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

25 LC 46 1213 House Bill 928 By: Representatives Willis of the 55th, Crawford of the 89th, McQueen of the 61st, Jackson of the 165th, and Miller of the 62nd A BILL TO BE ENTITLED AN ACT To amend Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to1 insurance generally, so as to provide that utilization review b y an insurer shall not be2 required in the instance in which a physician has determined th e existence of dense breast3 tissue and the medical necessity of a breast ultrasound; to provide for a definition; to provide4 for related matters; to provide for an effective date and appli cability; to repeal conflicting5 laws; and for other purposes.6 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7 SECTION 1.8 Chapter 24 of Title 33 of the Official Code of Georgia Annotate d, relating to insurance9 generally, is amended by revising Code Section 33-24-59.32, rel ating to cost-sharing10 requirements for diagnostic and supplemental breast screening examinations, as follows: 11 "33-24-59.32.12 (a) As used in this Code section, the term:13 (1) 'Breast magnetic resonance imaging' or 'breast MRI' means a diagnostic and14 screening tool, including standard and abbreviated breast MRI, that uses radio waves and15 magnets to produce detailed images of structures within the breast.16 H. B. 928 - 1 - 25 LC 46 1213 (2) 'Breast ultrasound' means a noninvasive diagnostic and scr eening tool that uses17 high-frequency sound waves and their echoes to produce detailed images of structures18 within the breast.19 (3) 'Cost-sharing requirement' means a deductible, coinsurance, or copayment and any20 maximum limitation on the application of such a deductible, coinsurance, copayment, or21 similar out-of-pocket expense.22 (4) 'Dense breast tissue' means heterogeneously or extremely dense breast tissue based23 on nationally recognized guidelines or systems for breast imagi ng reporting of24 mammography, including, but not limited to, the Breast Imaging Reporting and Data25 System established by the American College of Radiology.26 (4)(5) 'Diagnostic breast examination' means a medically necessary a nd clinically27 appropriate examination of the breast, including such examinati on using breast MRI,28 breast ultrasound, or mammogram, that is:29 (A) Used to evaluate an abnormality seen or suspected from a screening examination30 for breast cancer; or31 (B) Used to evaluate an abnormality detected by another means of examination.32 (5)(6) 'Health benefit policy' means any individual or group plan, policy, or contract for33 health care healthcare services issued, delivered, issued for delivery, executed, or34 renewed by an insurer in this state.35 (6)(7) 'Insurer' means any person, corporation, or other entity auth orized to provide36 health benefit policies under this title.37 (7)(8) 'Mammogram' means a diagnostic or screening mammography exam using a38 low-dose X-ray to produce an image of the breast.39 (8)(9) 'Supplemental breast screening examination' means a medically necessary and40 clinically appropriate examination of the breast, including such examination using breast41 MRI, breast ultrasound, or mammogram, that is:42 H. B. 928 - 2 - 25 LC 46 1213 (A) Used to screen for breast cancer when there is no abnormality seen or suspected43 in the breast; or44 (B) Based on personal or family medical history or additional factors that may increase45 the individual's risk of breast cancer.46 (b) A health benefit policy that provides coverage for diagnostic breast examinations for47 breast cancer shall include provisions that ensure that the cost-sharing req uirements48 applicable to diagnostic breast examinations and supplemental breast screening49 examinations are no less favorable than the cost-sharing requir ements applicable to50 screening mammography for breast cancer.51 (c) Nothing in this Code section shall be construed to preclude existing utilization review52 provided under Chapter 46 of this title, except that, if a supp lemental breast screening53 examination reveals the existence of dense breast tissue, following the patient notification54 required in Code Section 31-1-17, the diagnosing physician may determine whether a55 breast ultrasound is medically necessary, and such determinatio n shall not be disputed56 through utilization review or any other procedure by an insurer for purposes of denying57 insurance coverage for such examinee.58 (d) If under federal law application of subsection (b) of this Code section would result in59 Health Savings Account ineligibility under Section 223 of the Internal Revenue Code, such60 cost-sharing requirement shall apply only for Health Savings Ac count qualified High61 Deductible Health Plans with respect to the deductible of such plan after the enrollee has62 satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except63 with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C)64 of the Internal Revenue Code, in which case the requirements of subsection (b) of this65 Code section shall apply regardless of whether the minimum deductible under Section 22366 of the Internal Revenue Code has been satisfied.67 H. B. 928 - 3 - 25 LC 46 1213 (e) The Commissioner shall promulgate rules and regulations necessary to implement the68 provisions of this Code section in accordance with current guid elines established by69 professional medical organizations such as the National Comprehensive Cancer Network."70 SECTION 2.71 This Act shall become effective on July 1, 2025, and shall apply to all applicable policies,72 contracts, and certificates executed, delivered, issued for delivery, or renewed in this state73 on or after October 1, 2025.74 SECTION 3.75 All laws and parts of laws in conflict with this Act are repealed.76 H. B. 928 - 4 -