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

Georgia law already requires health insurance policies to charge no more in cost-sharing (deductibles, copays, coinsurance) for diagnostic and supplemental breast exams than they charge for routine screening mammograms. This bill amends that law (O.C.G.A. § 33-24-59.32) to add a new protection: if a supplemental breast screening exam finds dense breast tissue, and the patient's doctor decides a follow-up breast ultrasound is medically necessary, an insurer cannot dispute that decision through utilization review or any other process to deny coverage. The bill also adds a formal definition of 'dense breast tissue' based on nationally recognized breast imaging guidelines, such as the system used by the American College of Radiology, and makes small wording updates elsewhere in the definitions section. The changes would take effect July 1, 2025, and apply to insurance policies and contracts issued or renewed in Georgia on or after October 1, 2025.

• Bars insurers from using utilization review (an insurer's process for checking if care is medically necessary) to dispute a doctor's finding that a breast ultrasound is medically necessary after dense breast tissue is found.
• Adds a formal legal definition of 'dense breast tissue' tied to recognized medical imaging classification systems like the American College of Radiology's system.
• Keeps the existing requirement that cost-sharing for diagnostic and supplemental breast exams be no less favorable than for routine screening mammograms.
• Ties the new utilization review exemption to the patient notification already required under a separate Georgia law (O.C.G.A. § 31-1-17).
• Sets the law to take effect July 1, 2025, applying to policies issued or renewed on or after October 1, 2025.

Georgia patients who undergo breast cancer screening and are found to have dense breast tissue, the physicians who diagnose them and order follow-up ultrasounds, and health insurers that write individual or group health benefit policies in the state, who lose the ability to challenge these specific ultrasound orders through utilization review.

Patients found to have dense breast tissue, which can hide tumors on a mammogram, would no longer risk having their doctor-ordered ultrasound denied or delayed by an insurer's internal review process, potentially speeding up follow-up care and reducing coverage disputes between doctors and insurance companies.

• Section 1 revises O.C.G.A. § 33-24-59.32 to add a definition of 'dense breast tissue' based on nationally recognized breast imaging guidelines.
• Section 1 adds language to subsection (c) stating that if a screening reveals dense breast tissue, a physician's determination that a breast ultrasound is medically necessary cannot be disputed through utilization review or other insurer procedures for denying coverage.
• Section 1 keeps intact the existing rule that cost-sharing for diagnostic and supplemental breast exams must be no less favorable than for standard screening mammograms.
• Section 1 retains an exception allowing higher cost-sharing under Health Savings Account qualified high-deductible plans until the federal minimum deductible is met, except for preventive care.
• Section 2 sets the effective date as July 1, 2025, applying to policies executed, delivered, issued, or renewed on or after October 1, 2025.
• Section 3 repeals conflicting laws.

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

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

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