Introduced Version
HOUSE BILL No. 1114
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 5-10-8; IC 27-8; IC 27-13-7.
Synopsis: Coverage for cancer screening and prescriptions. Requires
a state employee health plan to cover supplemental breast
examinations. Requires a policy of accident and sickness insurance and
a health maintenance organization to cover diagnostic breast
examinations and supplemental breast examinations. Provides that the
coverage of diagnostic breast examinations and supplemental breast
examinations may not be subject to any cost sharing requirements.
Prohibits a state employee health plan, a policy of accident and
sickness insurance, and a health maintenance organization that
provides coverage for advanced, metastatic cancer and associated
conditions from requiring that, before providing coverage of a
prescription drug, the insured fail to successfully respond to a different
prescription drug or prove a history of failure of a different prescription
drug.
Effective: July 1, 2024.
Pryor
January 8, 2024, read first time and referred to Committee on Insurance.
2024 IN 1114—LS 6439/DI 141 Introduced
Second Regular Session of the 123rd General Assembly (2024)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
Constitution) is being amended, the text of the existing provision will appear in this style type,
additions will appear in this style type, and deletions will appear in this style type.
Additions: Whenever a new statutory provision is being enacted (or a new constitutional
provision adopted), the text of the new provision will appear in this style type. Also, the
word NEW will appear in that style type in the introductory clause of each SECTION that adds
a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
between statutes enacted by the 2023 Regular Session of the General Assembly.
HOUSE BILL No. 1114
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 5-10-8-7.2, AS AMENDED BY P.L.56-2023,
2 SECTION 37, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
3 JULY 1, 2024]: Sec. 7.2. (a) As used in this section, "breast cancer
4 diagnostic service" means a procedure intended to aid in the diagnosis
5 of breast cancer. The term includes procedures performed on an
6 inpatient basis and procedures performed on an outpatient basis,
7 including the following:
8 (1) Breast cancer screening mammography.
9 (2) Surgical breast biopsy.
10 (3) Pathologic examination and interpretation.
11 (b) As used in this section, "breast cancer outpatient treatment
12 services" means procedures that are intended to treat cancer of the
13 human breast and that are delivered on an outpatient basis. The term
14 includes the following:
15 (1) Chemotherapy.
16 (2) Hormonal therapy.
17 (3) Radiation therapy.
2024 IN 1114—LS 6439/DI 141 2
1 (4) Surgery.
2 (5) Other outpatient cancer treatment services prescribed by a
3 physician.
4 (6) Medical follow-up services related to the procedures set forth
5 in subdivisions (1) through (5).
6 (c) As used in this section, "breast cancer rehabilitative services"
7 means procedures that are intended to improve the results of or to
8 ameliorate the debilitating consequences of the treatment of breast
9 cancer and that are delivered on an inpatient or outpatient basis. The
10 term includes the following:
11 (1) Physical therapy.
12 (2) Psychological and social support services.
13 (3) Reconstructive plastic surgery.
14 (d) As used in this section, "breast cancer screening mammography"
15 means a standard, two (2) view per breast, low-dose radiographic
16 examination of the breasts that is:
17 (1) furnished to an asymptomatic woman; and
18 (2) performed by a mammography services provider using
19 equipment designed by the manufacturer for and dedicated
20 specifically to mammography in order to detect unsuspected
21 breast cancer.
22 The term includes the interpretation of the results of a breast cancer
23 screening mammography by a physician.
24 (e) As used in this section, "cost sharing requirements" means:
25 (1) a deductible;
26 (2) coinsurance;
27 (3) a copayment; and
28 (4) any maximum limitation on the application of a
29 deductible, coinsurance, copayment, or similar out-of-pocket
30 expense.
31 (e) (f) As used in this section, "covered individual" means a female
32 individual who is:
33 (1) covered under a self-insurance program established under
34 section 7(b) of this chapter to provide group health coverage; or
35 (2) entitled to services under a contract with a health maintenance
36 organization (as defined in IC 27-13-1-19) that is entered into or
37 renewed under section 7(c) of this chapter.
