As Introduced
135th General Assembly
Regular Session H. B. No. 619
2023-2024
Representatives Schmidt, Denson
A BILL
To amend sections 1751.62, 3923.52, 3923.53, 1
5162.20, and 5164.08 of the Revised Code to 2
revise the law governing insurance and Medicaid 3
coverage of breast cancer screenings and 4
examinations. 5
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1751.62, 3923.52, 3923.53, 6
5162.20, and 5164.08 of the Revised Code be amended to read as 7
follows: 8
Sec. 1751.62. (A) As used in this section: 9
(1) "Screening mammography" means a radiologic examination 10
that, in accordance with applicable American college of 11
radiology guidelines, is utilized to detect unsuspected breast 12
cancer at an early stage in an asymptomatic woman and includes 13
the x-ray examination of the breast using equipment that is 14
dedicated specifically for mammography, including, but not 15
limited to, the x-ray tube, filter, compression device, screens, 16
film, and cassettes, and that has an average radiation exposure 17
delivery of less than one rad mid-breast. "Screening 18
mammography" includes digital breast tomosynthesis. "Screening 19
H. B. No. 619 Page 2
As Introduced
mammography" includes two views for each breast. The term also 20
includes the professional interpretation of the film. 21
"Screening mammography" does not include diagnostic 22
mammography. 23
(2) "Medicare reimbursement rate" means the reimbursement 24
rate paid in Ohio under the medicare program for screening 25
mammography that does not include digitization or computer-aided 26
detection, regardless of whether the actual benefit includes 27
digitization or computer-aided detection. 28
(3) "Diagnostic breast examination" means any examination 29
that, in accordance with applicable American college of 30
radiology guidelines, is deemed medically necessary by a 31
treating health care provider to diagnose breast cancer, 32
including diagnostic mammography, magnetic resonance imaging, 33
ultrasound, or biopsy. 34
(3) "Supplemental breast cancer screening" means any 35
additional screening method deemed medically necessary by a 36
treating health care provider for proper breast cancer screening 37
in accordance with applicable American college of radiology 38
guidelines, including magnetic resonance imaging, ultrasound, 39
contrast enhanced mammography, or molecular breast imaging. 40
(4) "Cost-sharing" means the cost to an enrollee under an 41
individual or group health insuring corporation policy, 42
contract, or agreement according to any coverage limit, 43
copayment, coinsurance, deductible, or other out-of-pocket 44
expense requirements imposed by the policy, contract, or 45
agreement. 46
(B) Notwithstanding section 3901.71 of the Revised Code, 47
every individual or group health insuring corporation policy, 48
H. B. No. 619 Page 3
As Introduced
contract, or agreement providing basic health care services that 49
is delivered, issued for delivery, or renewed in this state 50
shall provide benefits for the expenses of all of the following: 51
(1) To detect the presence of breast cancer in adult 52
womenindividuals, a screening mammography; 53
(2) To detect the presence of breast cancer in adult women 54
individuals meeting either or both of the conditions described 55
in division (C)(2) of this section, supplemental breast cancer 56
screening; 57
(3) To diagnose breast cancer in adult individuals meeting 58
the condition described in division (C)(3) of this section, a 59
diagnostic breast examination; 60
(4) To detect the presence of cervical cancer, cytologic 61
screening. 62
(C)(1) The benefits provided under division (B)(1) of this 63
section shall cover expenses for one screening mammography every 64
year, including digital breast tomosynthesis. 65
(2) The benefits provided under division (B)(2) of this 66
section shall cover expenses for supplemental breast cancer 67
screening for an adult woman individual who meets either or both 68
of the following conditions: 69
(a) The woman's individual's screening mammography 70
demonstrates, based on the breast imaging reporting and data 71
system established by the American college of radiology, that 72
the woman individual has dense breast tissue; 73
(b) The woman individual is at an increased risk of breast 74
cancer due to family history, prior personal history of breast 75
cancer, ancestry, genetic predisposition, or other reasons as 76
H. B. No. 619 Page 4
As Introduced
determined by the woman's individual's health care provider. 77
(3) The benefits provided under division (B)(3) of this 78
section shall cover expenses for diagnostic breast examination 79
for an adult individual who has an abnormality seen or suspected 80
from, or detected by, a screening mammography, supplemental 81
breast cancer screening, or another means of examination. 82
(D)(1) Subject to divisions (D)(2) and (3) of this 83
section, if a provider, hospital, or other health care facility 84
provides a service that is a component of the screening 85
mammography a benefit in provided under division (B)(1), (2), or 86
(3) of this section or a component of the supplemental breast 87
cancer screening benefit in division (B)(2) of this section and 88
submits a separate claim for that component, a separate payment 89
shall be made to the provider, hospital, or other health care 90
facility in an amount that corresponds to the ratio paid by 91
medicare in this state for that component. 92
(2) Regardless of whether separate payments are made for 93
the The total benefit provided under division (B)(1), or (2), or 94
(3) of this section, the total benefit for a screening 95
mammography or supplemental breast cancer screening shall not 96
exceed one hundred thirty per cent of the medicare reimbursement 97
rate in this state for screening mammography or supplemental 98
breast cancer screening. If there is more than one medicare 99
reimbursement rate in this state for screening mammography or a 100
component of a screening mammography or supplemental breast 101
cancer screening or a component of supplemental breast cancer 102
screening, the reimbursement limit shall be one hundred thirty 103
per cent of the lowest medicare and any separate payment for a 104
service that is a component of such a benefit under division (D) 105
(1) of this section, shall not be less than any reimbursement 106
H. B. No. 619 Page 5
As Introduced
rate previously paid by the same individual or group health 107
insuring corporation under a policy, contract, or agreement 108
providing basic health care services that is delivered, issued 109
