SSB 3135 (LSB 5676XC (5) 90)

SENATE FILE _____ 

BY  (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON BROWN)

A BILL FOR

An Act relating to insurance coverage for supplemental and diagnostic breast examinations.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.4A  Supplemental and diagnostic breast examinations.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Breast magnetic resonance imaging” or “breast MRI” means an examination of a breast, following administration of intravenous contrast, using a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.
   b.  “Breast ultrasound” means a noninvasive examination of a breast using high-frequency sound waves to produce detailed images of the breast.
   c.  “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense obligation imposed on a covered person by a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses.
   d.  “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.
   e.  “Diagnostic breast examination” means a medically necessary and appropriate examination of the breast that may include a diagnostic mammogram, breast magnetic resonance imaging, breast ultrasound, or other breast imaging, and that is performed for any of the following reasons:
   (1)  To evaluate an abnormality seen or suspected during a screening examination for breast cancer.
   (2)  To evaluate an abnormality detected by another means of examination.
   f.  “Diagnostic mammogram” means a detailed examination of a breast abnormality using X ray.
   g.  “Health care professional” means the same as defined in section 514J.102.
   h.  “Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.
   i.  “Screening mammogram” means an examination of a breast that aids in the early detection and diagnosis of breast abnormalities including breast cancer.
   j.  “Supplemental breast examination” means a medically necessary and appropriate examination of the breast that may include breast magnetic resonance imaging, breast ultrasound, contrast-enhanced mammography, or examination for dense breast tissue as described by the breast imaging reporting and data system of the American college of radiology, and that is performed to screen for breast cancer when there is no abnormality seen or suspected and based on an individual’s personal or family medical history, or additional factors that may increase the individual’s risk of breast cancer.
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall provide coverage for supplemental breast examinations and diagnostic breast examinations.
   b.  Coverage required under this section shall not be less favorable than coverage a health carrier offers for screening mammograms.
   c.  Cost-sharing requirements shall not be imposed by a health carrier for coverage required under this section.
   3.  a.  This section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2025:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   4.  The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to insurance coverage for supplemental breast examinations (supplemental examinations) and diagnostic breast examinations (diagnostic examinations).
   The bill requires a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses to provide coverage for supplemental examinations and diagnostic examinations. “Supplemental examination” and “diagnostic examination” are defined in the bill. Coverage required under the bill shall not be less favorable than coverage a health carrier offers for screening mammograms. The health carrier shall not impose cost-sharing for supplemental examinations or diagnostic examinations. “Cost-sharing” and “screening mammogram” are defined in the bill.
   The bill applies to the third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance which are not subject to the coverage requirements of the bill.
   The commissioner of insurance may adopt rules to administer the requirements of the bill.
   The provisions of the bill are applicable to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2025.