First Regular Session
Seventy-fifth General Assembly
STATE OF COLORADO
INTRODUCED
LLS NO. 25-0060.02 Brita Darling x2241
SENATE BILL 25-296
Senate Committees House Committees
Health & Human Services
A BILL FOR AN ACT
C
ONCERNING INSURANCE COVERAGE FOR PREVENTIVE BREAST101
CANCER EXAMINATIONS .102
Bill Summary
(Note: This summary applies to this bill as introduced and does
not reflect any amendments that may be subsequently adopted. If this bill
passes third reading in the house of introduction, a bill summary that
applies to the reengrossed version of this bill will be available at
http://leg.colorado.gov
.)
The bill makes changes to preventive care coverage by health
insurers for breast cancer screening, including by:
! Relocating in statute the high-risk breast cancer screening
requirements;
! Defining and creating parameters around the use of
diagnostic breast examinations and supplemental breast
SENATE SPONSORSHIP
Michaelson Jenet, Rich
HOUSE SPONSORSHIP
Bird and Stewart K., Rydin, Stewart R.
Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
Capital letters or bold & italic numbers indicate new material to be added to existing law.
Dashes through the words or numbers indicate deletions from existing law. examinations; and
! Clarifying that diagnostic and supplemental breast
examinations, in addition to regular breast cancer
screening, do not require cost sharing by the patient.
Be it enacted by the General Assembly of the State of Colorado:1
SECTION 1. In Colorado Revised Statutes, 10-16-104, amend2
(18)(b.5) and (18)(c)(III.5)(B) as follows:3
10-16-104. Mandatory coverage provisions - definitions - rules4
- applicability. (18) Prevention health-care services - rules -5
definitions. (b.5) (I) The coverage required by
PURSUANT TO this6
subsection (18) must include a preventive breast cancer screening study7
that is within appropriate use guidelines as determined by the American8
College of Radiology, the National Comprehensive Cancer Network, or9
their successor entities. for the actual cost of an annual breast cancer10
screening using the noninvasive imaging modality appropriate for the11
covered person's breast health needs, as determined by the covered12
person's provider.13
(II) [Similar to former section 10-16-104 (18)(b.5)(IV)] (A) For14
any breast imaging performed after the breast cancer screening study,15
whether it is diagnostic breast imaging for further evaluation or16
supplemental breast imaging within the same calendar year based on17
factors including a high lifetime risk for breast cancer or high breast18
density, the noninvasive imaging modality or modalities used must be the19
same as, or comparable to, the modality or modalities used for the breast20
cancer screening study. NOTWITHSTANDING OTHER COVERAGE21
PROVISIONS OF SUBSECTION (18)(b.5)(I) OF THIS SECTION, A POLICY OR22
CONTRACT SUBJECT TO THIS SUBSECTION (18) MUST COVER AN ANNUAL23
SB25-296-2- BREAST CANCER SCREENING USING THE APPROPRIATE NONINVASIVE1
IMAGING MODALITY OR COMBINATION OF MODALITIES RECOGNIZED BY THE2
A
MERICAN COLLEGE OF RADIOLOGY OR THE NATIONAL COMPREHENSIVE3
C
ANCER NETWORK, OR THEIR SUCCESSOR ENTITIES, FOR ALL INDIVIDUALS4
POSSESSING AT LEAST ONE RISK FACTOR FOR BREAST CANCER , INCLUDING:5
(A) A
FAMILY HISTORY OF BREAST CANCER ;6
(B) B
EING FORTY YEARS OF AGE OR OLDER; OR7
(C) A
N INCREASED LIFETIME RISK OF BREAST CANCER DETERMINED8
BY A RISK FACTOR MODEL, SUCH AS TYRER-CUZICK, BRCAPRO, OR GAIL,9
OR BY OTHER CLINICALLY APPROPRIATE RISK ASSESSMENT MODELS .10
(B) If the noninvasive imaging modality is recommended by the
11
covered person's provider and the breast imaging is within appropriate use12
guidelines as determined by the American College of Radiology, the13
National Comprehensive Cancer Network, or their successor entities, the14
covered person is not responsible for any cost-sharing amounts.15
(C) If the covered person receives more than one breast imaging16
that is in excess of what is recommended by the American College of17
Radiology, the National Comprehensive Cancer Network, or their18
successor entities, in a given calendar year or contract year, the other19
benefit provisions in the policy or contract apply with respect to the20
additional breast imaging.21
(III) Benefits for preventive breast cancer screening studies and22
breast imaging are determined on a calendar year or a contract year basis.23
