Coverage for Mammograms, Pap Smears, and Prostate-Specific Antigen Tests

  1. Law
  2. Georgia Code
  3. Insurance
  4. Individual Accident and Sickness Insurance
  5. Coverage for Mammograms, Pap Smears, and Prostate-Specific Antigen Tests

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  1. As used in this Code section, the term:
    1. "Female at risk" means a woman:
      1. Who has a personal history of breast cancer;
      2. Who has a personal history of biopsy proven benign breast disease;
      3. Whose grandmother, mother, sister, or daughter has had breast cancer; or
      4. Who has not given birth prior to age 30.
      1. "Mammogram" means any low-dose radiologic screening procedure for the early detection of breast cancer provided to a woman and which utilizes equipment approved by the Department of Community Health dedicated specifically for mammography and includes a physician's interpretation of the results of the procedure or interpretation by a radiologist experienced in mammograms in accordance with guidelines established by the American College of Radiology.
      2. Reimbursement for a mammogram authorized under this Code section shall be made only if the facility in which the mammogram was performed meets accreditation standards established by the American College of Radiology or equivalent standards established by this state.
      3. Policies subject to this Code section shall contain coverage for mammograms made with at least the following frequency:
        1. Once as a base-line mammogram for any female who is at least 35 but less than 40 years of age;
        2. Once every two years for any female who is at least 40 but less than 50 years of age;
        3. Once every year for any female who is at least 50 years of age; and
        4. When ordered by a physician for a female at risk.
    3. "Pap smear" or "Papanicolaou smear" means an examination, in accordance with standards established by the American College of Pathologists, of the tissues of the cervix of the uterus for the purpose of detecting cancer when performed upon the order of a physician, which examination may be made once a year or more often if ordered by a physician.
    4. "Policy" means any benefit plan, contract, or policy except a disability income policy, specified disease policy, or hospital indemnity policy.
    5. "Prostate-specific antigen test" means a measurement, in accordance with standards established by the American College of Pathologists, of a substance produced by the epithelium to determine if there is any benign or malignant prostate tissue.
    1. Every insurer authorized to issue an individual accident and sickness insurance policy in this state which includes coverage for any female shall include as part of or as a required endorsement to each such policy which is issued, delivered, issued for delivery, or renewed coverage for mammograms and Pap smears for the covered females which at least meets the minimum requirements of this Code section.
    2. Every insurer authorized to issue an individual accident and sickness insurance policy in this state which includes coverage for any male shall include as a part of or as a required endorsement to each such policy which is issued, delivered, issued for delivery, or renewed coverage for annual prostate-specific antigen tests for the covered males who are 45 years of age or older, or for covered males who are 40 years of age or older, if ordered by a physician.
  3. The coverage required under subsection (b) of this Code section may be subject to such exclusions, reductions, or other limitations as to coverages, deductibles, or coinsurance provisions as may be approved by the Commissioner.
  4. Nothing in this Code section shall be construed to prohibit the issuance of individual accident and sickness insurance policies which provide benefits greater than those required by subsection (b) of this Code section or more favorable to the insured than those required by subsection (b) of this Code section.
  5. The provisions of this Code section shall apply to individual accident and sickness insurance policies issued by a fraternal benefit society, a health care plan, a health maintenance organization, or any similar entity.
  6. Nothing contained in this Code section shall be deemed to prohibit the payment of different levels of benefits or from having differences in coinsurance percentages applicable to benefit levels for services provided by preferred and nonpreferred providers as otherwise authorized under the provisions of Article 2 of Chapter 30 of this title, relating to preferred provider arrangements.

(Code 1981, §33-29-3.2, enacted by Ga. L. 1990, p. 1057, § 1; Ga. L. 1992, p. 1975, § 1; Ga. L. 2009, p. 453, § 1-4/HB 228; Ga. L. 2017, p. 164, § 39/HB 127; Ga. L. 2019, p. 386, § 88/SB 133.)

The 2019 amendment, effective July 1, 2019, designated the existing provisions of the first through third sentences of paragraph (a)(2) as present subparagraphs (a)(2)(A) through (a)(2)(C), respectively, redesignated former subparagraphs (a)(2)(A) through (a)(2)(D) as present divisions (a)(2)(C)(i) through (a)(2)(C)(iv), respectively; substituted "'Prostate-specific" for "'Prostate specific" at the beginning of paragraph (a)(5); deleted "on or after July 1, 1992," following "or renewed" in paragraphs (b)(1) and (b)(2); and substituted "prostate-specific" for "prostate specific" in paragraph (b)(2).

Law reviews.

- For note on 1990 enactment of this Code section, see 7 Ga. St. U.L. Rev. 317 (1990). For note on 1992 amendment of this Code section, see 9 Ga. St. U.L. Rev. 280 (1992).


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