODALITIES USED TO SCREEN FOR, OR DIAGNOSE, 24 OCCULT BREAST CANCER. 25 (D) In addition to subparagraph (A), (B) or (C) of this paragraph, 26 every group or blanket policy that provides coverage for hospital, 27 surgical or medical care, except for a grandfathered health plan under 28 subparagraph (E) of this paragraph, shall provide coverage for the 29 following mammography screening services AND FOR COMPREHENSIVE ULTRA- 30 SOUND SCREENINGS OF AN ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS, 31 and such coverage shall not be subject to annual deductibles or coinsu- 32 rance: 33 (i) evidence-based items or services for mammography that have in 34 effect a rating of 'A' or 'B' in the current recommendations of the 35 United States preventive services task force; [and] 36 (ii) with respect to women, such additional preventive care and 37 screenings for mammography not described in item (i) of this subpara- 38 graph and as provided for in comprehensive guidelines supported by the 39 health resources and services administration[.]; AND 40 (III) COMPREHENSIVE ULTRASOUND SCREENINGS AS LONG AS DEEMED APPROPRI- 41 ATE BY THE AMERICAN COLLEGE OF RADIOLOGY OR THE AMERICAN CANCER SOCIETY 42 OF AN ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS IF: 43 (A) A MAMMOGRAM DEMONSTRATES THAT A WOMAN HAS DENSE BREAST TISSUE; OR 44 (B) A WOMAN IS BELIEVED TO BE AT INCREASED RISK FOR BREAST CANCER DUE 45 TO FAMILY HISTORY OR PRIOR PERSONAL HISTORY OF BREAST CANCER, POSITIVE 46 GENETIC TESTING OR OTHER INDICATIONS AS DETERMINED BY A PHYSICIAN. 47 FOR THE PURPOSES OF THIS SUBPARAGRAPH DENSE BREAST TISSUE SHALL MEAN 48 HETEROGENEOUSLY DENSE OR EXTREMELY DENSE TISSUE AS DEFINED IN NATIONALLY 49 RECOGNIZED GUIDELINES OR SYSTEMS FOR BREAST IMAGING REPORTING OF MAMMOG- 50 RAPHY SCREENING, INCLUDING, BUT NOT LIMITED TO, THE BREAST IMAGING 51 REPORTING AND DATA SYSTEM OF THE AMERICAN COLLEGE OF RADIOLOGY, AND ANY 52 EQUIVALENT NEW TERMS, AS SUCH GUIDELINES OR SYSTEMS ARE UPDATED. 53 S 3. Subsection (p) of section 4303 of the insurance law, as amended 54 by chapter 219 of the laws of 2011, is amended to read as follows: 55 (p) (1) A medical expense indemnity corporation, a hospital service 56 corporation or a health service corporation that provides coverage for A. 8319 4 1 hospital, surgical or medical care shall provide the following coverage 2 for mammography AND OTHER IMAGING screening for occult breast cancer: 3 (A) upon the recommendation of a physician, a mammogram at any age for 4 covered persons having a prior history of breast cancer or who have a 5 first degree relative with a prior history of breast cancer; 6 (B) a single baseline mammogram for covered persons aged thirty-five 7 through thirty-nine, inclusive; [and] 8 (C) an annual mammogram for covered persons aged forty and older[.]; 9 AND 10 (D) UPON RECOMMENDATION OF A PHYSICIAN, SUPPLEMENTAL SCREENING FOR A 11 COVERED PERSON USING OTHER IMAGING MODALITIES AS DEEMED APPROPRIATE BY 12 THE AMERICAN COLLEGE OF RADIOLOGY OR THE AMERICAN CANCER SOCIETY OF AN 13 ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS IF: 14 (A) A MAMMOGRAM PERFORMED PURSUANT TO THIS SUBPARAGRAPH DEMONSTRATES 15 THAT THE COVERED PERSON HAS DENSE BREAST TISSUE; OR 16 (B) A COVERED PERSON IS BELIEVED TO BE AT INCREASED RISK FOR BREAST 17 CANCER DUE TO FAMILY HISTORY OR PRIOR PERSONAL HISTORY OF BREAST CANCER, 18 POSITIVE GENETIC TESTING OR OTHER INDICATIONS AS DETERMINED BY A PHYSI- 19 CIAN. 20 FOR THE PURPOSES OF THIS SUBPARAGRAPH DENSE BREAST TISSUE SHALL MEAN 21 HETEROGENEOUSLY DENSE OR EXTREMELY DENSE TISSUE AS DEFINED IN NATIONALLY 22 RECOGNIZED GUIDELINES OR SYSTEMS FOR BREAST IMAGING REPORTING OF MAMMOG- 23 RAPHY SCREENING, INCLUDING, BUT NOT LIMITED TO, THE BREAST IMAGING 24 REPORTING AND DATA SYSTEM OF THE AMERICAN COLLEGE OF RADIOLOGY, AND ANY 25 EQUIVALENT NEW TERMS, AS SUCH GUIDELINES OR SYSTEMS ARE UPDATED. 26 (E) The coverage required in this paragraph or paragraph two of this 27 subsection may be subject to annual deductibles and coinsurance as may 28 be deemed appropriate by the superintendent and as are consistent with 29 those established for other benefits within a given contract. 