33-24-59.32. Cost-sharing requirements for diagnostic and supplemental breast screening examinations.

As used in this Code section, the term:#

1. (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. (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. (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. (4)

   “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:#

   1. (A)

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

   2. (B)

      Used to evaluate an abnormality detected by another means of examination.#

5. (5)

   “Health benefit policy” means any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, executed, or renewed by an insurer in this state.#

6. (6)

   “Insurer” means any person, corporation, or other entity authorized to provide health benefit policies under this title.#

7. (7)

   “Mammogram” means a diagnostic or screening mammography exam using a low-dose X-ray to produce an image of the breast.#

8. (8)

   “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:#

   1. (A)

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

   2. (B)

      Based on personal or family medical history or additional factors that may increase the individual’s risk of breast cancer.#

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

Nothing in this Code section shall be construed to preclude existing utilization review provided under Chapter 46 of this title.#

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.#

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.#