38 (f) (g) As used in this section, "mammography services provider"
39 means an individual or facility that:
40 (1) has been accredited by the American College of Radiology;
41 (2) meets equivalent guidelines established by the Indiana
42 department of health; or
2024 IN 1114—LS 6439/DI 141 3
1 (3) is certified by the federal Department of Health and Human
2 Services for participation in the Medicare program (42 U.S.C.
3 1395 et seq.).
4 (h) As used in this section, "supplemental breast examination"
5 means a medically necessary and appropriate examination of the
6 breast, including an examination using breast cancer screening
7 mammography, breast magnetic resonance imaging, or ultrasound
8 services, that is:
9 (1) used to screen for breast cancer when there is no
10 abnormality seen or detected; and
11 (2) based on:
12 (A) personal or family medical history; or
13 (B) additional factors;
14 that may increase the covered individual's risk of breast
15 cancer.
16 (g) (i) As used in this section, "woman at risk" means a woman who
17 meets at least one (1) of the following descriptions:
18 (1) A woman who has a personal history of breast cancer.
19 (2) A woman who has a personal history of breast disease that
20 was proven benign by biopsy.
21 (3) A woman whose mother, sister, or daughter has had breast
22 cancer.
23 (4) A woman who is at least thirty (30) years of age and has not
24 given birth.
25 (h) (j) A self-insurance program established under section 7(b) of
26 this chapter to provide health care coverage must provide covered
27 individuals with coverage for breast cancer diagnostic services, breast
28 cancer outpatient treatment services, and breast cancer rehabilitative
29 services. The coverage must provide reimbursement for breast cancer
30 screening mammography at a level at least as high as:
31 (1) the limitation on payment for screening mammography
32 services established in 42 CFR 405.534(b)(3) according to the
33 Medicare Economic Index at the time the breast cancer screening
34 mammography is performed; or
35 (2) the rate negotiated by a contract provider according to the
36 provisions of the insurance policy;
37 whichever is lower. Except as provided in subsection (o), the costs of
38 the coverage required by this subsection may be paid by the state or by
39 the employee or by a combination of the state and the employee.
40 (i) (k) A contract with a health maintenance organization that is
41 entered into or renewed under section 7(c) of this chapter must provide
42 covered individuals with breast cancer diagnostic services, breast
2024 IN 1114—LS 6439/DI 141 4
1 cancer outpatient treatment services, and breast cancer rehabilitative
2 services.
3 (j) (l) The coverage required by subsection (h) (j) and services
4 required by subsection (i) (k) may not be subject to dollar limits,
5 deductibles, or coinsurance provisions that are less favorable to
6 covered individuals than the dollar limits, deductibles, or coinsurance
7 provisions applying to physical illness generally under the
8 self-insurance program or contract with a health maintenance
9 organization.
10 (k) (m) The coverage for breast cancer diagnostic services required
11 by subsection (h) (j) and the breast cancer diagnostic services required
12 by subsection (i) (k) must include the following:
13 (1) In the case of a covered individual who is at least thirty-five
14 (35) years of age but less than forty (40) years of age, at least one
15 (1) baseline breast cancer screening mammography performed
16 upon the individual before she becomes forty (40) years of age.
17 (2) In the case of a covered individual who is:
18 (A) less than forty (40) years of age; and
19 (B) a woman at risk;
20 at least one (1) breast cancer screening mammography performed
21 upon the covered individual every year.
22 (3) In the case of a covered individual who is at least forty (40)
23 years of age, at least one (1) breast cancer screening
24 mammography performed upon the individual every year.
25 (4) Any additional mammography views that are required for
26 proper evaluation.
27 (5) Ultrasound services, if determined medically necessary by the
28 physician treating the covered individual.
29 (6) Supplemental breast examination.
30 (l) (n) The coverage for breast cancer diagnostic services required
31 by subsection (h) (j) and the breast cancer diagnostic services required
32 by subsection (i) (k) shall be provided in addition to any benefits
33 specifically provided for x-rays, laboratory testing, or wellness
34 examinations.
