Amended IN Assembly March 16, 2022 CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION Assembly Bill No. 2024Introduced by Assembly Member FriedmanFebruary 14, 2022 An act to repeal and add amend Section 1367.65 of the Health and Safety Code, and to repeal and add amend Section 10123.81 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 2024, as amended, Friedman. Health care coverage: diagnostic imaging. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract issued, amended, delivered, or renewed on or after January 1, 2000, or an individual or group policy of disability insurance or self-insured employee welfare benefit plan to provide coverage for mammography for screening or diagnostic purposes upon referral by specified professionals. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023, to provide coverage for medically necessary diagnostic or supplemental breast examinations, as defined, without a for screening or diagnostic purposes upon referral by specified professionals. The bill would require the cost-sharing imposed for a diagnostic or supplemental breast examination to be the same as the cost-sharing imposed for mammography under prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023. 2023, from imposing cost sharing for medically necessary or supplemental breast examinations.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. It is the intent of the Legislature to ensure that health care service plan contracts and health insurance policies provide coverage for both initial screening and diagnostic breast examinations and supplemental breast examinations deemed medically necessary and upon referral by a health care provider, without cost-sharing requirements.SEC. 2. Section 1367.65 of the Health and Safety Code is amended to read:1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(d) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 3. Section 10123.81 of the Insurance Code is amended to read:10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(c)(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.(e) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.SECTION 1.Section 1367.65 of the Health and Safety Code is repealed.SEC. 2.Section 1367.65 is added to the Health and Safety Code, to read:1367.65.(a)A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination.(b)Cost-sharing imposed for a diagnostic or supplemental breast examination shall be the same as the cost-sharing imposed for mammography under a health care service plan contract issued, amended, or renewed on or after January 1, 2023.(c)For purposes of this section:(1)Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2)Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3)Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4)Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or contrast-enhanced mammography that is either of the following:(A)Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.(5)Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6)Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A)Used to screen for breast cancer when an abnormality is not seen or suspected.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 3.Section 10123.81 of the Insurance Code is repealed.SEC. 4.Section 10123.81 is added to the Insurance Code, to read:10123.81.(a)A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination.(b)Cost-sharing imposed for a diagnostic or supplemental breast examination shall be the same as the cost-sharing imposed for mammography under a health insurance policy issued, amended, or renewed on or after January 1, 2023.(c)For purposes of this section:(1)Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2)Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3)Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4)Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or contrast-enhanced mammography that is either of the following:(A)Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.(5)Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6)Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A)Used to screen for breast cancer when an abnormality is not seen or suspected.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 5.No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.
Amended IN Assembly March 16, 2022 CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION Assembly Bill No. 2024Introduced by Assembly Member FriedmanFebruary 14, 2022 An act to repeal and add amend Section 1367.65 of the Health and Safety Code, and to repeal and add amend Section 10123.81 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 2024, as amended, Friedman. Health care coverage: diagnostic imaging. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract issued, amended, delivered, or renewed on or after January 1, 2000, or an individual or group policy of disability insurance or self-insured employee welfare benefit plan to provide coverage for mammography for screening or diagnostic purposes upon referral by specified professionals. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023, to provide coverage for medically necessary diagnostic or supplemental breast examinations, as defined, without a for screening or diagnostic purposes upon referral by specified professionals. The bill would require the cost-sharing imposed for a diagnostic or supplemental breast examination to be the same as the cost-sharing imposed for mammography under prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023. 2023, from imposing cost sharing for medically necessary or supplemental breast examinations.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES
Amended IN Assembly March 16, 2022
Amended IN Assembly March 16, 2022
CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION
Assembly Bill
No. 2024
Introduced by Assembly Member FriedmanFebruary 14, 2022
Introduced by Assembly Member Friedman
February 14, 2022
An act to repeal and add amend Section 1367.65 of the Health and Safety Code, and to repeal and add amend Section 10123.81 of the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 2024, as amended, Friedman. Health care coverage: diagnostic imaging.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract issued, amended, delivered, or renewed on or after January 1, 2000, or an individual or group policy of disability insurance or self-insured employee welfare benefit plan to provide coverage for mammography for screening or diagnostic purposes upon referral by specified professionals. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023, to provide coverage for medically necessary diagnostic or supplemental breast examinations, as defined, without a for screening or diagnostic purposes upon referral by specified professionals. The bill would require the cost-sharing imposed for a diagnostic or supplemental breast examination to be the same as the cost-sharing imposed for mammography under prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023. 2023, from imposing cost sharing for medically necessary or supplemental breast examinations.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract issued, amended, delivered, or renewed on or after January 1, 2000, or an individual or group policy of disability insurance or self-insured employee welfare benefit plan to provide coverage for mammography for screening or diagnostic purposes upon referral by specified professionals.
