| 1 | 1 | | HOUSE BILL NO. 5084 A bill to amend 1956 PA 218, entitled "The insurance code of 1956," by amending section 3406d (MCL 500.3406d), as amended by 2016 PA 276, and by adding section 3406z. the people of the state of michigan enact: Sec. 3406d. (1) Subject to dollar limits, deductibles, and coinsurance provisions that are not less favorable than those for physical illness generally, an An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall offer or include coverage for breast cancer diagnostic services, breast cancer outpatient treatment services, and breast cancer rehabilitative services, diagnostic breast examinations, and supplemental breast examinations. (2) Subject to dollar limits, deductibles, and coinsurance provisions that are not less favorable than those for physical illness generally, an An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall offer or include the following coverage for breast cancer screening mammography: (a) If performed on a woman an individual 35 years of age or older and under 40 years of age, coverage for 1 screening mammography examination during that 5-year period. (b) If performed on a woman an individual 40 years of age or older, coverage for 1 screening mammography examination every calendar year. (3) Coverage under this section is not subject to dollar limits, deductibles, or copayments. (4) (3) As used in this section: (a) "Breast cancer diagnostic services" means a procedure intended to aid in the diagnosis of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to mammography, surgical breast biopsy, and pathologic examination and interpretation. (b) "Breast cancer rehabilitative services" means a procedure intended to improve the result of, or ameliorate the debilitating consequences of, treatment of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to reconstructive plastic surgery, physical therapy, and psychological and social support services. (c) "Breast cancer screening mammography" means a standard 2-view per breast, low-dose radiographic examination of the breasts, using equipment designed and dedicated specifically for mammography, in order to detect unsuspected breast cancer. (d) "Breast cancer outpatient treatment services" means a procedure intended to treat cancer of the human breast, delivered on an outpatient basis, including but not limited to surgery, radiation therapy, chemotherapy, hormonal therapy, and related medical follow-up services. (e) "Diagnostic breast examinations" means a medically necessary and appropriate examination of the breast or an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound, that is used to evaluate either of the following: (i) An abnormality seen or suspected from a screening examination for breast cancer. (ii) An abnormality detected by another means of examination. (f) "Supplemental breast examinations" means a medically necessary and appropriate examination of the breast or an examination using breast magnetic resonance imaging or breast ultrasound, that is both of the following: (i) Used to screen for breast cancer if there is no abnormality seen or suspected. (ii) Based on personal or family medical history, or additional factors that may increase the individual's risk of breast cancer. Sec. 3406z. (1) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy that provides coverage for prescription drugs for advanced metastatic cancer and associated conditions shall not require, before coverage is provided, that an enrollee do either of the following: (a) Fail to successfully respond to a different prescription drug. (b) Prove a history of failure of a different prescription drug. (2) As used in this section: (a) "Advanced metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body. (b) "Associated conditions" means the symptoms or side effects associated with advanced metastatic cancer or its treatment, that, in the judgment of the health care provider, further jeopardize the health of the patient if left untreated. |
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| 23 | 23 | | HOUSE BILL NO. 5084 |
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| 24 | 24 | | |
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| 25 | 25 | | |
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| 26 | 26 | | |
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| 27 | 27 | | A bill to amend 1956 PA 218, entitled |
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| 28 | 28 | | |
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| 29 | 29 | | "The insurance code of 1956," |
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| 30 | 30 | | |
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| 31 | 31 | | by amending section 3406d (MCL 500.3406d), as amended by 2016 PA 276, and by adding section 3406z. |
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| 32 | 32 | | |
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| 33 | 33 | | the people of the state of michigan enact: |
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| 34 | 34 | | |
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| 35 | 35 | | Sec. 3406d. (1) Subject to dollar limits, deductibles, and coinsurance provisions that are not less favorable than those for physical illness generally, an An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall offer or include coverage for breast cancer diagnostic services, breast cancer outpatient treatment services, and breast cancer rehabilitative services, diagnostic breast examinations, and supplemental breast examinations. |
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| 36 | 36 | | |
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| 37 | 37 | | (2) Subject to dollar limits, deductibles, and coinsurance provisions that are not less favorable than those for physical illness generally, an An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall offer or include the following coverage for breast cancer screening mammography: |
