Senate File 136 - Introduced
SENATE FILE 136
BY SWEENEY
A BILL FOR
1 An Act relating to insurance coverage for diagnostic breast
2 cancer examinations, and including applicability provisions.
3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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1 Section 1. NEW SECTION. 514C.4A Diagnostic examinations
2 —— breast cancer.
3 1. As used in this section, unless the context otherwise
4 requires:
5 a. “Abnormality” means an abnormal feature, characteristic,
6 or occurrence in a covered person’s breast that meets any of
7 the following requirements:
8 (1) The abnormality is identified as a result of a covered
9 person’s screening mammogram.
10 (2) The abnormality is identified during the provision
11 of health care services to a covered person by a health care
12 professional.
13 (3) A health care professional determines an abnormality
14 exists based on a covered person’s medical history or the
15 covered person’s family medical history.
16 b. “Breast magnetic resonance imaging” or “breast MRI” means
17 an examination of a breast using a powerful magnetic field,
18 radio waves, and a computer to produce detailed pictures of the
19 structures within the breast.
20 c. “Breast ultrasound” means a noninvasive examination of
21 a breast using high-frequency sound waves to produce detailed
22 images of the breast.
23 d. “Cost-sharing” means any coverage limit, copayment,
24 coinsurance, deductible, or other out-of-pocket expense
25 obligation imposed on a covered person by a policy, contract,
26 or plan providing for third-party payment or prepayment of
27 health or medical expenses.
28 e. “Covered person” means a policyholder, subscriber, or
29 other person participating in a policy, contract, or plan that
30 provides for third-party payment or prepayment of health or
31 medical expenses.
32 f. “Diagnostic breast cancer examination” means an
33 examination of an abnormality, deemed medically necessary by a
34 covered person’s health care professional, for the detection
35 of breast cancer. The examination may be conducted using a
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1 diagnostic mammogram, breast magnetic resonance imaging, or a
2 breast ultrasound.
3 g. “Diagnostic mammogram” means a detailed examination of a
4 breast abnormality using X ray.
5 h. “Health care professional” means the same as defined in
6 section 514J.102.
7 i. “Health care services” means services for the diagnosis,
8 prevention, treatment, cure, or relief of a health condition,
9 illness, injury, or disease.
10 j. “Screening mammogram” means an examination of a breast
11 that aids in the early detection and diagnosis of breast
12 cancer.
13 2. Notwithstanding the uniformity of treatment requirements
14 of section 514C.6, a policy, contract, or plan providing
15 for third-party payment or prepayment of health or medical
16 expenses shall provide coverage for diagnostic breast cancer
17 examinations. The policy, contract, or plan shall not require
18 cost-sharing greater than the cost-sharing that the policy,
19 contract, or plan requires for a screening mammogram.
20 3. a. This section shall apply to the following classes of
21 third-party payment provider contracts, policies, or plans:
22 (1) Individual or group accident and sickness insurance
23 providing coverage on an expense-incurred basis.
24 (2) An individual or group hospital or medical service
25 contract issued pursuant to chapter 509, 514, or 514A.
26 (3) An individual or group health maintenance organization
27 contract regulated under chapter 514B.
28 (4) A plan established for public employees pursuant to
29 chapter 509A.
30 b. This section shall not apply to accident-only, specified
31 disease, short-term hospital or medical, hospital confinement
32 indemnity, credit, dental, vision, Medicare supplement,
33 long-term care, basic hospital and medical-surgical expense
34 coverage as defined by the commissioner of insurance,
35 disability income insurance coverage, coverage issued as a
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1 supplement to liability insurance, workers’ compensation or
2 similar insurance, or automobile medical payment insurance.
3 4. The commissioner of insurance shall adopt rules pursuant
4 to chapter 17A to administer this section.
5 Sec. 2. APPLICABILITY. This Act applies to third-party
6 payment provider contracts, policies, or plans delivered,
7 issued for delivery, continued, or renewed in this state on or
8 after January 1, 2022.
9 EXPLANATION
10 The inclusion of this explanation does not constitute agreement with
11 the explanation’s substance by the members of the general assembly.
12 This bill relates to insurance coverage for diagnostic
13 breast cancer examinations.
14 The bill requires a policy, contract, or plan providing for
15 third-party payment or prepayment of health or medical expenses
16 to provide coverage for diagnostic breast cancer examinations.
17 “Diagnostic breast cancer examination” is defined in the bill
18 as an examination of an abnormality, deemed medically necessary
19 by a covered person’s health care professional, for the
20 detection of breast cancer. The examination may be conducted
21 using a diagnostic mammogram, breast magnetic resonance
22 imaging, or breast ultrasound. “Abnormality”, “diagnostic
23 mammogram”, “breast magnetic resonance imaging”, and “breast
24 ultrasound” are also defined in the bill.
25 The policy, contract, or plan cannot require cost-sharing
26 greater than the cost-sharing that the policy, contract, or
27 plan requires for a screening mammogram. “Cost-sharing” and
28 “screening mammogram” are defined in the bill.
29 The bill applies to third-party payment providers enumerated
30 in the bill. The bill specifies the types of specialized
31 health-related insurance which are not subject to the coverage
32 requirements of the bill.
33 The commissioner of insurance is required to adopt rules to
34 administer the requirements of the bill.
35 The bill applies to third-party payment provider contracts,
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1 policies, or plans delivered, issued for delivery, continued,
2 or renewed in this state on or after January 1, 2022.
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