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A BILL TO BE ENTITLED
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AN ACT
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relating to coverage for mammography and supplemental breast cancer |
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screening under certain health benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1201.005, Insurance Code, is amended to |
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read as follows: |
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Sec. 1201.005. REFERENCES TO CHAPTER. In this chapter, a |
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reference to this chapter includes a reference to: |
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(1) Section 1202.052; |
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(2) Section 1271.005(a), to the extent that the |
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subsection relates to the applicability of Section 1201.105, and |
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Sections 1271.005(d) and (e); |
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(3) Chapter 1351; |
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(4) Subchapters C and E, Chapter 1355; |
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(5) Subchapter B, Chapter 1356; |
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(6) Chapter 1365; |
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(7) Subchapter A, Chapter 1367; and |
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(8) Subchapters A, B, and G, Chapter 1451. |
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SECTION 2. The heading to Chapter 1356, Insurance Code, is |
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amended to read as follows: |
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CHAPTER 1356. [LOW-DOSE] MAMMOGRAPHY AND OTHER BREAST CANCER |
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SCREENING |
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SECTION 3. Chapter 1356, Insurance Code, is amended by |
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designating Sections 1356.001 through 1356.004 as Subchapter A and |
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adding a subchapter heading to read as follows: |
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SUBCHAPTER A. GENERAL PROVISIONS |
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SECTION 4. Section 1356.001, Insurance Code, is amended to |
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read as follows: |
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Sec. 1356.001. DEFINITIONS. [DEFINITION.] In this |
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chapter: |
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(1) "Enrollee" means an individual enrolled in a |
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health benefit plan. |
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(2) "Low-dose mammography" [, "low-dose mammography"] |
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means the x-ray examination of the breast using equipment dedicated |
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specifically for mammography, including an x-ray tube, filter, |
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compression device, screens, films, and cassettes, with an average |
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radiation exposure delivery of less than one rad mid-breast, with |
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two views for each breast. |
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SECTION 5. Section 1356.002, Insurance Code, is amended to |
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read as follows: |
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Sec. 1356.002. APPLICABILITY OF CHAPTER. This chapter |
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applies only to a health benefit plan that is delivered, issued for |
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delivery, or renewed in this state and that is an individual or |
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group accident and health insurance policy, including a policy |
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issued by a group hospital service corporation operating under |
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Chapter 842, or that is an individual or group evidence of coverage |
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issued by a health maintenance organization operating under Chapter |
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843. |
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SECTION 6. Chapter 1356, Insurance Code, is amended by |
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designating Section 1356.005 as Subchapter B and adding a |
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subchapter heading to read as follows: |
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SUBCHAPTER B. LOW-DOSE MAMMOGRAPHY |
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SECTION 7. Subchapter B, Chapter 1356, Insurance Code, as |
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added by this Act, is amended by adding Section 1356.006 to read as |
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follows: |
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Sec. 1356.006. CHOICE OF PROVIDER; PRIOR APPROVAL. (a) A |
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health benefit plan that provides coverage for low-dose mammography |
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must allow an enrollee to have a covered mammogram performed by a |
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physician or provider selected by the enrollee other than the |
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enrollee's primary care physician or primary care provider. |
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(b) A health benefit plan may not require an enrollee to |
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receive prior approval before having a covered mammogram performed |
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by a physician or provider other than the enrollee's primary care |
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physician or primary care provider. |
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(c) This section does not affect the authority of a health |
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benefit plan issuer to establish selection criteria for physicians |
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and providers who provide services under the plan. |
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(d) A physician or provider that performs a mammogram |
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described by Subsection (a) must provide a copy of the mammogram |
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report to the enrollee's primary care physician or primary care |
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provider. |
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SECTION 8. Chapter 1356, Insurance Code, is amended by |
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adding Subchapters C and D to read as follows: |
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SUBCHAPTER C. SUPPLEMENTAL BREAST CANCER SCREENING |
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Sec. 1356.051. DEFINITION. In this subchapter, |
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"supplemental breast cancer screening" means a method of screening, |
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including ultrasound imaging, that is designed to supplement |
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mammography by detecting breast cancers that may not be visible |
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using only mammography. |
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Sec. 1356.052. OFFER OF OPTIONAL COVERAGE REQUIRED. (a) An |
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issuer of a health benefit plan that provides coverage for |
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mammography, including coverage for low-dose mammography required |
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by Subchapter B, must also offer to provide coverage for |
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supplemental breast cancer screening as part of an annual |
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well-woman examination covered under the plan if a licensed health |
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care professional treating the enrollee or screening the enrollee |
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for breast cancer finds that the enrollee has: |
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(1) dense breast tissue, as defined by the Breast |
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Imaging Reporting and Database System (Fifth Edition) established |
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by the American College of Radiology; and |
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(2) additional risk factors determined under |
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Subsection (c) for breast cancer that warrant supplemental breast |
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cancer screening beyond mammography. |
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(b) An additional premium may be charged for the coverage |
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described by Subsection (a). |
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(c) The commissioner by rule shall determine risk factors |
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described by Subsection (a)(2) based on scientific research and |
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models for breast cancer. |
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SUBCHAPTER D. DIAGNOSTIC MAMMOGRAPHY |
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Sec. 1356.101. DEFINITION. In this subchapter, "diagnostic |
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mammography" means a method of screening that is designed to |
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evaluate an abnormality in a breast, including an abnormality seen |
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or suspected on a screening mammogram or a subjective or objective |
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abnormality otherwise detected in the breast. |
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Sec. 1356.102. COVERAGE FOR DIAGNOSTIC MAMMOGRAM. (a) An |
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issuer of a health benefit plan that provides coverage for a |
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screening mammogram must provide coverage for a diagnostic |
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mammogram that is no less favorable than coverage for a screening |
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mammogram. |
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(b) The coverage for a diagnostic mammogram described by |
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Subsection (a) must be subject to the same dollar limits, |
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deductibles, and coinsurance factors as coverage for a screening |
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mammogram. |
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SECTION 9. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 10. This Act applies only to a health benefit plan |
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that is delivered, issued for delivery, or renewed on or after |
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January 1, 2018. A health benefit plan that is delivered, issued |
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for delivery, or renewed before January 1, 2018, is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 11. This Act takes effect September 1, 2017. |