Connecticut Seal

General Assembly

File No. 60

    February Session, 2018

Substitute House Bill No. 5208

House of Representatives, March 28, 2018

The Committee on Insurance and Real Estate reported through REP. SCANLON of the 98th Dist., Chairperson of the Committee on the part of the House, that the substitute bill ought to pass.

AN ACT CONCERNING MAMMOGRAMS, BREAST ULTRASOUNDS AND MAGNETIC RESONANCE IMAGING OF BREASTS.

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 Section 38a-503 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):

(a) For purposes of this section:

(1) "Healthcare Common Procedure Coding System" or "HCPCS" means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) "Mammogram" means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

[(a)] (b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for [mammographic examinations] mammograms to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, every year for any woman who is forty years of age or older.

(2) Such policy shall provide additional benefits for:

(A) 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

(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.

[(b)] (c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a copayment that exceeds a maximum of twenty dollars for an ultrasound screening under subparagraph (A) of subdivision (2) of subsection [(a)] (b) of this section.

[(c)] (d) 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, 2019):

(a) For purposes of this section:

(1) "Healthcare Common Procedure Coding System" or "HCPCS" means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) "Mammogram" means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

[(a)] (b) (1) 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 shall provide benefits for [mammographic examinations] mammograms to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, every year for any woman who is forty years of age or older.

(2) Such policy shall provide additional benefits for:

(A) 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

(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.

[(b)] (c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a copayment that exceeds a maximum of twenty dollars for an ultrasound screening under subparagraph (A) of subdivision (2) of subsection [(a)] (b) of this section.

[(c)] (d) 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, 2019

38a-503

Sec. 2

January 1, 2019

38a-530

INS

Joint Favorable Subst.

 

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

State Impact: None

Municipal Impact:

Municipalities

Effect

FY 19 $

FY 20 $

Various Municipalities

STATE MANDATE - Cost

See Below

See Below

Explanation

The bill does not result in a fiscal impact to the state health plan as the state does not currently impose cost sharing in-network for mammograms, including tomosynthesis.

The bill's expanded definition of mammogram, to include coverage codes for tomosynthesis will in a cost to certain fully-insured municipal plans, to the extent the expanded coverage definition precludes municipal plans from imposing cost sharing for tomosynthesis. Pursuant to federal law cost sharing for in network mammograms is prohibited.1 The coverage requirements may result in increased premium costs for the municipality when they enter into new health insurance contracts after January 1, 2019. Due to federal law, municipalities with self-insured plans are exempt from state

health insurance mandates. Lastly, many municipal plans may be recognized as “grandfathered”2 plans under the federal Affordable Care Act (ACA). It is uncertain what the effect of this mandate will have on the grandfathered status of those municipal plans.

The Out Years

The annualized ongoing fiscal impact identified above would continue into the future and be reflected in future premiums.

OLR Bill Analysis

sHB 5208

AN ACT CONCERNING MAMMOGRAMS, BREAST ULTRASOUNDS AND MAGNETIC RESONANCE IMAGING OF BREASTS.

SUMMARY

This bill expands coverage for mammograms and tomosynthesis under certain health insurance policies. It does so by defining “mammogram” as a mammographic examination or tomosynthesis, including any procedure with one of 10 specific Healthcare Common Procedure Coding System (HCPCS) billing codes or any subsequent corresponding codes.

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; or (4) hospital or medical services, including those provided under an HMO plan. It also applies to individual policies providing limited health benefits.

By law, such policies must cover baseline mammograms for women age 35 through 39, and annual mammograms for women age 40 or older. The federal Affordable Care Act prohibits certain health insurance policies from imposing copays or deductibles for mammograms conducted in accordance with national guidelines.

EFFECTIVE DATE: January 1, 2019

MAMMOGRAM DEFINITION

The bill defines “mammogram” to include 10 HCPCS codes and any subsequent corresponding codes. However, at least some of the 10 HCPCS codes listed in the bill are inactive. Table 1 below lists the 10 codes included in the bill and any subsequent codes.

HCPCS is a set of billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services. They are based on current procedural technology codes developed by the American Medical Association.

Table 1: HCPCS Codes for Mammograms

Code Listed In Bill

Description

Subsequent Code

77051

Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; diagnostic mammography

77065 (unilateral)

77066 (bilateral)

77052

Computer-aided detection with further review for interpretation, with or without digitization of film radiographic images; screening mammography

77067

77055

Mammography; unilateral (one breast)

77065

77056

Mammography; bilateral (both breasts)

77066

77057

Screening mammography, bilateral (2-view study of each breast)

77067

77063

Screening digital breast tomosynthesis, bilateral

None

G0202

Screening mammography, producing direct digital image, bilateral, all views

None

G0204

Diagnostic mammography, including computer-aided detection when performed; bilateral

None

G0206

Diagnostic mammography, including computer-aided detection when performed; unilateral

None

G0279

Diagnostic digital breast tomosynthesis, unilateral or bilateral

None

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable Substitute

Yea

21

Nay

0

(03/15/2018)

TOP

1 https://www.healthcare.gov/preventive-care-women/

2 Grandfathered plans include most group health insurance plans and some individual plans created or purchased on or before March 23, 2010.