House File 874 - Introduced
HOUSE FILE 874
BY GAINES and THEDE
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 an examination of a breast
21 using sound waves to produce pictures of the internal
22 structures 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 using a low-dose x-ray system to see inside the breast, and
12 that aids in the early detection and diagnosis of breast
13 cancer.
14 2. Notwithstanding the uniformity of treatment requirements
15 of section 514C.6, a policy, contract, or plan providing
16 for third-party payment or prepayment of health or medical
17 expenses shall provide coverage for diagnostic breast cancer
18 examinations. The policy, contract, or plan shall not require
19 cost-sharing greater than the cost-sharing that the policy,
20 contract, or plan requires for a screening mammogram.
21 3. a. This section shall apply to the following classes of
22 third-party payment provider contracts, policies, or plans:
23 (1) Individual or group accident and sickness insurance
24 providing coverage on an expense-incurred basis.
25 (2) An individual or group hospital or medical service
26 contract issued pursuant to chapter 509, 514, or 514A.
27 (3) An individual or group health maintenance organization
28 contract regulated under chapter 514B.
29 (4) A plan established for public employees pursuant to
30 chapter 509A.
31 b. This section shall not apply to accident-only, specified
32 disease, short-term hospital or medical, hospital confinement
33 indemnity, credit, dental, vision, Medicare supplement,
34 long-term care, basic hospital and medical-surgical expense
35 coverage as defined by the commissioner of insurance,
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1 disability income insurance coverage, coverage issued as a
2 supplement to liability insurance, workers’ compensation or
3 similar insurance, or automobile medical payment insurance.
4 4. The commissioner of insurance shall adopt rules pursuant
5 to chapter 17A to administer this section.
6 Sec. 2. APPLICABILITY. This Act applies to third-party
7 payment provider contracts, policies, or plans delivered,
8 issued for delivery, continued, or renewed in this state on or
9 after January 1, 2022.
10 EXPLANATION
11 The inclusion of this explanation does not constitute agreement with
12 the explanation’s substance by the members of the general assembly.
13 This bill relates to insurance coverage for diagnostic
14 breast cancer examinations.
15 The bill requires a policy, contract, or plan providing for
16 third-party payment or prepayment of health or medical expenses
17 to provide coverage for diagnostic breast cancer examinations.
18 “Diagnostic breast cancer examination” is defined in the bill
19 as an examination of an abnormality, deemed medically necessary
20 by a covered person’s health care professional, for the
21 detection of breast cancer. The examination may be conducted
22 using a diagnostic mammogram, breast magnetic resonance
23 imaging, or breast ultrasound. “Abnormality”, “diagnostic
24 mammogram”, “breast magnetic resonance imaging”, and “breast
25 ultrasound” are also defined in the bill.
26 The policy, contract, or plan cannot require cost-sharing
27 greater than the cost-sharing that the policy, contract, or
28 plan requires for a screening mammogram. “Cost-sharing” and
29 “screening mammogram” are defined in the bill.
30 The bill applies to third-party payment providers enumerated
31 in the bill. The bill specifies the types of specialized
32 health-related insurance which are not subject to 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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