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SCLD Update |
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| Other Topics in this Issue: Breast Cancer Detection |
Breast Cancer Detection During 1997, 20 states passed measures addressing third-party reimbursement for breast cancer treatment or screening services. Treatment Reimbursement: Fifteen states passed laws in 1997 pertaining to insurance coverage following a mastectomy. Legislation in eight of these states—Connecticut, Louisiana, New Hampshire, New York, North Carolina, Oklahoma, Tennessee, and Texas—require insurers to provide coverage for breast reconstructive surgery. The Connecticut and New York laws both require specified insurers to provide coverage for the reconstruction of the breast on which the mastectomy was performed, and on the other breast to provide symmetry. In New York, the manner in which the surgery and reconstruction are performed must be determined to be appropriate by the attending physician and the patient, and coverage may be subject to deductible and co-insurance provisions. Legislation in New Hampshire, Tennessee, and Texas mandates that specified insurers, health maintenance organizations (HMOs), and other managed care organizations (Tennessee only) that cover mastectomies also cover breast reconstruction. This coverage must apply not only to the diseased breast, but also to the reconstruction of the other breast to achieve symmetry. Coverage in Tennessee and Texas may be subject to applicable copayments, co-insurance, and deductibles. Oklahoma now requires specified insurers, including HMOs, preferred provider organizations (PPOs), public employee health plans, and Medicaid, that provide benefits for breast cancer treatment to also cover all stages of breast reconstructive surgery following a mastectomy. The coverage must apply to surgery on both the diseased and the non-diseased breast, and insurers must provide policy holders with written notice of coverage. Louisiana and North Carolina now require that specified insurers, including HMOs, PPOs, and certain public employee health plans, that provide coverage for mastectomies to also provide coverage for the reconstruction of the breast on which the mastectomy was performed, and on the other breast to provide a symmetrical appearance. Coverage is subject to the same deductible and co-insurance limitations applied to similar services under the same policy. However, in Louisiana, reimbursement for the reconstructive surgery is required only if it is performed under the same policy or plan as the mastectomy. Seven other states—Arkansas, Florida, Indiana, Missouri, Montana, New Jersey, and Pennsylvania—require insurers to provide coverage for breast reconstructive surgery and prosthetic devices incident to mastectomy. In Arkansas, Florida, and Missouri, specified insurers and HMOs that cover mastectomy also must reimburse for prosthetic devices and cover reconstructive surgery following a mastectomy. In Florida and Missouri, coverage is subject to deductibles and co-insurance, and in Florida only, HMOs may charge an additional premium for the coverage. The Arkansas law also applies to public employee health plans. Legislation passed in Indiana requires specified insurers and HMOs that cover mastectomy to also cover prosthetic devices as well as breast reconstructive surgery to produce symmetry. Coverage is subject to deductibles and co-insurance provisions. The Montana law mandates that specified insurers cover prosthetic devices and reconstructive surgery following a mastectomy on both the diseased and non-diseased breast. Furthermore, the law requires contracts providing outpatient x-ray or radiation therapy to cover outpatient chemotherapy following breast cancer surgery. New Jersey expanded its coverage of breast reconstructive surgery, so that specified insurers must now provide benefits for the reconstruction of both breasts following a mastectomy to provide symmetry. HMOs must provide the same coverage and cover the cost of protheses, and HMOs that provide outpatient x-ray or radiation therapy must cover outpatient chemotherapy following breast cancer surgery. The legislation passed in Pennsylvania requires HMOs, the state medical assistance program, and other specified insurers that provide coverage for mastectomies, to also cover prosthetic devices and reconstructive surgery on both breasts to produce symmetry. However, coverage for the prosthetic devices may be limited to six years following the mastectomy. At the same time, Virginia passed a law requiring the state plan for medical assistance to cover high-dose chemotherapy and bone marrow transplants for individuals over age 21. Eligible individuals must have been diagnosed with breast cancer and must meet specified requirements. Screening Reimbursement: Six states—Alabama, Illinois, Louisiana, Maine, Montana, and Nevada—enacted measures addressing insurance coverage for mammography screening. Alabama's law requires specified insurers, including HMOs, PPOs, and Medicaid, that cover mastectomies, to also cover mammography screening. Screening must be provided: (1) at least every 2 years for women ages 40 to 49 years, (2) annually for women ages 50 and over, or (3) more frequently for women in either age group based on a physician's recommendation. Insurers and HMOs must comply with these requirements or be subject to licensure and administrative penalties. Illinois, Louisiana, Maine, and Nevada amended existing mammography screening laws. Illinois now requires specified insurers, HMOs, public employee health plans, and Medicaid to provide coverage for an annual mammogram for women ages 40 and older. Louisiana requires the State Employees' Group Benefits Program to provide coverage for: (1) a baseline mammogram for women ages 35 to 39, (2) a biennial mammogram for women ages 40 to 49, and (3) annually for women ages 50 and over. In Maine, designated insurers, including HMOs, must provide coverage for annual screening mammograms for women ages 40 and over. Nevada amended its law by prohibiting designated insurers, including HMOs, from requiring prior authorization for a baseline mammogram for women ages 35 to 40, or for annual mammograms for women over age 40. Montana enacted a resolution urging the United States Congress to change Medicare coverage to allow women over age 65 to receive annual mammogram screening. Inpatient Care In 1997, 14 states passed legislation regarding inpatient care following a mastectomy. Seven states—Arkansas, Connecticut, New Jersey, New Mexico, Oklahoma, Rhode Island, and Texas—impose minimum inpatient length of stay requirements following a mastectomy; however, different lengths of stay are permitted if recommended by the physician in consultation with the patient. The Arkansas legislation prohibits specified insurers and HMOs that cover mastectomies from restricting benefits for any mastectomy-related hospital stay to less than 48 hours, unless an earlier discharge is determined appropriate by both the physician