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| 38 | 38 | | |
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| 39 | 39 | | (a) If performed on a woman an individual 35 years of age or older and under 40 years of age, coverage for 1 screening mammography examination during that 5-year period. |
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| 40 | 40 | | |
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| 41 | 41 | | (b) If performed on a woman an individual 40 years of age or older, coverage for 1 screening mammography examination every calendar year. |
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| 42 | 42 | | |
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| 43 | 43 | | (3) Coverage under this section is not subject to dollar limits, deductibles, or copayments. |
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| 44 | 44 | | |
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| 45 | 45 | | (4) (3) As used in this section: |
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| 46 | 46 | | |
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| 47 | 47 | | (a) "Breast cancer diagnostic services" means a procedure intended to aid in the diagnosis of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to mammography, surgical breast biopsy, and pathologic examination and interpretation. |
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| 48 | 48 | | |
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| 49 | 49 | | (b) "Breast cancer rehabilitative services" means a procedure intended to improve the result of, or ameliorate the debilitating consequences of, treatment of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to reconstructive plastic surgery, physical therapy, and psychological and social support services. |
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| 50 | 50 | | |
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| 51 | 51 | | (c) "Breast cancer screening mammography" means a standard 2-view per breast, low-dose radiographic examination of the breasts, using equipment designed and dedicated specifically for mammography, in order to detect unsuspected breast cancer. |
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| 52 | 52 | | |
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| 53 | 53 | | (d) "Breast cancer outpatient treatment services" means a procedure intended to treat cancer of the human breast, delivered on an outpatient basis, including but not limited to surgery, radiation therapy, chemotherapy, hormonal therapy, and related medical follow-up services. |
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| 54 | 54 | | |
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| 55 | 55 | | (e) "Diagnostic breast examinations" means a medically necessary and appropriate examination of the breast or an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound, that is used to evaluate either of the following: |
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| 56 | 56 | | |
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| 57 | 57 | | (i) An abnormality seen or suspected from a screening examination for breast cancer. |
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| 58 | 58 | | |
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| 59 | 59 | | (ii) An abnormality detected by another means of examination. |
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| 60 | 60 | | |
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| 61 | 61 | | (f) "Supplemental breast examinations" means a medically necessary and appropriate examination of the breast or an examination using breast magnetic resonance imaging or breast ultrasound, that is both of the following: |
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| 62 | 62 | | |
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| 63 | 63 | | (i) Used to screen for breast cancer if there is no abnormality seen or suspected. |
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| 64 | 64 | | |
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| 65 | 65 | | (ii) Based on personal or family medical history, or additional factors that may increase the individual's risk of breast cancer. |
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| 66 | 66 | | |
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| 67 | 67 | | Sec. 3406z. (1) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy that provides coverage for prescription drugs for advanced metastatic cancer and associated conditions shall not require, before coverage is provided, that an enrollee do either of the following: |
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| 68 | 68 | | |
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| 69 | 69 | | (a) Fail to successfully respond to a different prescription drug. |
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| 70 | 70 | | |
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| 71 | 71 | | (b) Prove a history of failure of a different prescription drug. |
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| 72 | 72 | | |
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| 73 | 73 | | (2) As used in this section: |
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| 74 | 74 | | |
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| 75 | 75 | | (a) "Advanced metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body. |
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| 76 | 76 | | |
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| 77 | 77 | | (b) "Associated conditions" means the symptoms or side effects associated with advanced metastatic cancer or its treatment, that, in the judgment of the health care provider, further jeopardize the health of the patient if left untreated. |
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