85R9271 PMO-F
By: Hernandez H.B. No. 1466
A BILL TO BE ENTITLED
AN ACT
relating to coverage for mammography and supplemental breast cancer
screening under certain health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1201.005, Insurance Code, is amended to
read as follows:
Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a
reference to this chapter includes a reference to:
(1) Section 1202.052;
(2) Section 1271.005(a), to the extent that the
subsection relates to the applicability of Section 1201.105, and
Sections 1271.005(d) and (e);
(3) Chapter 1351;
(4) Subchapters C and E, Chapter 1355;
(5) Subchapter B, Chapter 1356;
(6) Chapter 1365;
(7) Subchapter A, Chapter 1367; and
(8) Subchapters A, B, and G, Chapter 1451.
SECTION 2. The heading to Chapter 1356, Insurance Code, is
amended to read as follows:
CHAPTER 1356. [LOW-DOSE] MAMMOGRAPHY AND OTHER BREAST CANCER
SCREENING
SECTION 3. Chapter 1356, Insurance Code, is amended by
designating Sections 1356.001 through 1356.004 as Subchapter A and
adding a subchapter heading to read as follows:
SUBCHAPTER A. GENERAL PROVISIONS
SECTION 4. Section 1356.001, Insurance Code, is amended to
read as follows:
Sec. 1356.001. DEFINITIONS. [DEFINITION.] In this
chapter:
(1) "Enrollee" means an individual enrolled in a
health benefit plan.
(2) "Low-dose mammography" [, "low-dose mammography"]
means the x-ray examination of the breast using equipment dedicated
specifically for mammography, including an 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.
SECTION 5. Section 1356.002, Insurance Code, is amended to
read as follows:
Sec. 1356.002. APPLICABILITY OF CHAPTER. This chapter
applies only to a health benefit plan that is delivered, issued for
delivery, or renewed in this state and that is an individual or
group accident and health insurance policy, including a policy
issued by a group hospital service corporation operating under
Chapter 842, or that is an individual or group evidence of coverage
issued by a health maintenance organization operating under Chapter
843.
SECTION 6. Chapter 1356, Insurance Code, is amended by
designating Section 1356.005 as Subchapter B and adding a
subchapter heading to read as follows:
SUBCHAPTER B. LOW-DOSE MAMMOGRAPHY
SECTION 7. Subchapter B, Chapter 1356, Insurance Code, as
added by this Act, is amended by adding Section 1356.006 to read as
follows:
Sec. 1356.006. CHOICE OF PROVIDER; PRIOR APPROVAL. (a) A
health benefit plan that provides coverage for low-dose mammography
must allow an enrollee to have a covered mammogram performed by a
physician or provider selected by the enrollee other than the
enrollee's primary care physician or primary care provider.
(b) A health benefit plan may not require an enrollee to
receive prior approval before having a covered mammogram performed
by a physician or provider other than the enrollee's primary care
physician or primary care provider.
(c) This section does not affect the authority of a health
benefit plan issuer to establish selection criteria for physicians
and providers who provide services under the plan.
(d) A physician or provider that performs a mammogram
described by Subsection (a) must provide a copy of the mammogram
report to the enrollee's primary care physician or primary care
provider.
SECTION 8. Chapter 1356, Insurance Code, is amended by
adding Subchapters C and D to read as follows:
SUBCHAPTER C. SUPPLEMENTAL BREAST CANCER SCREENING
Sec. 1356.051. DEFINITION. In this subchapter,
"supplemental breast cancer screening" means a method of screening,
including ultrasound imaging, that is designed to supplement
mammography by detecting breast cancers that may not be visible
using only mammography.
Sec. 1356.052. OFFER OF OPTIONAL COVERAGE REQUIRED. (a) An
issuer of a health benefit plan that provides coverage for
mammography, including coverage for low-dose mammography required
by Subchapter B, must also offer to provide coverage for
supplemental breast cancer screening as part of an annual
well-woman examination covered under the plan if a licensed health
care professional treating the enrollee or screening the enrollee
for breast cancer finds that the enrollee has:
(1) dense breast tissue, as defined by the Breast
Imaging Reporting and Database System (Fifth Edition) established
by the American College of Radiology; and
(2) additional risk factors determined under
Subsection (c) for breast cancer that warrant supplemental breast
cancer screening beyond mammography.
(b) An additional premium may be charged for the coverage
described by Subsection (a).
(c) The commissioner by rule shall determine risk factors
described by Subsection (a)(2) based on scientific research and
models for breast cancer.
SUBCHAPTER D. DIAGNOSTIC MAMMOGRAPHY
Sec. 1356.101. DEFINITION. In this subchapter, "diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
Sec. 1356.102. COVERAGE FOR DIAGNOSTIC MAMMOGRAM. (a) An
issuer of a health benefit plan that provides coverage for a
screening mammogram must provide coverage for a diagnostic
mammogram that is no less favorable than coverage for a screening
mammogram.
(b) The coverage for a diagnostic mammogram described by
Subsection (a) must be subject to the same dollar limits,
deductibles, and coinsurance factors as coverage for a screening
mammogram.
SECTION 9. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 10. This Act applies only to a health benefit plan
that is delivered, issued for delivery, or renewed on or after
January 1, 2018. A health benefit plan that is delivered, issued
for delivery, or renewed before January 1, 2018, is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
SECTION 11. This Act takes effect September 1, 2017.