HB928: HB928 Insurance; utilization review by an insurer shall not be required in the instance in which a physician has determined the existence of dense breast tissue and the medical necessity of a breast ultrasound; provide

Georgia law already requires health insurance policies to charge no more in cost-sharing for diagnostic and supplemental breast screening exams, such as ultrasounds and MRIs, than they charge for a standard screening mammogram (O.C.G.A. § 33-24-59.32). This bill adds a new definition of 'dense breast tissue' based on nationally recognized breast imaging guidelines, and it changes what insurers can do once that tissue is found. Under the bill, if a supplemental breast screening exam shows dense breast tissue and, after the required patient notification, the diagnosing physician decides a breast ultrasound is medically necessary, an insurer cannot dispute that decision through utilization review or any other process to deny coverage. The bill also directs the state insurance Commissioner to write rules following current cancer-screening guidelines. It would take effect July 1, 2025, and apply to policies issued or renewed on or after October 1, 2025.

• Adds a formal definition of 'dense breast tissue' tied to nationally recognized mammography reporting standards, including the American College of Radiology's system.
• Prohibits insurers from using utilization review or any other process to dispute a physician's determination that a breast ultrasound is medically necessary once dense breast tissue is found.
• Keeps in place the existing rule that cost-sharing for diagnostic and supplemental breast exams cannot be less favorable than for a standard screening mammogram.
• Directs the state Insurance Commissioner to issue rules implementing the section consistent with current guidelines from professional medical organizations like the National Comprehensive Cancer Network.
• Sets an effective date of July 1, 2025, applying to insurance policies and contracts issued or renewed on or after October 1, 2025.

Georgians covered by individual or group health benefit policies issued in the state, insurers that sell those policies, physicians who diagnose breast conditions, and the state Insurance Commissioner's office, which must write implementing rules.

Patients found to have dense breast tissue, which can hide tumors on a standard mammogram, would no longer face insurer pushback once their doctor orders a follow-up ultrasound, potentially speeding up access to that additional screening and removing a possible coverage denial step.

• Section 1 amends O.C.G.A. § 33-24-59.32 to add a definition of 'dense breast tissue' based on nationally recognized breast imaging guidelines such as the Breast Imaging Reporting and Data System.
• Section 1 revises subsection (c) so that once dense breast tissue is found and the required patient notification under O.C.G.A. § 31-1-17 occurs, a physician's medical necessity determination for a breast ultrasound cannot be challenged by insurer utilization review or any other process used to deny coverage.
• Section 1 keeps the existing cost-sharing parity rule and the Health Savings Account/high deductible plan exception tied to federal tax law.
• Section 1 keeps the requirement that the Insurance Commissioner issue rules matching current guidelines from professional medical organizations.
• Section 2 sets the effective date as July 1, 2025, applying to policies issued, delivered, or renewed on or after October 1, 2025.
• Section 3 repeals conflicting laws.

1. 2026-01-12House Second Readers (House)
2. 2025-04-04House First Readers (House)
3. 2025-04-04House Hopper (House)

• Inga Willis (D, HD-055)Primary sponsor
• Omari Crawford (D, HD-089)
• Mekyah McQueen (D, HD-061)
• Edna Jackson (D, HD-165)
• Tanya Miller (D, HD-062)

• health insurance
• breast cancer screening
• dense breast tissue
• utilization review
• insurance coverage mandates