30 (2) (A) For purposes of paragraph one of this subsection, mammography 31 screening means an X-ray examination of the breast using dedicated 32 equipment, including X-ray tube, filter, compression device, screens, 33 films and cassettes, with an average glandular radiation dose less than 34 0.5 rem per view per breast. 35 (B) FOR PURPOSES OF PARAGRAPH ONE OF THIS SUBSECTION, IMAGING MODALI- 36 TIES ARE MODALITIES USED TO SCREEN FOR, OR DIAGNOSE, OCCULT BREAST 37 CANCER. 38 (3) In addition to paragraph one or two of this subsection, every 39 contract that provides coverage for hospital, surgical or medical care, 40 except for a grandfathered health plan under paragraph four of this 41 subsection, shall provide coverage for the following mammography screen- 42 ing services AND FOR COMPREHENSIVE ULTRASOUND SCREENINGS OF AN ENTIRE 43 BREAST OR THE ENTIRETY OF BOTH BREASTS, and such coverage shall not be 44 subject to annual deductibles or coinsurance: 45 (A) evidence-based items or services for mammography that have in 46 effect a rating of 'A' or 'B' in the current recommendations of the 47 United States preventive services task force; [and] 48 (B) with respect to women, such additional preventive care and screen- 49 ings for mammography not described in subparagraph (A) of this paragraph 50 and as provided for in comprehensive guidelines supported by the health 51 resources and services administration[.]; AND 52 (C) COMPREHENSIVE ULTRASOUND SCREENINGS AS LONG AS DEEMED APPROPRIATE 53 BY THE AMERICAN COLLEGE OF RADIOLOGY OR THE AMERICAN CANCER SOCIETY OF 54 AN ENTIRE BREAST OR THE ENTIRETY OF BOTH BREASTS IF: 55 (I) A MAMMOGRAM DEMONSTRATES THAT A WOMAN HAS DENSE BREAST TISSUE; OR A. 8319 5 1 (II) A WOMAN IS BELIEVED TO BE AT INCREASED RISK FOR BREAST CANCER DUE 2 TO FAMILY HISTORY OR PRIOR PERSONAL HISTORY OF BREAST CANCER, POSITIVE 3 GENETIC TESTING OR OTHER INDICATIONS AS DETERMINED BY A PHYSICIAN. 4 FOR THE PURPOSES OF THIS SUBPARAGRAPH DENSE BREAST TISSUE SHALL MEAN 5 HETEROGENEOUSLY DENSE OR EXTREMELY DENSE TISSUE AS DEFINED IN NATIONALLY 6 RECOGNIZED GUIDELINES OR SYSTEMS FOR BREAST IMAGING REPORTING OF MAMMOG- 7 RAPHY SCREENING, INCLUDING, BUT NOT LIMITED TO, THE BREAST IMAGING 8 REPORTING AND DATA SYSTEM OF THE AMERICAN COLLEGE OF RADIOLOGY, AND ANY 9 EQUIVALENT NEW TERMS, AS SUCH GUIDELINES OR SYSTEMS ARE UPDATED. 10 (4) For purposes of this subsection, "grandfathered health plan" means 11 coverage provided by a corporation in which an individual was enrolled 12 on March twenty-third, two thousand ten for as long as the coverage 13 maintains grandfathered status in accordance with section 1251(e) of the 14 Affordable Care Act, 42 U.S.C. S 18011(e). 15 S 4. Section 2404-c of the public health law, as added by chapter 265 16 of the laws of 2012, is amended to read as follows: 17 S 2404-c. Breast cancer; duty of providers of mammography services to 18 notify and inform. Every provider of mammography services shall, if a 19 patient's mammogram demonstrates dense breast tissue, provide notifica- 20 tion to such patient that shall include, but not be limited to, the 21 following information, in any summary of the mammography report sent, 22 pursuant to the federal mammography quality standards act, to the 23 patient AND THE PATIENT'S PHYSICIAN: 24 Your mammogram shows that your breast tissue is dense. Dense breast 25 tissue is very common and is not abnormal. However, dense breast tissue 26 can make it harder to find cancer on a mammogram and may also be associ- 27 ated with an increased risk of breast cancer. 28 This information about the result of your mammogram is given to you to 29 raise your awareness. Use this information to talk to your doctor about 30 your own risks for breast cancer. At that time, ask your doctor if more 31 screening tests might be useful, based on your risk. A report of your 32 results was sent to your physician. 33 For the purposes of this section dense breast tissue shall mean heter- 34 ogeneously dense or extremely dense tissue as defined in nationally 35 recognized guidelines or systems for breast imaging reporting of mammog- 36 raphy screening, including, but not limited to, the breast imaging 37 reporting and data system of the American College of Radiology, and any 38 equivalent new terms, as such guidelines or systems are updated. 39 S 5. This act shall take effect on the one hundred eightieth day after 40 it shall have become a law.