(a) For purposes of this section:
(1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and
(2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.
(b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for mammograms to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, every year for any woman who is forty years of age or older.
(2) Such policy shall provide additional benefits for:
(A) Comprehensive ultrasound screening of an entire breast or breasts if: (i) A mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology; (ii) a woman is believed to be at increased risk for breast cancer due to (I) family history or prior personal history of breast cancer, (II) positive genetic testing, or (III) other indications as determined by a woman's physician or advanced practice registered nurse; or (iii) such screening is recommended by a woman's treating physician for a woman who (I) is forty years of age or older, (II) has a family history or prior personal history of breast cancer, or (III) has a prior personal history of breast disease diagnosed through biopsy as benign; and
(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.
(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.
(d) Each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's or advanced practice registered nurse's office and you should contact your physician or advanced practice registered nurse if you have any questions or concerns about this report.”.
(P.A. 88-124, S. 1; P.A. 90-243, S. 93; P.A. 01-171, S. 22; P.A. 05-69, S. 1; P.A. 06-38, S. 1; P.A. 09-41, S. 1; P.A. 11-67, S. 1; 11-171, S. 1; P.A. 12-150, S. 1; P.A. 14-97, S. 1; P.A. 16-82, S. 1; P.A. 18-159, S. 1; P.A. 19-98, S. 11; 19-117, S. 209.)
History: P.A. 90-243 substituted reference to health insurance policies for references to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174gg transferred to Sec. 38a-503 in 1991; P.A. 01-171 added “amended or continued” re policies in this state, substituted “October 1, 2001,” for “October 1, 1988,” re policy date, consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter, and substituted “each” for “every”; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require benefits for comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012; P.A. 14-97 amended Subsec. (b) to add provision limiting copayment for breast ultrasound screening to maximum of $20, effective January 1, 2015; P.A. 16-82 amended Subsec. (a)(1) by adding “, which may be provided by breast tomosynthesis at the option of the woman covered under the policy,” in Subparas. (A) and (B), effective January 1, 2017; P.A. 18-159 added new Subsec. (a) defining “Healthcare Common Procedure Coding System” and “Mammogram”, redesignated existing Subsecs. (a) to (c) as Subsecs. (b) to (d), and made conforming changes, effective January 1, 2019; P.A. 19-98 amended Subsec. (d) to add references to advanced practice registered nurse; P.A. 19-117 amended Subsec. (b)(2)(A) by designating existing provisions re heterogeneous or dense breast tissue as Subpara. (A)(i), designating existing provisions re women believed to be at increased risk for breast cancer as Subpara. (A)(ii) and adding Subpara. (A)(iii) re screening recommended by woman's treating physician, and amended Subsec. (c) by deleting provision re maximum of $20 for ultrasound screening and adding provisions prohibiting coinsurances, copayments, deductibles, out-of-pocket expenses and concerning high deductible plans, effective January 1, 2020.