The preventive and diagnostic coverages provided pursuant to this24
subsection (18)(b.5) do not diminish or limit diagnostic benefits otherwise25
allowable under a policy or contract. THE COVERAGE REQUIRED26
PURSUANT TO THIS SUBSECTION (18)(b.5) MUST INCLUDE:27
SB25-296
-3- (A) A MEDICALLY NECESSARY AND APPROPRIATE DIAGNOSTIC1
EXAMINATION OF THE BREAST THAT IS USED TO EVALUATE AN2
ABNORMALITY SEEN OR SUSPECTED FROM A SCREENING EXAMINATION FOR3
BREAST CANCER OR USED TO EVALUATE AN ABNORMALITY DETECTED BY4
ANOTHER MEANS OF EXAMINATION ; AND5
(B) A
MEDICALLY NECESSARY AND APPROPRIATE SUPPLEMENTAL6
EXAMINATION OF THE BREAST THAT IS USED TO SCREEN FOR BREAST7
CANCER WHEN THERE IS NO ABNORMALITY SEEN OR SUSPECTED AND THAT8
IS BASED ON PERSONAL OR FAMILY MEDICAL HISTORY OR ADDITIONAL9
FACTORS THAT INCREASE THE INDIVIDUAL 'S RISK OF BREAST CANCER,10
INCLUDING HETEROGENEOUSLY OR EXTREMELY DENSE BREASTS .11
(IV) Notwithstanding the other coverage provisions of this
12
subsection (18)(b.5), a policy or contract subject to this subsection (18)13
must cover an annual breast cancer screening using the appropriate14
noninvasive imaging modality or combination of modalities recognized15
by the American College of Radiology, the National Comprehensive16
Cancer Network, or their successor entities, for all individuals possessing17
at least one risk factor for breast cancer, including THE COVERAGE18
REQUIRED PURSUANT TO THIS SUBSECTION (18)(b.5) MUST COVER THE19
FOLLOWING SERVICES , WITHOUT COST -SHARING REQUIREMENTS ,20
INCLUDING DEDUCTIBLES , COINSURANCE, COPAYMENTS, OR ANY21
MAXIMUM LIMITATION ON THE APPLICATION OF SUCH DEDUCTIBLES ,22
COINSURANCE, OR COPAYMENTS OR SIMILAR OUT-OF-POCKET EXPENSES:23
(A) A family history of breast cancer BREAST CANCER SCREENING24
STUDIES;25
(B) Being forty years of age or older; or DIAGNOSTIC26
EXAMINATIONS OF THE BREAST THAT ARE MEDICALLY NECESSARY AND27
SB25-296
-4- APPROPRIATE, IN ACCORDANCE WITH THE NATIONAL COMPREHENSIVE1
C
ANCER NETWORK GUIDELINES, INCLUDING SUCH AN EXAMINATION USING2
CONTRAST-ENHANCED MAMMOGRAPHY , DIAGNOSTIC MAMMOGRAPHY ,3
BREAST MAGNETIC RESONANCE IMAGING , BREAST ULTRASOUND , OR4
MOLECULAR BREAST IMAGING ; AND5
(C) An increased lifetime risk of breast cancer determined by a
6
risk factor model such as Tyrer-Cuzick, BRCAPRO, or GAIL or by other7
clinically appropriate risk assessment models SUPPLEMENTAL8
EXAMINATIONS OF THE BREAST THAT ARE MEDICALLY NECESSARY AND9
APPROPRIATE, IN ACCORDANCE WITH THE NATIONAL COMPREHENSIVE10
C
ANCER NETWORK GUIDELINES, INCLUDING SUCH AN EXAMINATION USING11
CONTRAST-ENHANCED MAMMOGRAPHY , BREAST MAGNETIC RESONANCE12
IMAGING, BREAST ULTRASOUND, OR MOLECULAR BREAST IMAGING .13
(V) I
F APPLICATION OF THIS SUBSECTION (18) WOULD MAKE A14
COVERED PERSON 'S HEALTH SAVINGS ACCOUNT CONTRIBUTIONS15
INELIGIBLE UNDER SECTION 223 OF THE FEDERAL "INTERNAL REVENUE16
C
ODE OF 1986", 26 U.S.C. SEC. 223, THIS SUBSECTION (18) APPLIES TO THE17
DEDUCTIBLE APPLICABLE TO THE COVERED PERSON 'S HEALTH BENEFIT18
PLAN AFTER THE COVERED PERSON HAS SATISFIED THE MINIMUM19
DEDUCTIBLE AMOUNT UNDER 26 U.S.C. SEC. 223; EXCEPT THAT, WITH20
RESPECT TO ITEMS OR SERVICES THAT ARE PREVENTIVE CARE PURSUANT21
TO 26 U.S.C. SEC. 223 (c)(2)(C), THIS SUBSECTION (18) APPLIES,22
REGARDLESS OF WHETHER THE MINIMUM DEDUCTIBLE UNDER 26 U.S.C.23
SEC. 223 HAS BEEN SATISFIED.24
(c) As used in this subsection (18):25
(III.5) "Breast cancer screening study" and "breast imaging"26
mean:27
SB25-296
-5- (B) A mammogram using a OR OTHER noninvasive imaging1
modality or modalities, as recommended by the medical provider; or2
SECTION 2. Act subject to petition - effective date. This act3
takes effect at 12:01 a.m. on the day following the expiration of the4
ninety-day period after final adjournment of the general assembly; except5
that, if a referendum petition is filed pursuant to section 1 (3) of article V6
of the state constitution against this act or an item, section, or part of this7
act within such period, then the act, item, section, or part will not take8
effect unless approved by the people at the general election to be held in9
November 2026 and, in such case, will take effect on the date of the10
official declaration of the vote thereon by the governor.11
SB25-296
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