This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023, to provide coverage for medically necessary diagnostic or supplemental breast examinations, as defined, without a for screening or diagnostic purposes upon referral by specified professionals. The bill would require the cost-sharing imposed for a diagnostic or supplemental breast examination to be the same as the cost-sharing imposed for mammography under prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023. 2023, from imposing cost sharing for medically necessary or supplemental breast examinations.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. It is the intent of the Legislature to ensure that health care service plan contracts and health insurance policies provide coverage for both initial screening and diagnostic breast examinations and supplemental breast examinations deemed medically necessary and upon referral by a health care provider, without cost-sharing requirements.SEC. 2. Section 1367.65 of the Health and Safety Code is amended to read:1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(d) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 3. Section 10123.81 of the Insurance Code is amended to read:10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(c)(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.(e) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.SECTION 1.Section 1367.65 of the Health and Safety Code is repealed.SEC. 2.Section 1367.65 is added to the Health and Safety Code, to read:1367.65.(a)A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination.(b)Cost-sharing imposed for a diagnostic or supplemental breast examination shall be the same as the cost-sharing imposed for mammography under a health care service plan contract issued, amended, or renewed on or after January 1, 2023.(c)For purposes of this section:(1)Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2)Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3)Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4)Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or contrast-enhanced mammography that is either of the following:(A)Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.(5)Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6)Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A)Used to screen for breast cancer when an abnormality is not seen or suspected.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 3.Section 10123.81 of the Insurance Code is repealed.SEC. 4.Section 10123.81 is added to the Insurance Code, to read:10123.81.(a)A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination.(b)Cost-sharing imposed for a diagnostic or supplemental breast examination shall be the same as the cost-sharing imposed for mammography under a health insurance policy issued, amended, or renewed on or after January 1, 2023.(c)For purposes of this section:(1)Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2)Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3)Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4)Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or contrast-enhanced mammography that is either of the following:(A)Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.(5)Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6)Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A)Used to screen for breast cancer when an abnormality is not seen or suspected.(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.SEC. 5.No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. It is the intent of the Legislature to ensure that health care service plan contracts and health insurance policies provide coverage for both initial screening and diagnostic breast examinations and supplemental breast examinations deemed medically necessary and upon referral by a health care provider, without cost-sharing requirements.
SECTION 1. It is the intent of the Legislature to ensure that health care service plan contracts and health insurance policies provide coverage for both initial screening and diagnostic breast examinations and supplemental breast examinations deemed medically necessary and upon referral by a health care provider, without cost-sharing requirements.
SECTION 1. It is the intent of the Legislature to ensure that health care service plan contracts and health insurance policies provide coverage for both initial screening and diagnostic breast examinations and supplemental breast examinations deemed medically necessary and upon referral by a health care provider, without cost-sharing requirements.
### SECTION 1.
SEC. 2. Section 1367.65 of the Health and Safety Code is amended to read:1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(d) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
SEC. 2. Section 1367.65 of the Health and Safety Code is amended to read:
### SEC. 2.
1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(d) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(d) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(d) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
1367.65. (a) On or after January 1, 2000, each health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered, or renewed shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.
(b)This section does not prevent application of copayment or deductible provisions in a plan, nor shall this section be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. This section does not authorize a plan enrollee to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the plan enrollee is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.
(b) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.
(c) A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.
(d) For purposes of this section:
(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.
(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.
(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.
(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:
(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.
(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.
(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.
(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:
(A) Used to screen for breast cancer when an abnormality is not seen or suspected.
(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
SEC. 3. Section 10123.81 of the Insurance Code is amended to read:10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(c)(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.(e) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
SEC. 3. Section 10123.81 of the Insurance Code is amended to read:
### SEC. 3.
10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(c)(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.(e) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(c)(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.(e) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.(c)(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.(e) For purposes of this section:(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:(A) Used to screen for breast cancer when an abnormality is not seen or suspected.(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
10123.81. (a) An individual or group policy of disability insurance or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.
(b)This section does not prevent the application of copayment or deductible provisions in a policy, nor does this section require that a policy be extended to cover any other procedures under an individual or a group policy. This section does not authorize a policyholder to receive the services required to be covered by this section if those services are furnished by a nonparticipating provider, unless the policyholder is referred to that provider by a participating physician, nurse practitioner, or certified nurse-midwife providing care.
(b) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.
(c) A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement for medically necessary diagnostic or supplemental breast examinations.
(c)
(d) This section shall not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.
(e) For purposes of this section:
(1) Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.
(2) Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.
(3) Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.
(4) Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is either of the following:
(A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.
(B) Necessary based on personal or family medical history or additional factors, including known genetic mutations, that may increase the individuals risk of breast cancer.
(5) Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.
(6) Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:
(A) Used to screen for breast cancer when an abnormality is not seen or suspected.
(B) Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
### SEC. 4.
(a)A health care service plan contract issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination.
(b)Cost-sharing imposed for a diagnostic or supplemental breast examination shall be the same as the cost-sharing imposed for mammography under a health care service plan contract issued, amended, or renewed on or after January 1, 2023.
(c)For purposes of this section:
(1)Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.
(2)Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.
(3)Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.
(4)Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or contrast-enhanced mammography that is either of the following:
(A)Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.
(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
(5)Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.
(6)Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:
(A)Used to screen for breast cancer when an abnormality is not seen or suspected.
(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
(a)A health insurance policy issued, amended, or renewed on or after January 1, 2023, shall provide coverage for medically necessary diagnostic or supplemental breast examination.
(b)Cost-sharing imposed for a diagnostic or supplemental breast examination shall be the same as the cost-sharing imposed for mammography under a health insurance policy issued, amended, or renewed on or after January 1, 2023.
(c)For purposes of this section:
(1)Breast magnetic resonance imaging means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.
(2)Breast ultrasound means a noninvasive diagnostic tool that uses high-frequency sound.
(3)Cost-sharing means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense.
(4)Diagnostic breast examination means a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or contrast-enhanced mammography that is either of the following:
(A)Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer.
(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
(5)Diagnostic mammography means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast.
(6)Supplemental breast examination means a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is either of the following:
(A)Used to screen for breast cancer when an abnormality is not seen or suspected.
(B)Necessary based on personal or family medical history or additional factors that may increase the individuals risk of breast cancer.
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.