SCLD Update
July 1997

Breast Cancer Detection
Third-Party Reimbursement

The Alabama Breast Cancer Screening Act (S.B. 17) requires specified insurers, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), and Medicaid, that provide coverage for mastectomy to also provide coverage for screening mammography, effective October 1, 1997. Screening must be provided: (1) at least every 2 years for women ages 40 to 49 years, (2) annually for women age 50 and over, or (3) more frequently for women in either age group based on a physician's recommendation. An insurer's or HMO's license may be suspended or revoked, or other administrative penalties may be imposed for any violation of these requirements.

The Arkansas Health Care Consumer Act (H.B. 1843) requires certain insurers, HMOs, and public employee health plans that provide coverage for mastectomy to provide reimbursement for prosthetic devices and breast reconstructive surgery. See the additional summary of this bill in the Breast Cancer Detection/Inpatient Care section.

Connecticut's S.B. 334 requires designated insurers to provide benefits for reconstructive surgery on: (1) each breast on which a mastectomy was performed, and (2) a nondiseased breast to provide symmetry. These benefits are subject to the same terms and conditions as all other benefits. See the additional summary of this bill in the Breast Cancer Detection/Inpatient Care section.

An amendment in Florida (S.B. 530) expands the state's breast cancer treatment coverage provisions, effective October 1, 1997. The law requires certain insurers and HMOs that provide coverage for mastectomies to also provide coverage for prosthetic devices and reconstructive surgery. Coverage is subject to deductibles and co-insurance, and HMOs may charge an additional premium for the coverage. See additional summary of this bill in the Breast Cancer Detection/Inpatient Care section.

In Illinois, H.B. 1881 deleted the previous mammography screening guidelines for women ages 40 to 49 and 50 and older. Specified insurers, HMOs, public employee health plans, and Medicaid are now required to provide coverage for an annual mammogram for women age 40 and older. See the additional summaries of this bill in the Breast Cancer Detection/Inpatient Care section, the Cervical Cancer Detection/Third-Party Reimbursement section, and the Prostate Cancer Detection/Third-Party Reimbursement section.

Legislation in Indiana (H.B. 1684), New Hampshire (H.B. 442), Tennessee (H.B. 697), and Texas (S.B. 217) requires specified insurers, HMOs, and other managed care organizations (Tennessee only) that cover mastectomy to also provide coverage for breast reconstruction. The coverage applies to reconstruction of the breast on which the mastectomy was performed as well as surgery and reconstruction on the other breast to produce symmetry. Indiana's law also provides coverage for prosthetic devices. In Indiana and Tennessee, deductibles and copayments apply, and in Texas deductibles and copayments may apply. The laws enacted in New Hampshire and Texas are effective January 1, 1998.

The Act to Establish Breast Cancer Patient Protection in Maine (L.D. 1556) amends certain provisions regarding third-party reimbursement for screening mammography. Effective January 1, 1998, designated insurers and HMOs must provide coverage for annual screening mammograms for women ages 40 and older. See the additional summary of this bill in the Breast Cancer Detection/Inpatient Care section.

In Montana, S.B. 324 requires that, effective January 1, 1998, designated insurers provide coverage for: (1) reconstructive surgery on the diseased breast after mastectomy, and (2) one reconstructive surgery on the nondiseased breast to establish symmetry. Benefits for reconstructive surgery include the costs of prostheses and, under contracts providing outpatient x-ray or radiation therapy, outpatient chemotherapy following breast cancer surgery. See additional summaries of this bill in the Breast Cancer Detection/Inpatient Care section and the Breast Cancer Detection/Treatment Options section.

The enactment of S.B. 1783 expands coverage requirements for breast reconstructive surgery in New Jersey. Specified insurers must now provide benefits for surgery to restore and achieve symmetry between the two breasts following a mastectomy. HMOs must provide the same coverage, as well as coverage for the cost of prostheses. Also, HMOs that cover outpatient x-ray or radiation therapy must cover outpatient chemotherapy following surgical treatment for breast cancer. Benefits must be provided by specified insurers and HMOs to the same extent as for any other sickness.

The Oklahoma Breast Cancer Patient Protection Act (H.B. 1532) requires that, effective January 1, 1998, specified insurers, including HMOs, PPOs, public employee health plans, and Medicaid, that provide benefits for the treatment of breast cancer also provide coverage for breast reconstructive surgery resulting from a mastectomy. The coverage must include all stages of reconstructive breast surgery performed on a nondiseased breast to establish symmetry with the reconstructed diseased breast. Insurers must provide written notice of coverage to policy holders. See the additional summary of this bill in the Breast Cancer Detection/Treatment Options section.

A resolution in Montana, S.J.R. 8, urges the United States Congress to change Medicare coverage to allow women over age 65 to receive annual mammogram screening.

Inpatient Care

During this quarter, 11 states enacted legislation addressing inpatient care following a mastectomy. The Arkansas Health Care Consumer Act (H.B. 1843) prohibits specified insurers and health maintenance organizations (HMOs) that provide coverage for mastectomy from restricting benefits for any mastectomy-related hospital stay to less than 48 hours, unless the patient and physician determine that an early discharge is appropriate. See the additional summary of this bill in the Breast Cancer Detection/Third-Party Reimbursement section.

