PA 18-159—sHB 5208

Insurance and Real Estate Committee

Appropriations Committee

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

SUMMARY: This act expands the types of breast imaging services that certain health insurance policies must cover. It does so by defining “mammogram” as a mammographic examination or breast tomosynthesis, including any procedure with one of 13 specific Healthcare Common Procedure Coding System (HCPCS) billing codes or any subsequent corresponding codes.

The act 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, these 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 according to national guidelines.

EFFECTIVE DATE: January 1, 2019

MAMMOGRAM DEFINITION

The act defines “mammogram” to include 13 HCPCS codes and any subsequent corresponding codes. Table 1 below lists the included codes and a description of what each covers.

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

Table 1: HCPCS Codes for Mammograms

Code Listed In Act

Description

77051

77065

77066

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

77052

77067

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

77055

Mammography; unilateral (one breast)

77056

Mammography; bilateral (both breasts)

77057

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

77063

Screening digital breast tomosynthesis, bilateral

G0202

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

G0204

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

G0206

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

G0279

Diagnostic digital breast tomosynthesis, unilateral or bilateral