| 47 | | - | Section 1. Section 431:10A-116, Hawaii Revised Statutes, is amended to read as follows: "§431:10A-116 Coverage for specific services. Every person insured under a policy of accident and health or sickness insurance delivered or issued for delivery in this State shall be entitled to the reimbursements and coverages specified below: (1) Notwithstanding any provision to the contrary, whenever a policy, contract, plan, or agreement provides for reimbursement for any visual or optometric service, which is within the lawful scope of practice of a duly licensed optometrist, the person entitled to benefits or the person performing the services shall be entitled to reimbursement whether the service is performed by a licensed physician or by a licensed optometrist. Visual or optometric services shall include eye or visual examination, or both, or a correction of any visual or muscular anomaly, and the supplying of ophthalmic materials, lenses, contact lenses, spectacles, eyeglasses, and appurtenances thereto; (2) Notwithstanding any provision to the contrary, for all policies, contracts, plans, or agreements issued on or after May 30, 1974, whenever provision is made for reimbursement or indemnity for any service related to surgical or emergency procedures, which is within the lawful scope of practice of any practitioner licensed to practice medicine in this State, reimbursement or indemnification under the policy, contract, plan, or agreement shall not be denied when the services are performed by a dentist acting within the lawful scope of the dentist's license; (3) Notwithstanding any provision to the contrary, whenever the policy provides reimbursement or payment for any service, which is within the lawful scope of practice of a psychologist licensed in this State, the person entitled to benefits or performing the service shall be entitled to reimbursement or payment, whether the service is performed by a licensed physician or licensed psychologist; (4) Notwithstanding any provision to the contrary, each policy, contract, plan, or agreement issued on or after February 1, 1991, except for policies that only provide coverage for specified diseases or other limited benefit coverage, but including policies issued by companies subject to chapter 431, article 10A, part II and chapter 432, article 1 shall provide coverage for screening by low-dose mammography for occult breast cancer as follows: (A) For women forty years of age and older, an annual mammogram; and (B) For a woman of any age with an above-average risk for breast cancer as determined by the use of a risk-factor modeling tool, a history of breast cancer, or whose mother or sister has had a history of breast cancer, [a] an annual mammogram [upon the recommendation of the woman's physician]. The services provided in this paragraph are subject to any coinsurance provisions that may be in force in these policies, contracts, plans, or agreements. For the purpose of this paragraph, the term "low‑dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast. An insurer may provide the services required by this paragraph through contracts with providers; provided that the contract is determined to be a cost-effective means of delivering the services without sacrifice of quality and meets the approval of the director of health; [and] (5) Notwithstanding any provision to the contrary, each policy, contract, plan, or agreement issued on or after January 1, 2022, except for policies that only provide coverage for specified diseases or other limited benefit coverage, but including policies issued by companies subject to chapter 431, article 10A, part II and chapter 432, article 1 shall provide as additional breast cancer screening coverage: (A) For women age thirty or older, a formal risk factor screening assessment informed by any readily available risk factor modeling tool; and (B) For any woman, regardless of age, any additional supplemental imaging, such as breast magnetic resonance imaging, digital breast tomosynthesis, or ultrasound, as deemed medically necessary by an applicable American College of Radiology guideline. For purposes of this subparagraph, "digital breast tomosynthesis" means a radiologic procedure that involves the acquisition of a projection of images over the stationary breast to produce cross-sectional digital three‑dimensional images of the breast; and [(5)] (6) (A) (i) Notwithstanding any provision to the contrary, whenever a policy, contract, plan, or agreement provides coverage for the children of the insured, that coverage shall also extend to the date of birth of any newborn child to be adopted by the insured; provided that the insured gives written notice to the insurer of the insured's intent to adopt the child prior to the child's date of birth or within thirty days after the child's birth or within the time period required for enrollment of a natural born child under the policy, contract, plan, or agreement of the insured, whichever period is longer; provided further that if the adoption proceedings are not successful, the insured shall reimburse the insurer for any expenses paid for the child; and (ii) Where notification has not been received by the insurer prior to the child's birth or within the specified period following the child's birth, insurance coverage shall be effective from the first day following the insurer's receipt of legal notification of the insured's ability to consent for treatment of the infant for whom coverage is sought; and (B) When the insured is a member of a health maintenance organization, coverage of an adopted newborn is effective: (i) From the date of birth of the adopted newborn when the newborn is treated from birth pursuant to a provider contract with the health maintenance organization, and written notice of enrollment in accord with the health maintenance organization's usual enrollment process is provided within thirty days of the date the insured notifies the health maintenance organization of the insured's intent to adopt the infant for whom coverage is sought; or (ii) From the first day following receipt by the health maintenance organization of written notice of the insured's ability to consent for treatment of the infant for whom coverage is sought and enrollment of the adopted newborn in accord with the health maintenance organization's usual enrollment process if the newborn has been treated from birth by a provider not contracting or affiliated with the health maintenance organization." SECTION 2. Section 432:1-605, Hawaii Revised Statutes, is amended to read as follows: "§432:1-605 [Mammogram] Breast cancer screening[.]; mammography. (a) Notwithstanding any provision to the contrary, each policy, contract, plan, or agreement issued on or after February 1, 1991, except for policies that only provide coverage for specified diseases or other limited benefit coverage, but including policies issued by companies subject to chapter 431, article 10A, part II and chapter 432, article 1 shall provide coverage for screening by low-dose mammography for occult breast cancer as follows: (1) For women forty years of age and older, an annual mammogram; and (2) For a woman of any age with an above-average risk for breast cancer as determined by the use of a risk‑factor modeling tool, a history of breast cancer, or whose mother or sister has had a history of breast cancer, [a] an annual mammogram [upon the recommendation of the woman's physician]. (b) Notwithstanding any provision to the contrary, each policy, contract, plan, or agreement issued on or after January 1, 2022, except for policies that only provide coverage for specified diseases or other limited benefit coverage, but including policies issued by companies subject to chapter 431, article 10A, part II and chapter 432, article 1 shall provide as additional breast cancer screening coverage: (1) For women age thirty or older, a formal risk factor screening assessment informed by any readily available risk factor modeling tool; and (2) For any woman, regardless of age, any additional supplemental imaging, such as breast magnetic resonance imaging, digital breast tomosynthesis, or ultrasound, as deemed medically necessary by an applicable American College of Radiology guideline. [(b)] (c) The services provided in [subsection] subsections (a) and (b) are subject to any coinsurance provisions that may be in force in these policies, contracts, plans, or agreements. [(c)] (d) For purposes of this section[,]: ["low-dose] "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid‑breast, with two views for each breast. "Digital breast tomosynthesis" means a radiologic procedure that involves the acquisition of a projection of images over the stationary breast to produce cross-sectional digital three‑dimensional images of the breast. [(d)] (e) An insurer may provide the services required by this section through contracts with providers; provided that the contract is determined to be a cost-effective means of delivering the services without sacrifice of quality and meets the approval of the director of health." SECTION 3. (a) The auditor shall conduct an impact assessment report pursuant to sections 23-51 and 23-52, Hawaii Revised Statutes, to assess the social and financial impacts of the proposed mandated coverage specified in sections 1 and 2 of this Act. (b) The auditor shall submit a report of its findings and recommendations, including any proposed legislation, to the legislature no later than twenty days prior to the convening of the regular session of 2022. SECTION 4. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored. SECTION 5. This Act shall take effect on July 1, 2060. |
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| 47 | + | SECTION 1. The legislature is committed to ensuring that all women have ready access to breast cancer screening, regardless of age and ethnicity, provided the screenings are requested by state licensed and authorized medical practitioners. The legislature has serious reservations about the implementation of United States preventive services task force (USPSTF) guidelines with respect to breast cancer screening. In 2009 and 2016, the USPSTF released recommendations that were a significant departure from screening guidelines issued by leading clinical organizations such as the American College of Radiology, the National Comprehensive Cancer Network, and the American Medical Association. If the USPSTF guidelines were implemented, insurance plans would no longer be required to cover annual mammography without cost sharing for millions of women ages forty to forty-nine. The legislature recognizes that the federal government has delayed implementation of USPSTF guidelines via legislation, most recently with the Consolidated Appropriations Act, 2021, which is scheduled to expire January 1, 2023. The legislature finds that there is ample data showing that annual mammographic screenings significantly reduces breast cancer deaths and morbidity and that effective screening programs are in the best interest of the State and its people. The legislature further recognizes that certain ethnic groups suffer a disproportionately higher rate of breast cancer diagnoses before age fifty. The legislature is concerned that minority women would also be disproportionately and adversely impacted by USPSTF guidelines limiting their access to life-saving screenings. The purpose of this Act is to improve breast cancer detection rates in the State by: (1) Increasing the categories of women required to be covered for mammogram screenings; (2) Requiring the existing health insurance mandate for coverage of low-dose mammography to include advancing technology in digital mammography and breast tomosynthesis; (3) Defining "digital breast tomosynthesis"; and (4) Requiring health care providers to be reimbursed at rates accurately reflecting the resource costs specific to each service, including any increased resource cost after January 1, 2021. SECTION 2. Section 431:10A-116, Hawaii Revised Statutes, is amended to read as follows: "§431:10A-116 Coverage for specific services. Every person insured under a policy of accident and health or sickness insurance delivered or issued for delivery in this State shall be entitled to the reimbursements and coverages specified below: (1) Notwithstanding any provision to the contrary, whenever a policy, contract, plan, or agreement provides for reimbursement for any visual or optometric service[, which] that is within the lawful scope of practice of a duly licensed optometrist, the person entitled to benefits or the person performing the services shall be entitled to reimbursement whether the service is performed by a licensed physician or by a licensed optometrist. Visual or optometric services shall include eye or visual examination, or both, or a correction of any visual or muscular anomaly, and the supplying of ophthalmic materials, lenses, contact lenses, spectacles, eyeglasses, and appurtenances thereto; (2) Notwithstanding any provision to the contrary, for all policies, contracts, plans, or agreements issued on or after May 30, 1974, whenever provision is made for reimbursement