for delivery, or renewed in this state after the effective date 110
of this amendment to the same provider, hospital, or other 111
health care facility for the same benefit or service that is a 112
component of such benefit. 113
(3) The benefit paid in accordance with division divisions 114
(D)(1) and (2) of this section shall constitute full payment. No 115
provider, hospital, or other health care facility shall seek or 116
receive remuneration in excess of the payment made in accordance 117
with division divisions (D)(1) and (2) of this section, except 118
for approved deductibles and copayments. 119
(E) The (E)(1) Except as provided in division (E)(2) of 120
this section, the benefits provided under division (B)(1) or , 121
(2), or (3) of this section shall be provided only for screening 122
mammographies or , supplemental breast cancer screenings, or 123
diagnostic breast examinations that are performed in a health 124
care facility or mobile mammography screening unit that is 125
accredited under the American college of radiology mammography 126
accreditation program or in a hospital as defined in section 127
3727.01 of the Revised Code. 128
(2) With respect to diagnostic breast examinations that 129
are biopsies, the policy shall not, as a condition of coverage, 130
require biopsies to be performed in a facility, mobile 131
mammography screening unit, or hospital as described in division 132
(E)(1) of this section. 133
(F) The benefits provided under division (B) of this 134
section shall be provided according to the terms of the 135
subscriber contract. 136
H. B. No. 619 Page 6
As Introduced
(G) The benefits provided under division (B)(3) (B)(4) of 137
this section shall be provided only for cytologic screenings 138
that are processed and interpreted in a laboratory certified by 139
the college of American pathologists or in a hospital as defined 140
in section 3727.01 of the Revised Code. 141
(H) No individual or group health insuring corporation 142
policy, contract, or agreement providing basic health care 143
services that is delivered, issued for delivery, or renewed in 144
this state shall impose a cost-sharing requirement for the 145
benefits provided under division (B) of this section. 146
Sec. 3923.52. (A) As used in this section and section 147
3923.53 of the Revised Code: 148
(1) "Screening mammography" means a radiologic examination 149
that, in accordance with applicable American college of 150
radiology guidelines, is utilized to detect unsuspected breast 151
cancer at an early stage in asymptomatic women and includes the 152
x-ray examination of the breast using equipment that is 153
dedicated specifically for mammography, including, but not 154
limited to, the x-ray tube, filter, compression device, screens, 155
film, and cassettes, and that has an average radiation exposure 156
delivery of less than one rad mid-breast. "Screening 157
mammography" includes digital breast tomosynthesis. "Screening 158
mammography" includes two views for each breast. The term also 159
includes the professional interpretation of the film. 160
"Screening mammography" does not include diagnostic 161
mammography. 162
(2) "Diagnostic breast examination" means any examination 163
that, in accordance with applicable American college of 164
radiology guidelines, is deemed medically necessary by a 165
H. B. No. 619 Page 7
As Introduced
treating health care provider to diagnose breast cancer, 166
including diagnostic mammography, magnetic resonance imaging, 167
ultrasound, or biopsy. 168
(3) "Cost-sharing" means the cost to an individual insured 169
under an individual or group policy of sickness and accident 170
insurance or a public employee benefit plan according to any 171
coverage limit, copayment, coinsurance, deductible, or other 172
out-of-pocket expense requirements imposed by the policy or 173
plan. 174
(4) "Supplemental breast cancer screening" means any 175
additional screening method deemed medically necessary by a 176
treating health care provider for proper breast cancer screening 177
in accordance with applicable American college of radiology 178
guidelines, including magnetic resonance imaging, ultrasound, 179
contrast enhanced mammography, or molecular breast imaging. 180
(B) Notwithstanding section 3901.71 of the Revised Code, 181
every policy of individual or group sickness and accident 182
insurance that is delivered, issued for delivery, or renewed in 183
this state shall provide benefits for the expenses of all of the 184
following: 185
(1) To detect the presence of breast cancer in adult 186
womenindividuals, a screening mammography; 187
(2) To detect the presence of breast cancer in adult women 188
individuals meeting either or both of the conditions described 189
in division (C)(2) of this section, supplemental breast cancer 190
screening; 191
(3) To diagnose breast cancer in adult individuals meeting 192
the condition described in division (C)(3) of this section, a 193
diagnostic breast examination; 194
H. B. No. 619 Page 8
As Introduced
(4) To detect the presence of cervical cancer, cytologic 195
screening. 196
(C)(1) The benefits provided under division (B)(1) of this 197
section shall cover expenses for one screening mammography every 198
year, including digital breast tomosynthesis. 199
(2) The benefits provided under division (B)(2) of this 200
section shall cover expenses for supplemental breast cancer 201
screening for an adult woman individual who meets either or both 202
of the following conditions: 203
(a) The woman's individual's screening mammography 204
demonstrates, based on the breast imaging reporting and data 205
system established by the American college of radiology, that 206
the woman individual has dense breast tissue; 207
(b) The woman individual is at an increased risk of breast 208
cancer due to family history, prior personal history of breast 209
cancer, ancestry, genetic predisposition, or other reasons as 210
determined by the woman's individual's health care provider. 211
(3) The benefits provided under division (B)(3) of this 212
section shall cover expenses for diagnostic breast examination 213
for an adult individual who has an abnormality seen or suspected 214
from, or detected by, a screening mammography, supplemental 215
breast cancer screening, or another means of examination. 216
(D) As used in this division, "medicare reimbursement 217
rate" means the reimbursement rate paid in this state under the 218
medicare program for screening mammography that does not include 219
digitization or computer-aided detection, regardless of whether