35 (o) The coverage for breast cancer diagnostic services required
36 by subsection (j) and the breast cancer diagnostic services required
37 by subsection (k) may not be subject to any cost sharing
38 requirements.
39 SECTION 2. IC 5-10-8-18.5 IS ADDED TO THE INDIANA CODE
40 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
41 1, 2024]: Sec. 18.5. (a) This section applies only to a prescription
42 drug that is:
2024 IN 1114—LS 6439/DI 141 5
1 (1) consistent with best practices for the treatment of
2 advanced, metastatic cancer or an associated condition;
3 (2) supported by peer reviewed, evidence based literature;
4 and
5 (3) approved by the federal Food and Drug Administration.
6 (b) As used in this section, "advanced, metastatic cancer" means
7 cancer that has spread from the primary or original site of the
8 cancer to nearby tissues, lymph nodes, or other areas or parts of
9 the body.
10 (c) As used in this section, "associated conditions" means the
11 symptoms or side effects associated with advanced, metastatic
12 cancer or its treatment, which would, in the judgment of a health
13 care practitioner, further jeopardize the health of the covered
14 individual if left untreated.
15 (d) As used in this section, "covered individual" means an
16 individual entitled to coverage under a state employee health plan.
17 (e) As used in this section, "state employee health plan" refers
18 to the following that provide coverage for prescription drugs:
19 (1) A self-insurance program established under section 7(b) of
20 this chapter.
21 (2) A contract with a prepaid health care delivery plan that is
22 entered into or renewed under section 7(c) of this chapter.
23 (f) A state employee health plan that provides coverage for
24 advanced, metastatic cancer and associated conditions may not
25 require that, before the state employee health plan provides
26 coverage of a prescription drug, the covered individual:
27 (1) fail to successfully respond to a different prescription
28 drug; or
29 (2) prove a history of failure of a different prescription drug.
30 SECTION 3. IC 27-8-5-32 IS ADDED TO THE INDIANA CODE
31 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
32 1, 2024]: Sec. 32. (a) This section applies only to a prescription drug
33 that is:
34 (1) consistent with best practices for the treatment of
35 advanced, metastatic cancer or an associated condition;
36 (2) supported by peer reviewed, evidence based literature;
37 and
38 (3) approved by the federal Food and Drug Administration.
39 (b) As used in this section, "advanced, metastatic cancer" means
40 cancer that has spread from the primary or original site of the
41 cancer to nearby tissues, lymph nodes, or other areas or parts of
42 the body.
2024 IN 1114—LS 6439/DI 141 6
1 (c) As used in this section, "associated conditions" means the
2 symptoms or side effects associated with advanced, metastatic
3 cancer or its treatment, which would, in the judgment of a health
4 care practitioner, further jeopardize the health of the insured if left
5 untreated.
6 (d) As used in this section, "insured" means an individual who
7 is entitled to coverage under a policy of accident and sickness
8 insurance.
9 (e) As used in this section, "policy of accident and sickness
10 insurance" means a policy of accident and sickness insurance that
11 provides coverage for prescription drugs.
12 (f) A policy of accident and sickness insurance that provides
13 coverage for advanced, metastatic cancer and associated conditions
14 may not require that, before the policy of accident and sickness
15 insurance provides coverage of a prescription drug, the insured:
16 (1) fail to successfully respond to a different prescription
17 drug; or
18 (2) prove a history of failure of a different prescription drug.
19 SECTION 4. IC 27-8-14-2.5 IS ADDED TO THE INDIANA CODE
20 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
21 1, 2024]: Sec. 2.5. As used in this chapter, "cost sharing
22 requirements" means:
23 (1) a deductible;
24 (2) coinsurance;
25 (3) a copayment; and
26 (4) any maximum limitation on the application of a
27 deductible, coinsurance, copayment, or similar out-of-pocket
28 expense.
