Tony Evers, Governor of Wisconsin
Nathan Houdek, Commissioner of Insurance
125 South Webster Street, P.O. Box 7873 | Madison, WI 53707- 7873
p: 608- 266-3585 | p: 1 -800-236-8517 | f: 608 -266-9935
ociinformation@wisconsin.gov | oci.wi.gov
March 21, 2023
Mr. Michael J. Queensland
Senate Chief Clerk
State Capitol
P.O. Box 7882
Madison, WI 53707
Mr. Ted Blazel
Assembly Chief Clerk
17 West Main Street
Room 401
Madison, WI 53703
Re: Social and Financial Impact Report—2023 Senate Bill 121—relating to coverage of breast cancer
screenings by the Medical Assistance program and health insurance policies and plans.
Dear Chief Clerks Queensland and Blazel:
Pursuant to Wis. Stat. § 601.423, the Office of the Commissioner of Insurance (OCI) is submitting a social
and financial impact report on 2023 Senate Bill 121, relating to coverage of breast cancer screenings by
the Medical Assistance program and health insurance policies and plans.
Coverage of Mammograms
OCI has determined that 2023 Senate Bill 121 requires a social and financial impact report for the
following reasons:
1.The provision requires coverage of a particular treatment, equipment, or drug.
2
.Requires a particular benefit design or imposes conditions on cost- sharing under an insurance policy,
plan, or contract for the treatment of a particular disease, condition, or other health care need, for a
particular type of health care treatment or service, or for the provision of equipment, supplies, or drugs
used in connection with a health care treatment or service.
Social Impact
OCI has reviewed the provisions contained in 2023 Senate Bill 121, in particular sections 5 through 17
creating and amending Wis. Stat. § 632.895 (8), that require insurers offering disability insurance policies
and non- federal governmental self-funded plans, to cover mammograms and additional radiographic
modalities for the screening and evaluation of breast cancer for women who are believed to be at higher
risk for cancer including breast cancer. Insurers and non-federal governmental self-funded plans may
impose the same exclusions, limitations, and cost-sharing provisions that generally apply to
mammograms. However, 2023 Senate Bill 121 amends the provision by eliminating the amount of cost-
sharing that can be imposed for essential breast screenings beyond mammography under Wis. Stat. § 632.895 (8) (d) 2. It should be noted that the current draft provides additional screening and evaluation
for women. The treatment and the elimination of cost-sharing, while possibly reflective of the higher
incidence in females of breast cancer than males, may be viewed as discriminatory by the federal
government and Qualified Health Plans (QHPs), and the expanded screening and evaluation m ay need to
be expanded to all individuals regardless of gender.
2023 S
B 121 (LRB-1280/1)
The health insurance provisions outlined in the bill have the potential to affect Wisconsin consumers who
have coverage for, and utilize, mammograms and other essential breast cancer screenings through fully
insured or non- federal, governmental self-funded plans. OCI is unable to determine how these proposals
could impact access or affordability.
QHPs, in order to be considered as providing essential health benefits, must offer preventive health
screenings coverage pursuant to 45 CFR § 147.130 under the Affordable Care Act (ACA). Non-federal
governmental self-funded plans are currently subject to Wis. Stat. § 632.895 (9) to (17). This bill would
update Wis. Stat. § 632.895 (8) to add mammograms as a mandatorily covered preventive health
screening. Therefore, at a minimum, residents who are insured by disability insurance plans, QHPs , and
residents who are covered by self-funded non-federal governmental health plans would be eligible for
coverage of mammograms and additional radiographic modalities for screening or evaluation of breast
cancer in women without health insurers charging a cost-sharing amount.
There are several categories of disability insurance plans that are not currently subject to all ACA
requirements including, “grandfathered plans” (plans that were in existence as of March 23, 2010, have
been continually offered and have benefits that have not significantly changed over time), and
“transitional plans” (plans offered primarily to employers that have been exempted from full compliance
with the ACA). Although not required by federal law, it is indeterminate as to how many fully insured
disability insurance plans that are not QHPs provide coverage for mammograms, the additional breast
cancer screening, or impose cost-sharing greater than the proposed cap. OCI is unable to definitively
determine how many residents could benefit from the proposed mandated coverage. Further, the
availability of insurance coverage for consumers without these health insurance provisions is
indeterminate.
Financial Impact
OCI is unable to determine what financial impact , if any, the newly proposed health insurance bill may
have on insurers. The legislation is intended, in part, to increase consumer access to , and affordability of,
essential breast screenings beyond mammography by requiring insurers to eliminate a cost-sharing
amount for a supplemental breast screening examination or diagnostic breast examination. This provision
may result in increased utilization of regular mammogram screening, additional radiographic modalities
for breast cancer screenings, and possibly improve adherence that could improve a consumer’s medical
outcomes. Improved overall health may reduce the necessity for other, more expensive health care
treatments.
Currently under the ACA, individual, small, and large group health plans must provide essential health
benefits coverage including preventive screenings, and may impose exclusions, limitations, and cost-
sharing provisions that generally apply to similar coverage. Insurers offering coverage through the federal
marketplace exchange must provide coverage that is substantially similar to the state’s established
benchmark plan and may not discriminate based upon gender. The state’s benchmark plan includes both
state and federal coverage requirements and plans are required to offer preventive screenings consistent
with 45 CFR § 147.130. Insurers offering grandfathered plans or transitional plans, non-federal
governmental health plans, self-funded private employer plans, and large employer group health plans
are not restricted to offering a plan that is similar to the Wisconsin benchmark plan. Large employers and
non-federal governmental plans may select a benchmark plan from another state provided the plan
includes Wisconsin’s mandated benefits. For these latter groups, OCI is unable to determine whether the
newly proposed and amended coverage of mammograms and additional breast cancer screenings would
provide more expansive benefits than are currently provided. Therefore, OCI cannot determine whether or
not there would be an additional cost for the proposed additions and modifications to the current
mandate covering mammograms .
Federal guidance requires a state that mandates health benefits in excess of the benchmark plan to defray
the cost of the additional mandated health benefits, but only for coverage offered through the federal
marketplace exchange (see, 45 CFR § 155.170). Wisconsin’s benchmark plan was established as of January
1, 2014, and included all statutory health mandates active on that date. 2023 Senate Bill 121 in sections 5
through 17 amends and creates additional essential health benefits for the screening and evaluation for
breast cancer that is to be covered by disability insurers including QHPs offered through the federal
exchange. The state would only be required to defray costs if the expanded coverage for breast cancer
screening, including the additional radiographic modalities as proposed in 2023 Senate Bill 121, was
found by the federal government to be in excess of th e current benchmark plan.
OCI is unable to determine the extent to which this additional requirement could increase administrative
and claims costs or how the proposed requirements on insurers may impact premium costs passed on to
consumers and employers.
Please contact Sarah Smith at (608) 209-6309 or Sarah.Smith2@wisconsin.gov
if you have any questions.
Respectfully submitted,
Nathan Houdek
Commissioner
Cc: The Honorable Tony Evers, Governor of Wisconsin