Connecticut passed S.B. 334, which requires certain insurers to provide inpatient coverage for at least 48 hours following a mastectomy or lymph node dissection. Different lengths of stay are permitted, upon the recommendation of the physician in consultation with the patient. See the additional summary of this bill in the Breast Cancer Detection/Third-Party Reimbursement section.

Effective October 1, 1997, Florida's S.B. 530 prohibits specified insurers and HMOs that cover breast cancer treatment from limiting inpatient coverage for mastectomies to any period that is less than that determined by the treating physician to be medically necessary. Medical necessity is to be determined in accordance with prevailing medical standards and after consultation with the patient. Coverage may be subject to deductibles and copayments. See the additional summary of this bill in the Breast Cancer Detection/Third-Party Reimbursement section.

By enacting H.B. 1881, Illinois requires certain insurers, HMOs, and public employee health plans to provide inpatient coverage following a mastectomy for a length of time determined by the attending physician to be medically necessary. See the additional summaries of this bill in the Breast Cancer Detection/Third-Party Reimbursement section, the Cervical Cancer Detection/Third-Party Reimbursement section, and the Prostate Cancer Detection/Third-Party Reimbursement section.

Effective January 1, 1998, legislation enacted in Maine (L.D. 1556) and Montana (S.B. 324) requires designated insurers, HMOs, and public employee health plans (Montana only), to provide coverage for inpatient care following a mastectomy, a lumpectomy, or a lymph node dissection. The period of coverage must be determined by the physician and patient. In Maine, insurers must provide written notice of coverage to policy holders. See the additional summary of the Maine bill in the Breast Cancer Detection/Third-Party Reimbursement section. See the additional summaries of the Montana bill in the Breast Cancer Detection/Third-Party Reimbursement section and the Breast Cancer Detection/Treatment Options section.

Two laws enacted in New Jersey (S.B. 1704 and S.B. 1705) require specified insurers, HMOs, and contracts purchased by the state Health Benefits Commission to provide coverage for inpatient care for a minimum of: (1) 72 hours following a modified radical mastectomy, and (2) 48 hours following a simple mastectomy. These requirements do not apply if a patient and physician determine a shorter length of stay is appropriate. Benefits provided by specified insurers and HMOs must be provided to the same extent as for any other condition.

Three states—New Mexico, Rhode Island, and Texas—enacted laws requiring certain insurers and HMOs to provide coverage for a minimum inpatient hospital stay of 48 hours after a mastectomy and 24 hours after a lymph node dissection. In all three states, these requirements do not apply if the patient and physician determine a shorter length of stay is appropriate. In New Mexico (S.B. 964), coverage may be subject to deductibles and co-insurance payments. In Rhode Island (H.B. 5280/S.B. 38) and Texas (H.B. 349, effective January 1, 1998) insurers must provide written notice of coverage to policy holders.

Effective January 1, 1998, the Oklahoma Breast Cancer Patient Protection Act (H.B. 1532) requires specified insurers, including HMOs, PPOs, public employee health plans, and Medicaid, that provide benefits for the treatment of breast cancer to provide inpatient coverage for: (1) at least 48 hours following a mastectomy, and (2) at least 24 hours following a lymph node dissection. These requirements do not apply if a patient and physician determine a shorter length of stay is appropriate. Insurers must provide written notice of coverage to policy holders. See additional summary of this bill in the Breast Cancer Detection/Third-Party Reimbursement section.

Mammography Quality Assurance

Under S.B. 1166, the New Mexico Department of Human Services is now required to ensure that mammograms covered under Medicaid are performed according to nationally recognized standards.

Texas enacted H.B. 1534, which provides that certification of mammography systems is valid for three years, effective September 1, 1997. No later than 60 days after certification, the state Department of Health will inspect mammography systems that have not been fully certified under the Federal Mammography Quality Standards Act of 1992 (P.L. 102-539). A facility with a mammography system failing to meet the certification standards must notify all patients who received mammograms within the 30 days prior to the failed inspection. The notification must: (1) inform the patient of the mammography system's failure to meet certification requirements, (2) recommend that the patient have another mammogram at a facility with a certified mammography system, and (3) list the three facilities with certified mammography systems in closest proximity to the original facility.

Research

A resolution in New Jersey, A.R. 6, urges the President and Congress of the United States to support legislation that provides funding for research into the causes of high breast cancer rates in the state.

Research and Prevention

Connecticut enacted H.B. 6891, which establishes a Breast Cancer Research and Education Account ("Account"). Beginning with the 1997 tax year, taxpayers may contribute any part of a refund to the Account. Monies in the Account must be used by the state Department of Public Health to assist breast cancer research, education, and community service programs.

Screening Programs

Legislation in Connecticut (H.B. 6702) appropriates to the state Department of Public Health $1,830,923 for Breast and Cervical Cancer Detection and Treatment for fiscal year 1997-1998 and $1,875,923 for fiscal year 1998-1999. See the additional summary of this bill in the Cervical Cancer Detection/Screening Programs section.

Treatment Options

Under S.B. 324 in Montana, failure of a physician to provide for written informed consent for breast cancer treatment constitutes unprofessional conduct. "Written informed consent" is defined as an agreement freely executed by the patient certifying that full disclosure has been made regarding: (1) the full range of medical treatment alternatives; (2) the advantages, disadvantages, risks, and descriptions of these treatments; and (3) aspects of recovery, including the options available for reconstructive surgery. See the additional summaries of this bill in the the Breast Cancer Detection/Third-Party Reimbursement section and the Breast Cancer Detection/Inpatient Care section.