29 SECTION 5. IC 27-8-14-2.7 IS ADDED TO THE INDIANA CODE
30 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
31 1, 2024]: Sec. 2.7. As used in this chapter, "diagnostic breast
32 examination" means a medically necessary and appropriate
33 examination of the breast, including an examination using
34 diagnostic mammography, breast magnetic resonance imaging, or
35 ultrasound services, that is:
36 (1) used to evaluate an abnormality seen or suspected from a
37 screening examination for breast cancer; or
38 (2) used to evaluate an abnormality detected by another
39 means of examination.
40 SECTION 6. IC 27-8-14-4.5 IS ADDED TO THE INDIANA CODE
41 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
42 1, 2024]: Sec. 4.5. As used in this chapter, "supplemental breast
2024 IN 1114—LS 6439/DI 141 7
1 examination" means a medically necessary and appropriate
2 examination of the breast, including an examination using
3 diagnostic mammography, breast magnetic resonance imaging, or
4 ultrasound services, that is:
5 (1) used to screen for breast cancer when there is no
6 abnormality seen or detected; and
7 (2) based on:
8 (A) personal or family medical history; or
9 (B) additional factors;
10 that may increase the insured's risk of breast cancer.
11 SECTION 7. IC 27-8-14-6 IS AMENDED TO READ AS
12 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 6. (a) Except as
13 provided in subsection (f), (g), an insurer must provide coverage for
14 breast cancer screening mammography and diagnostic breast
15 examination in any accident and sickness insurance policy that the
16 insurer issues in Indiana.
17 (b) Except as provided in subsection (f), (g), the coverage that an
18 insurer must provide under this section must include the following:
19 (1) If the insured is at least thirty-five (35) but less than forty (40)
20 years of age, coverage for at least one (1) baseline breast cancer
21 screening mammography performed upon the insured before she
22 becomes forty (40) years of age.
23 (2) If the insured is:
24 (A) less than forty (40) years of age; and
25 (B) a woman at risk;
26 one (1) breast cancer screening mammography performed upon
27 the insured every year.
28 (3) If the insured is at least forty (40) years of age, one (1) breast
29 cancer screening mammography performed upon the insured
30 every year.
31 (4) Any additional mammography views that are required for
32 proper evaluation.
33 (5) Ultrasound services, if determined medically necessary by the
34 physician treating the insured.
35 (6) Supplemental breast examination.
36 (c) Except as provided in subsection (f), (g), the coverage that an
37 insurer must provide under this section must provide reimbursement
38 for breast cancer screening mammography at a level at least as high as:
39 (1) the limitation on payment for screening mammography
40 services established in 42 CFR 405.534(b)(3) according to the
41 Medicare Economic Index at the time the breast cancer screening
42 mammography is performed; or
2024 IN 1114—LS 6439/DI 141 8
1 (2) the rate negotiated by a contract provider according to the
2 provisions of the insurance policy;
3 whichever is lower.
4 (d) Except as provided in subsection (f), (g), the coverage that an
5 insurer must provide under this section may not be subject to dollar
6 limits, deductibles, or coinsurance provisions that are less favorable to
7 the insured than the dollar limits, deductibles, or coinsurance
8 provisions applying to physical illness generally under the accident and
9 sickness insurance policy.
10 (e) Except as provided in subsection (f), (g), the coverage that an
11 insurer must provide is in addition to any benefits specifically provided
12 for x-rays, laboratory testing, or wellness examinations.
13 (f) Except as provided in subsection (g), the coverage that an
14 insurer must provide under this section may not be subject to any
15 cost sharing requirements.
16 (f) (g) In the case of insurance policies that are not employer based,
17 the insurer must offer to provide the coverage described in subsections
18 (a) through (e). (f).
19 SECTION 8. IC 27-13-7-15.3 IS AMENDED TO READ AS
20 FOLLOWS [EFFECTIVE JULY 1, 2024]: Sec. 15.3. (a) As used in this
21 section, "breast cancer screening mammography" has the meaning set
22 forth in IC 27-8-14-2.
23 (b) As used in this section, "cost sharing requirements" has the
24 meaning set forth in IC 27-8-14-2.5.
25 (c) As used in this section, "diagnostic breast examination" has
26 the meaning set forth in IC 27-8-14-2.7.
27 (d) As used in this section, "supplemental breast examination"
28 has the meaning set forth in IC 27-8-14-4.5.