and the patient. In Connecticut, certain insurers must provide coverage for at least 48 hours following a mastectomy or lymph node dissection. Two laws passed by the New Jersey legislature require specified insurers, HMOs, and contracts purchased by the state Health Benefits Commission to cover inpatient care for a minimum of 48 hours following a simple mastectomy, and a minimum of 72 hours following a modified radical mastectomy. In New Mexico, Oklahoma, Rhode Island, and Texas, legislation was passed requiring certain insurers to provide inpatient coverage for a minimum of 48 hours after a mastectomy and for at least 24 hours following a lymph node dissection. The New Mexico, Rhode Island, and Texas laws apply to certain insurers and HMOs, while the Oklahoma law applies to specified insurers that provide treatment for breast cancer; these insurers include HMOs, PPOs, public employee health plans, and Medicaid. Measures passed in seven other states—Florida, Illinois, Maine, Montana, New York, North Carolina, and Pennsylvania—require the length of coverage to be determined by a physician, rather than specifying minimum lengths of stay. The Florida law prohibits specified insurers and HMOs that cover breast cancer treatment from limiting inpatient coverage following a mastectomy to any period that is less than what is determined by the treating physician to be medically necessary. In Illinois, certain insurers, HMOs, and public employee health plans are required to provide inpatient coverage following a mastectomy for a length of time determined by the attending physician to be medically necessary. The legislation enacted in Maine requires designated insurers and HMOs to provide coverage following a mastectomy, lumpectomy, or lymph node dissection, with the period of coverage determined by the physician and the patient. In Montana, HMOs, public employee health plans, and other specified insurers must provide coverage for inpatient care following a mastectomy, lumpectomy, or lymph node dissection, and the length of coverage must be decided by both the physician and the patient. New York insurance policies that cover inpatient hospital care must provide coverage for breast cancer patients undergoing mastectomies, lymph node dissections, or lumpectomies, for a period of time determined to be medically appropriate by the attending physician in consultation with the patient. The North Carolina law requires specified insurers and HMOs that provide coverage for mastectomy and post-mastectomy inpatient care to ensure that the decision to discharge a patient after a mastectomy is made by the attending physician in consultation with the patient, and that the length of the hospital stay is based on the patient's health and medical history. Legislation passed in Pennsylvania requires specified insurers, including HMOs and the state medical assistance program, to provide coverage for inpatient care following a mastectomy, with the period of coverage to be determined by the treating physician. Five states (Maine, New York, Oklahoma, Rhode Island, and Texas) require specified insurers to give written notice of inpatient care coverage to policy holders. At the same time, inpatient care coverage may be subject to deductibles and copayments in Florida, New Mexico, New York, and Pennsylvania. In addition to these laws, Georgia passed a resolution creating a State Senate Committee on Women's Care Issues "Committee" to study issues relating to hospital inpatient care following a mastectomy. The Committee must report its finding and any recommended actions by December 1, 1998. Mammography Quality Assurance New Mexico and Texas both passed laws regarding mammography quality assurance. The New Mexico Department of Human Services must ensure that mammograms covered by Medicaid are performed according to nationally recognized standards. Due to legislation passed in Texas, mammography systems certification is valid for 3 years, with inspection by the Department of Health within 60 days of certification. Facilities that fail inspection must notify all patients who received a mammogram during the 30 days prior to the failed inspection. Research Four states—Arkansas, California, New Jersey, and Washington—passed measures relating to breast cancer research. Arkansas passed three laws in 1997. The first law establishes: (1) the Breast Cancer Research Program to support research into the cause, cure, treatment, early detection, and prevention of breast cancer, and (2) the Breast Cancer Control Program to provide for the early detection, diagnosis, and treatment of breast cancer. This law also allocates 90 percent of the revenue derived from cigarette and tobacco product excise tax increases to the two breast cancer program funds. However, these additional taxes may not be collected in any year in which the Arkansas General Assembly appropriates a designated amount of money to both the Breast Cancer Research Fund and the Breast Cancer Control Fund. [Since the state passed two laws which appropriate sufficient funds to support the Breast Cancer Control Program and the Breast Cancer Research Program for fiscal years 1997-98 and 1998-99, the excise tax increases are not currently in effect.] California passed a law requiring that contributions to the state Breast Cancer Research Fund be allocated to the University of California in support of the state's Breast Cancer Research Program. California, New Jersey, and Washington passed resolutions relating to breast cancer research. One resolution adopted in California urges the Congress and President of the United States to create the "Cure Breast Cancer Research" postage stamp to supplement available funds for breast cancer research. Another California resolution recognizes the need to prioritize breast cancer research and funding to support that research. New Jersey adopted a resolution which urges the President and Congress of the United States to support legislation to fund research into the causes of high breast cancer rates in the state. The Washington resolution appeals to the President and Congress of the United States to appropriate additional funds for breast cancer research and to mandate that cancer activists be among those individuals who decide how the funds are spent. Research and Prevention Connecticut passed legislation that established a Breast Cancer Research and Education Account to assist breast cancer research, education, and community service programs. Beginning with the 1997 tax year, taxpayers may contribute any part of their tax refunds to this account. Screening Programs Legislation in Connecticut appropriated specified funds to the state Department of Public Health for Breast Cancer Detection and Treatment for fiscal years 1997-98 and 1998-99. Treatment Options In Montana, 1997 legislation establishes that the failure of a physician to obtain written informed consent for breast cancer treatment, as defined by law, constitutes unprofessional conduct. |
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