or indemnity for any service related to surgical or emergency procedures[, which] that is within the lawful scope of practice of any practitioner licensed to practice medicine in this State, reimbursement or indemnification under the policy, contract, plan, or agreement shall not be denied when the services are performed by a dentist acting within the lawful scope of the dentist's license; (3) Notwithstanding any provision to the contrary, whenever the policy provides reimbursement or payment for any service[, which] that is within the lawful scope of practice of a psychologist licensed in this State, the person entitled to benefits or performing the service shall be entitled to reimbursement or payment, whether the service is performed by a licensed physician or licensed psychologist; (4) Notwithstanding any provision to the contrary, each policy, contract, plan, or agreement issued on or after February 1, 1991, except for policies that only provide coverage for specified diseases or other limited benefit coverage, but including policies issued by companies subject to chapter 431, article 10A, part II and chapter 432, article 1, and health maintenance organizations under chapter 432D, shall provide coverage for screening by low-dose mammography for occult breast cancer as follows: (A) For women age thirty-five to thirty-nine, inclusive, a baseline mammogram; (B) For women forty years of age and older, an annual mammogram; [and] (C) For women age thirty to fifty, deemed by a licensed physician or clinician to have an above-average risk for breast cancer, an annual mammogram; provided that a formal risk factor screening assessment is first made and informed by any readily available risk factor modeling tool; [(B)] (D) For [a woman] women of any age with a history of breast cancer or whose mother or sister has had a history of breast cancer, a mammogram upon the recommendation of the woman's physician[.]; and (E) For women of any age, any additional or supplemental imaging, such as breast magnetic resonance imaging or ultrasound, deemed medically necessary by an applicable American College of Radiology guideline. The services provided in this paragraph are subject to any coinsurance provisions that may be in force in these policies, contracts, plans, or agreements[.], and shall be at least as favorable and subject to the same dollar limits, deductibles, and co-payments as other radiological examinations; provided, however, that on and after January 1, 2021, providers of health care services specified under this section shall be reimbursed at rates accurately reflecting the resource costs specific to each modality, including any increased resource cost. For the purpose of this paragraph, the term "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast[.], and includes both digital mammography and digital breast tomosynthesis, and interpreting and rendering a report by a radiologist or other physician based on the screening. For the purposes of this paragraph, the term "digital breast tomosynthesis" means a radiologic procedure that allows a volumetric reconstruction of the whole breast from a finite number of low-dose twodimensional projections obtained by different x-ray tube angles, creating a series of images forming a three dimensional representation of the breast. An insurer may provide the services required by this paragraph through contracts with providers; provided that the contract is determined to be a cost-effective means of delivering the services without sacrifice of quality and meets the approval of the director of health; and (5) (A) (i) Notwithstanding any provision to the contrary, whenever a policy, contract, plan, or agreement provides coverage for the children of the insured, that coverage shall also extend to the date of birth of any newborn child to be adopted by the insured; provided that the insured gives written notice to the insurer of the insured's intent to adopt the child prior to the child's date of birth or within thirty days after the child's birth or within the time period required for enrollment of a natural born child under the policy, contract, plan, or agreement of the insured, whichever period is longer; provided further that if the adoption proceedings are not successful, the insured shall reimburse the insurer for any expenses paid for the child; and (ii) Where notification has not been received by the insurer prior to the child's birth or within the specified period following the child's birth, insurance coverage shall be effective from the first day following the insurer's receipt of legal notification of the insured's ability to consent for treatment of the infant for whom coverage is sought; and (B) When the insured is a member of a health maintenance organization, coverage of an adopted newborn is effective: (i) From the date of birth of the adopted newborn when the newborn is treated from birth pursuant to a provider contract with the health maintenance organization, and written notice of enrollment in accord with the health maintenance organization's usual enrollment process is provided within thirty days of the date the insured notifies the health maintenance organization of the insured's intent to adopt the infant for whom coverage is sought; or (ii) From the first day following receipt by the health maintenance organization of written notice of the insured's ability to consent for treatment of the infant for whom coverage is sought and enrollment of the adopted newborn in accord with the health maintenance organization's usual enrollment process if the newborn has been treated from birth by a provider not contracting or affiliated with the health maintenance organization." SECTION 3. Section 432:1-605, Hawaii Revised Statutes, is amended by amending subsection (c) to read as follows: "(c) For purposes of this section[, "low-dose mammography"]: "Digital breast tomosynthesis" means a radiologic procedure that allows a volumetric reconstruction of the whole breast from a finite number of low-dose twodimensional projections obtained by different x-ray tube angles, creating a series of images forming a three dimensional representation of the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast[.], and includes both digital mammography and digital breast tomosynthesis, and interpreting and rendering a report by a radiologist or other physician based on the screening." SECTION 4. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored. SECTION 5. This Act shall take effect on July 1, 2050. |
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