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.