General Assembly |
File No. 12 |
January Session, 2011 |
Senate, February 22, 2011
The Committee on Insurance and Real Estate reported through SEN. CRISCO of the 17th Dist., Chairperson of the Committee on the part of the Senate, that the bill ought to pass.
AN ACT CONCERNING BREAST ULTRASOUND SCREENINGS.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. Section 38a-503 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2012):
(a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), [(6),] (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state [on or after October 1, 2001,] shall provide benefits for mammographic examinations to any woman covered under the policy which are at least equal to the following minimum requirements: (1) A baseline mammogram for any woman who is thirty-five to thirty-nine years of age, inclusive; and (2) a mammogram every year for any woman who is forty years of age or older.
(b) Such policy shall:
[provide] (1) Provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman's physician or advanced practice registered nurse; and
(2) Not impose a coinsurance, copayment, deductible or other out-of-pocket expense for such ultrasound screening, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to this subdivision.
[(b) Benefits] (c) Except as specified under subdivision (2) of subsection (b) of this section, benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy.
[(c)] (d) On and after October 1, 2009, each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: "If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's office and you should contact your physician if you have any questions or concerns about this report.".
Sec. 2. Section 38a-530 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2012):
(a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state [on or after October 1, 2001,] shall provide benefits for mammographic examinations to any woman covered under the policy which are at least equal to the following minimum requirements: (1) A baseline mammogram for any woman who is thirty-five to thirty-nine years of age, inclusive; and (2) a mammogram every year for any woman who is forty years of age or older.
(b) Such policy shall:
[provide] (1) Provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman's physician or advanced practice registered nurse; and
(2) Not impose a coinsurance, copayment, deductible or other out-of-pocket expense for such ultrasound screening, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-520, shall not be subject to this subdivision.
[(b) Benefits] (c) Except as specified under subdivision (2) of subsection (b) of this section, benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy.
[(c)] (d) On and after October 1, 2009, each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: "If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's office and you should contact your physician if you have any questions or concerns about this report.".
This act shall take effect as follows and shall amend the following sections: | ||
Section 1 |
January 1, 2012 |
38a-503 |
Sec. 2 |
January 1, 2012 |
38a-530 |
INS |
Joint Favorable |
The following Fiscal Impact Statement and Bill Analysis are prepared for the benefit of the members of the General Assembly, solely for purposes of information, summarization and explanation and do not represent the intent of the General Assembly or either chamber thereof for any purpose. In general, fiscal impacts are based upon a variety of informational sources, including the analyst's professional knowledge. Whenever applicable, agency data is consulted as part of the analysis, however final products do not necessarily reflect an assessment from any specific department.
OFA Fiscal Note
Agency Affected |
Fund-Effect |
FY 12 $ |
FY 13 $ |
Comptroller Misc. Accounts (Fringe Benefits) |
GF & TF - Cost |
Potential |
Potential |
Municipalities |
Effect |
FY 12 $ |
FY 13 $ |
Various Municipalities |
STATE MANDATE - Cost |
Potential |
Potential |
Explanation
As of July 1, 2010, the State Employees' Health plan went self-insured. Pursuant to current federal law, self-insured health plans are exempt from state health mandates, however in previous self funded arrangements the state has traditionally adopted all state mandates. To the extent the state continues this practice of voluntary mandate adoption, the following impacts are anticipated.
It is estimated the state's cost will increase on average $55 for each out-of-network breast ultrasound, as a result of eliminating out-of-pocket expenses, including copayments and deductibles for breast ultrasound screening. The increased cost is attributable to covering the copay of breast ultrasound screenings for those individuals who use out-of-network providers1.
The bill's provisions may increase costs to certain fully insured municipal plans which include copayments for breast ultrasound screening. The coverage requirements may result in increased premium costs when municipalities enter into new health insurance contracts after January 1, 2012. Due to current federal law, municipalities with self-insured plans are exempt from state health insurance mandates.
The state employee health plan and many municipal health plans are recognized as “grandfathered” health plans under the Patient Protection and Affordability Act (PPACA)2. It is unclear what effect the adoption of certain health mandates will have on the grandfathered status of the state employee health plan or grandfathered municipal plans PPACA3.
The Out Years
The annualized ongoing fiscal impact identified above would continue into the future subject to inflation.
The federal health care reform act requires that, effective January 1, 2014, all states must establish a health benefit exchange, which will offer qualified plans that must include a federally defined essential benefits package. While states are allowed to mandate benefits in excess of the basic package, the federal law appears to require the state to pay the cost of any such additional mandated benefits. The extent of these costs will depend on the mandates included in the federal essential benefit package, which have not yet been determined. Neither the agency nor mechanism for the state to pay these costs has been established.
OLR Bill Analysis
AN ACT CONCERNING BREAST ULTRASOUND SCREENINGS.
This bill prohibits health insurers from imposing a coinsurance, copayment, deductible, or other out-of-pocket expense on a breast ultrasound screening. Thus, it requires health insurance policies to cover the full cost of breast ultrasound screening. Under current law, such screening is subject to any policy provision applying to other services covered under the policy.
The bill applies to individual and group health insurance policies that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including those provided by HMOs. It also applies to individual health insurance policies that cover limited benefits. But the bill specifies that it does not apply to high deductible health plans designed to be compatible with federally qualified health savings accounts.
The bill makes technical and conforming changes. It also removes an erroneous reference to individual accident only policies.
EFFECTIVE DATE: January 1, 2012
BACKGROUND
Breast Ultrasound Screening Coverage Requirement
By law, the policies listed above must cover breast ultrasounds of a woman's entire breast or breasts if (1) a mammogram shows heterogeneous or dense breast tissue based on the American College of Radiology's Breast Imaging Reporting and Database System (BI-RADS) or (2) a woman is considered at an increased breast cancer risk because of family history, her own prior breast cancer history, positive genetic testing, or other indications determined by her physician or advanced-practice registered nurse.
Policies must also cover a baseline mammogram for a woman age 35 to 39 and a yearly mammogram for a woman age 40 or older. Coverage is subject to any policy provisions applying to other services covered under the policy.
BI-RADS Categories
The American College of Radiology collaborated with the National Cancer Institute, the Centers for Disease Control and Prevention, the American Medical Association, and others to develop BI-RADS, which is used to standardize mammography reporting. There are two BI-RADS scales: (1) one characterizes breast density and (2) the other characterizes a radiologist's reading of what he or she sees on a mammogram.
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable
Yea |
15 |
Nay |
3 |
(02/08/2011) |
1 Breast ultrasound screenings can range from $250-$300. (University of Connecticut, (2010). Connecticut Mandate Health Insurance Benefits Review; Vol. 2, Ch. 1, p. 40.)
2 Grandfathered plans include most group insurance plans and some individual health plans created or purchased on or before March 23, 2010. Pursuant to the PPACA, all health plans, including those with grandfathered status are required to provide the following as of September 23, 2010: 1) No lifetime limits on coverage, 2) No rescissions of coverage when individual gets sick or has previously made an unintentional error on an application, and 3) Extension of parents' coverage to young adults until age 26. (www.healthcare.gov)
3 According to the PPACA, compared to the plans' policies as of March 23, 2010, grandfathered plans who make any of the following changes within a certain margin may lose their grandfathered status: 1) Significantly cut or reduce benefits, 2) Raise co-insurance charges, 3) Significantly raise co-payment charges, 4) Significantly raise deductibles, 5) Significantly lower employer contributions, and 5) Add or tighten annual limits on what insurer pays. (www.healthcare.gov)