HB 928: 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

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 to insurance generally, so as to provide that 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; to provide for a definition; to provide for related matters; to provide for an effective date and applicability; to repeal conflicting laws; and for other purposes.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:

SECTION 1.

Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to insurance generally, is amended by revising Code Section 33-24-59.32, relating to cost-sharing requirements for diagnostic and supplemental breast screening examinations, as follows:

"33-24-59.32.

(a) As used in this Code section, the term:

(1) 'Breast magnetic resonance imaging' or 'breast MRI' means a diagnostic and screening tool, including standard and abbreviated breast MRI, that uses radio waves and magnets to produce detailed images of structures within the breast.

(2) 'Breast ultrasound' means a noninvasive diagnostic and screening tool that uses high-frequency sound waves and their echoes to produce detailed images of structures within the breast.

(3) 'Cost-sharing requirement' means a deductible, coinsurance, or copayment and any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense.

(4) 'Dense breast tissue' means heterogeneously or extremely dense breast tissue based on nationally recognized guidelines or systems for breast imaging reporting of mammography, including, but not limited to, the Breast Imaging Reporting and Data System established by the American College of Radiology.

(4)(5) 'Diagnostic breast examination' means a medically necessary and clinically appropriate examination of the breast, including such examination using breast MRI, breast ultrasound, or mammogram, that is:

(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer; or

(B) Used to evaluate an abnormality detected by another means of examination. (5)(6) 'Health benefit policy' means any individual or group plan, policy, or contract for health care healthcare services issued, delivered, issued for delivery, executed, or renewed by an insurer in this state.

(6)(7) 'Insurer' means any person, corporation, or other entity authorized to provide health benefit policies under this title.

(7)(8) 'Mammogram' means a diagnostic or screening mammography exam using a low-dose X-ray to produce an image of the breast.

(8)(9) 'Supplemental breast screening examination' means a medically necessary and clinically appropriate examination of the breast, including such examination using breast MRI, breast ultrasound, or mammogram, that is:

(A) Used to screen for breast cancer when there is no abnormality seen or suspected in the breast; or

(B) Based on personal or family medical history or additional factors that may increase the individual's risk of breast cancer.

(b) A health benefit policy that provides coverage for diagnostic breast examinations for breast cancer shall include provisions that ensure that the cost-sharing requirements applicable to diagnostic breast examinations and supplemental breast screening examinations are no less favorable than the cost-sharing requirements applicable to screening mammography for breast cancer.

(c) Nothing in this Code section shall be construed to preclude existing utilization review provided under Chapter 46 of this title, except that, if a supplemental breast screening examination reveals the existence of dense breast tissue, following the patient notification required in Code Section 31-1-17, the diagnosing physician may determine whether a breast ultrasound is medically necessary, and such determination shall not be disputed through utilization review or any other procedure by an insurer for purposes of denying insurance coverage for such examinee.

(d) If under federal law application of subsection (b) of this Code section would result in Health Savings Account ineligibility under Section 223 of the Internal Revenue Code, such cost-sharing requirement shall apply only for Health Savings Account qualified High Deductible Health Plans with respect to the deductible of such plan after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of subsection (b) of this Code section shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.

(e) The Commissioner shall promulgate rules and regulations necessary to implement the provisions of this Code section in accordance with current guidelines established by professional medical organizations such as the National Comprehensive Cancer Network."

SECTION 2.

This Act shall become effective on July 1, 2025, and shall apply to all applicable policies, contracts, and certificates executed, delivered, issued for delivery, or renewed in this state on or after October 1, 2025.

SECTION 3.

All laws and parts of laws in conflict with this Act are repealed.