§ 38a-530 — Mandatory coverage for diagnostic and screening mammography, diagnostic and screening breast ultrasound, diagnostic and screening magnetic resonance imaging, breast biopsies, prophylactic mastectomies and breast reconstructive surgery. Breast density information included in report.

Connecticut § 38a-530

• Jurisdiction: Connecticut
• Title 38a: Insurance
• Ch. 700c: Health Insurance

Text

(a) For purposes of this section: (1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and (2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code. (b) (1) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for diagnostic and screening mammograms for insureds that are at least equal to the following minimum requirements: (A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, for an insured who is: (i) Thirty-five to thirty-nine years of age, inclusive; or (ii) Younger than thirty-five years of age if the insured is believed to be at increased risk for breast cancer due to: (I) A family history of breast cancer; (II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene variant that materially increases the insured's risk for breast cancer; (III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or (IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider; and (B) A mammogram, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, every year for an insured who is: (i) Forty years of age or older; or (ii) Younger than forty years of age if the insured is believed to be at increased risk for breast cancer due to: (I) A family history, or prior personal history, of breast cancer; (II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; (III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or (IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider. (2) Such policy shall provide additional benefits for: (A) Comprehensive diagnostic and screening ultrasounds of an entire breast or breasts if: (i) A mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology; or (ii) An insured is believed to be at increased risk for breast cancer due to: (I) A family history or prior personal history of breast cancer; (II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; (III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or (IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider; (B) Diagnostic and screening magnetic resonance imaging of an entire breast or breasts: (i) In accordance with guidelines established by the American Cancer Society for an insured who is thirty-five years of age or older; or (ii) If an insured is younger than thirty-five years of age and believed to be at increased risk for breast cancer due to: (I) A family history, or prior personal history, of breast cancer; (II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; (III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or (IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider; (C) Breast biopsies; (D) Prophylactic mastectomies for an insured who is believed to be at increased risk for breast cancer due to positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; and (E) Breast reconstructive surgery for an insured who has undergone: (i) A prophylactic mastectomy; or (ii) A mastectomy as part of the insured's course of treatment for breast cancer. (c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-520 , to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable. (d) Each mammography report provided to an insured shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's, physician assistant's or advanced practice registered nurse's office and you should contact your physician, physician assistant or advanced practice registered nurse if you have any questions or concerns about this report.”. See Sec. 38a-503 for similar provisions re individual policies.

Legislative History

(P.A. 90-243, S. 114; P.A. 01-171, S. 23; P.A. 05-69, S. 2; P.A. 06-38, S. 2; P.A. 09-41, S. 2; P.A. 11-67, S. 2; 11-171, S. 2; P.A. 12-150, S. 2; P.A. 14-97, S. 2; P.A. 16-82, S. 2; P.A. 18-159, S. 2; P.A. 19-98, S. 13; 19-117, S. 210; July Sp. Sess. P.A. 20-4, S. 33; P.A. 21-196, S. 73; P.A. 22-90, S. 2.) History: P.A. 01-171 added “amended or continued” re policies in this state, substituted “October 1, 2001,” for “October 1, 1988,” re policy date, and consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012; P.A. 14-97 amended Subsec. (b) to add provision limiting copayment for breast ultrasound screening to maximum of $20, effective January 1, 2015; P.A. 16-82 amended Subsec. (a)(1) by adding “, which may be provided by breast tomosynthesis at the option of the woman covered under the policy,” in Subparas. (A) and (B), effective January 1, 2017; P.A. 18-159 added new Subsec. (a) defining “Healthcare Common Procedure Coding System” and “Mammogram”, redesignated existing Subsecs. (a) to (c) as Subsecs. (b) to (d), and made conforming changes, effective January 1, 2019; P.A. 19-98 amended Subsec. (d) by adding references to advanced practice registered nurses; P.A. 19-117 amended Subsec. (b)(2)(A) by designating existing provisions re heterogeneous or dense breast tissue as Subpara. (A)(i), designating existing provisions re women believed to be at increased risk for breast cancer as Subpara. (A)(ii) and adding Subpara. (A)(iii) re screening recommended by woman's treating physician, and amended Subsec. (c) by deleting provision re maximum of $20 for ultrasound screening and adding provisions prohibiting coinsurances, copayments, deductibles, out-of-pocket expenses and high deductible plans, effective January 1, 2020; July Sp. Sess. P.A. 20-4 amended Subsec. (c) by substituting “high deductible health plan” for “high deductible plan”; P.A. 21-196 amended Subsecs. (b)(2)(A) and (d) by adding references to physician assistant; P.A. 22-90 amended Subsec. (b) by adding “diagnostic and screening” re coverage for mammograms, replaced “woman” with “insured”, added Subpara. (A)(ii) and corresponding subclauses (I) through (IV) re coverage for baseline mammogram for insured under thirty-five years of age if at increased risk for breast cancer due to family history, positive genetic testing for harmful variants, prior treatment for a childhood cancer involving radiation directed at the chest or other indications determined by insured's provider, added Subpara. (B)(ii) and corresponding subclauses (I) through (IV) re coverage for annual mammogram for insured younger than 40 years of age if at increased risk for breast cancer due to family history, positive genetic testing for harmful variants, prior treatment for a childhood cancer involving radiation directed at the chest or other indications determined by insured's provider, amended Subsec. (b)(2) by replacing “ultrasound screening” with “diagnostic and screening ultrasounds” in Subpara. (A), adding in clause (ii)(II)that at increased risk includes positive genetic testing for harmful variants, adding in clause (ii)(III) that at increased risk includes prior treatment for a childhood cancer involving radiation directed at the chest, adding in clause (ii)(IV) reference to certified nurse midwife or other medical provider and deleting former clause (iii) of Subpara. (2)(A) re screening recommendation by physician, replacing “magnetic” with “diagnostic and screening magnetic” in Subpara. (B), adding in coverage requirements in clauses (i) through (iv) of Subpara. (B) and corresponding subclauses re insured who is at least 35 years of age and believed to be at increased risk for breast cancer due to family history, positive genetic testing for harmful variants, prior treatment for a childhood cancer involving radiation directed at the chest or other indications determined by insured's provider, added Subpara. (C) in Subsec. (b)(2) re coverage for breast biopsies, added Subpara. (D) in Subsec. (b)(2) re coverage for prophylactic mastectomies for insured at increased risk due to positive genetic testing of harmful variants, added Subpara. (E) in Subsec. (b)(2) re coverage for breast reconstructive surgery for insured who has undergone prophylactic mastectomy or mastectomy as part of breast cancer treatment, in Subsec. (d) replaced “a patient” with “an insured” and made technical changes in Subsec. (b), effective January 1, 2023.