29 (b) (e) As used in this section, "woman at risk" has the meaning set
30 forth in IC 27-8-14-5.
31 (c) (f) Except as provided in subsection (g), (k), a health
32 maintenance organization issued a certificate of authority in Indiana
33 shall provide breast cancer screening mammography and diagnostic
34 breast examination as a covered service services under every group
35 contract that provides coverage for basic health care services.
36 (d) (g) Except as provided in subsection (g), (k), the coverage that
37 a health maintenance organization must provide under this section must
38 include the following:
39 (1) If the enrollee is at least thirty-five (35) years of age but less
40 than forty (40) years of age and a female, coverage for at least one
41 (1) baseline breast cancer screening mammography performed
42 upon the enrollee before the enrollee becomes forty (40) years of
2024 IN 1114—LS 6439/DI 141 9
1 age.
2 (2) If the enrollee is less than forty (40) years of age and a woman
3 at risk, one (1) breast cancer screening mammography performed
4 upon the enrollee every year.
5 (3) If the enrollee is at least forty (40) years of age and a female,
6 one (1) breast cancer screening mammography performed upon
7 the enrollee every year.
8 (4) Any additional mammography views that are required for
9 proper evaluation.
10 (5) Ultrasound services, if determined medically necessary by the
11 physician treating the enrollee.
12 (6) Supplemental breast examination.
13 (e) (h) Except as provided in subsection (g), (k), the coverage that
14 a health maintenance organization must provide under this section may
15 not be subject to a contract provision that is less favorable to an
16 enrollee or a subscriber than contract provisions applying to physical
17 illness generally under the health maintenance organization contract.
18 (f) (i) Except as provided in subsection (g), (k), the coverage that a
19 health maintenance organization must provide under this section is in
20 addition to services specifically provided for x-rays, laboratory testing,
21 or wellness examinations.
22 (j) Except as provided in subsection (k), the coverage that a
23 health maintenance organization must provide under this section
24 may not be subject to any cost sharing requirements.
25 (g) (k) In the case of coverage that is not employer based, the health
26 maintenance organization must offer to provide the coverage described
27 in subsections (c) (f) through (f). (j).
28 SECTION 9. IC 27-13-7-29 IS ADDED TO THE INDIANA CODE
29 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
30 1, 2024]: Sec. 29. (a) This section applies only to a prescription drug
31 that is:
32 (1) consistent with best practices for the treatment of
33 advanced, metastatic cancer or an associated condition;
34 (2) supported by peer reviewed, evidence based literature;
35 and
36 (3) approved by the federal Food and Drug Administration.
37 (b) As used in this section, "advanced, metastatic cancer" means
38 cancer that has spread from the primary or original site of the
39 cancer to nearby tissues, lymph nodes, or other areas or parts of
40 the body.
41 (c) As used in this section, "associated conditions" means the
42 symptoms or side effects associated with advanced, metastatic
2024 IN 1114—LS 6439/DI 141 10
1 cancer or its treatment, which would, in the judgment of a health
2 care practitioner, further jeopardize the health of the enrollee if
3 left untreated.
4 (d) As used in this section, "group contract" refers to a group
5 contract that provides coverage for prescription drugs.
6 (e) As used in this section, "health maintenance organization"
7 refers to a health maintenance organization that provides coverage
8 for prescription drugs. The term includes the following:
9 (1) A limited service health maintenance organization.
10 (2) A person that administers prescription drug benefits on
11 behalf of a health maintenance organization or a limited
12 service health maintenance organization.
13 (f) As used in this section, "individual contract" refers to an
14 individual contract that provides coverage for prescription drugs.
15 (g) A health maintenance organization that provides coverage
16 under an individual contract or a group contract for advanced,
17 metastatic cancer and associated conditions may not require that,
18 before the health maintenance organization provides coverage of
19 a prescription drug, the enrollee:
20 (1) fail to successfully respond to a different prescription
21 drug; or
22 (2) prove a history of failure of a different prescription drug.
2024 IN 1114—LS 6439/DI 141