SECTION 8. Chapter 1356,
Insurance Code, is amended by adding Subchapter B to read as follows:
SUBCHAPTER B. SUPPLEMENTAL
BREAST CANCER SCREENING
Sec. 1356.051. DEFINITION.
In this subchapter,
"supplemental breast cancer screening" means a method of
screening designed to supplement mammography by detecting breast cancers
that may not be visible using only mammography. The term may include:
(1) a breast MRI examination; or
(2) any other screening method recommended by a professional
association or agency with expertise in mammography, including the National
Cancer Institute and the National Comprehensive Cancer Network, based on a
patient's specific risk factors.
Sec. 1356.052.
APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health
benefit plan that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or an individual or
group evidence of coverage or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital
service corporation operating under Chapter 842;
(3) a fraternal benefit
society operating under Chapter 885;
(4) a stipulated premium
company operating under Chapter 884;
(5) an exchange operating
under Chapter 942;
(6) a health maintenance
organization operating under Chapter 843;
(7) a multiple employer welfare arrangement that holds a certificate
of authority under Chapter 846; or
(8) an approved nonprofit
health corporation that holds a certificate of authority under Chapter 844.
(b) This subchapter applies to group health coverage made available
by a school district in accordance with Section 22.004, Education Code.
(c) Notwithstanding Section 172.014, Local Government Code, or any
other law, this subchapter applies to health and accident coverage provided
by a risk pool created under Chapter 172, Local Government Code.
(d) Notwithstanding any provision in Chapter 1551, 1575, 1579, or
1601 or any other law, this subchapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579; and
(4) basic coverage under Chapter 1601.
(e) Notwithstanding
Section 1501.251 or any other law, this subchapter applies to coverage
under a small employer health benefit plan subject to Chapter 1501.
Sec. 1356.053.
APPLICABILITY TO CERTAIN GOVERNMENT PROGRAMS. To the extent allowed by
federal law, the state Medicaid program and a managed care organization
that contracts with the Health and Human Services Commission to provide
health care services to Medicaid recipients through a managed care plan
shall provide the benefits required under this subchapter to a Medicaid
recipient.
Sec. 1356.054.
EXCEPTION. This subchapter does not apply to:
(1) a plan that provides
coverage:
(A) for wages or payments
in lieu of wages for a period during which an employee is absent from work
because of sickness or injury;
(B) as a supplement to a
liability insurance policy;
(C) for credit insurance;
(D) only for dental or
vision care;
(E) only for hospital
expenses; or
(F) only for indemnity
for hospital confinement;
(2) a Medicare
supplemental policy as defined by Section 1882(g)(1), Social Security Act
(42 U.S.C. Section 1395ss(g)(1));
(3) a workers'
compensation insurance policy;
(4) medical payment
insurance coverage provided under a motor vehicle insurance policy; or
(5) a long-term care
policy, including a nursing home fixed indemnity policy, unless the
commissioner determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described by
Section 1356.052.
Sec. 1356.055. COVERAGE
REQUIRED.
A health benefit plan that
provides coverage for mammography, including coverage for low-dose
mammography required by Subchapter A, must also provide coverage for
supplemental breast cancer screening if a physician
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 (Fourth
Edition) established by the American College of Radiology; and
(2) additional risk
factors for breast cancer that the physician
believes warrant supplemental breast cancer screening beyond
mammography.
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SECTION 9. Chapter 1356,
Insurance Code, is amended by adding Subchapter B to read as follows:
SUBCHAPTER B.
SUPPLEMENTAL BREAST CANCER SCREENING
Sec. 1356.051. DEFINITIONS.
In this subchapter:
(1) "Health benefit exchange" means an American Health
Benefit Exchange administered by the federal government or created pursuant
to Section 1311(b), Patient Protection and Affordable Care Act (42 U.S.C.
Section 18031).
(2) "Qualified health plan" has the meaning assigned by
Section 1301(a), Patient Protection and Affordable Care Act (42 U.S.C.
Section 18021).
(3) "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.
APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health
benefit plan that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or an individual or
group evidence of coverage or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital
service corporation operating under Chapter 842;
(3) a fraternal benefit
society operating under Chapter 885;
(4) a stipulated premium
company operating under Chapter 884;
(5) an exchange operating
under Chapter 942;
(6) a health maintenance
organization operating under Chapter 843; or
(7) an approved nonprofit
health corporation that holds a certificate of authority under Chapter 844.
(b) Notwithstanding
Section 1501.251 or any other law, this subchapter applies to coverage
under a small employer health benefit plan subject to Chapter 1501.
No
equivalent provision.
Sec. 1356.053.
EXCEPTION. This subchapter does not apply to:
(1) a plan that provides
coverage:
(A) only for benefits for a specified disease or for another limited
benefit;
(B) only for accidental death or dismemberment;
(C) for wages or payments
in lieu of wages for a period during which an employee is absent from work
because of sickness or injury;
(D) as a supplement to a
liability insurance policy;
(E) for credit insurance;
(F) only for dental or
vision care;
(G) only for hospital
expenses; or
(H) only for indemnity
for hospital confinement;
(2) a Medicare
supplemental policy as defined by Section 1882(g)(1), Social Security Act
(42 U.S.C. Section 1395ss);
(3) a workers'
compensation insurance policy;
(4) medical payment
insurance coverage provided under a motor vehicle insurance policy;
(5) a long-term care
policy, including a nursing home fixed indemnity policy, unless the
commissioner determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described by
Section 1356.052; or
(6) a qualified health plan offered through a health benefit
exchange.
Sec. 1356.054. OFFER OF
OPTIONAL COVERAGE REQUIRED. (a) The issuer of a health benefit plan that
provides coverage for mammography, including coverage for low-dose
mammography required by Subchapter A, 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 (Fourth
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.
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