Location:
INSURANCE - HEALTH - MANDATES;

OLR Research Report


CONNECTICUT'S BREAST SCREENING INSURANCE COVERAGE REQUIREMENT

By: Janet Kaminski Leduc, Senior Legislative Attorney

ISSUE

Describe Connecticut's breast screening insurance coverage law and briefly summarize any changes to it.

SUMMARY

Connecticut law requires certain health insurance policies to cover a baseline mammogram for a woman age 35 to 39 and one every year for a woman age 40 or older (CGS 38a-503 and 38a-530, as amended by PA 16-82). Beginning January 1, 2017, it allows the covered mammogram to be provided by breast tomosynthesis (a three-dimensional mammogram) at the woman's option.

Policies must additionally cover a comprehensive ultrasound of a woman's entire breast(s) if (1) a mammogram shows heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System (BI-RADS) established by the American College of Radiology or (2) the woman is at increased risk for breast cancer due to family history, her own history, genetic testing, or other indications determined by her physician or advanced-practice registered nurse (APRN). They must also cover magnetic resonance imaging (MRI) of a woman's breast(s) in accordance with American Cancer Society guidelines.

Under the state law, benefits payable for breast screening services are subject to any policy provisions applying to other covered services, except a policy cannot impose a copayment of more than $20 for a breast ultrasound screening. (Under federal law, some mammograms must be covered with no cost sharing, as described in the Connecticut Insurance Department's Bulletin HC-114.)

State law applies to (1) individual or group health insurance policies delivered, renewed, amended, or continued in Connecticut that cover basic hospital expenses; basic medical-surgical expenses; major medical expenses; or hospital or medical services, including those provided under an HMO plan and (2) individual health insurance policies that provide limited benefit health coverage.

Table 1 outlines the development of the breast screening insurance coverage law, beginning with its implementation in 1988.

Table 1: Development of Connecticut's Breast Screening Insurance Coverage Law

Public Act (PA) and Effective Date

Brief Summary

PA 88-124

October 1, 1988

Establishes the requirement that policies cover mammograms to detect breast cancer in women, as follows: one initial exam for women age 35 to 39; one exam every two years for women age 40 to 49, or more frequently if recommended by a physician; and one exam annually for women age 50 or older.

PA 90-243

October 1, 1990

Separates the law between individual and group policies and transfers citation from CGS 38-174gg to CGS 38a-503 and 38a-530.

PA 01-171

October 1, 2001

Requires policies to cover annual mammograms beginning at age 40, instead of age 50.

PA 05-69

October 1, 2005

Requires policies to cover a physician-recommended comprehensive ultrasound screening of an entire breast or breasts for a woman classified as category 2, 3, 4, or 5 on BI-RADS, as established by the American College of Radiology.

PA 06-38

October 1, 2006

Changes when policies must cover a comprehensive ultrasound screening of a woman's entire breast or breasts. Requires such coverage if (1) a mammogram shows heterogeneous or dense breast tissue on BI-RADS or (2) a woman is at increased risk of breast cancer because of family history, her own breast cancer history, positive genetic testing, or other determinations by her physician or APRN.

PA 09-41

October 1, 2009

Requires mammography reports (i.e., written results of a mammogram) given to a patient to include information about breast density based on BI-RADS. When applicable, a report must include a notice about breast density specified in the law.

PA 11-67

January 1, 2012

Requires policies to cover an MRI of a woman's entire breast or breasts if (1) a mammogram shows heterogeneous or dense breast tissue on BI-RADS or (2) a woman is at increased risk of breast cancer because of family history, her own breast cancer history, positive genetic testing, or other determinations by her physician or APRN.

PA 11-171

January 1, 2012

Requires policies to cover an MRI of a woman's breasts in accordance with guidelines established by the American Cancer Society or American College of Radiology.

PA 12-150

June 15, 2012

Reconciles PA 11-67 and PA 11-171. Requires policies to cover breast MRIs in accordance with the American Cancer Society guidelines.

PA 14-97

January 1, 2015

Prohibits policies from imposing a copayment of more than $20 for a breast ultrasound screening for which the policies are required to provide coverage (e.g., presence of dense breast tissue or increased risk of breast cancer).

PA 16-82

January 1, 2017

Requires policies to cover mammograms provided by breast tomosynthesis at the insured woman's option.

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