Section 764c - Coverage for mammographic examinations and diagnostic breast imaging (a) All group or individual health or sickness or accident insurance policies providing hospital or medical/surgical coverage and all group or individual subscriber contracts or certificates issued by any entity subject to 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations), this act, the act of December 29, 1972 (P.L. 1701, No. 364), known as the "Health Maintenance Organization Act," theact of July 29, 1977 (P.L. 105, No. 38) , known as the "Fraternal Benefit Society Code," or an employe welfare benefit plan as defined in section 3 of the Employee Retirement Income Security Act of 1974 ( Public Law 93-406,29 U.S.C. § 1001 et seq.) providing hospital or medical/surgical coverage shall also provide coverage for mammographic examinations. The minimum coverage required shall include all costs associated with a mammogram every year for women 40 years of age or older with any mammogram based on a physician's recommendation for women under 40 years of age. Prior to payment for a screening mammogram, insurers shall verify that the screening mammography service provider is properly licensed by the department in accordance with the act of July 9, 1992 (P.L. 449, No. 93) , known as the "Mammography Quality Assurance Act." Nothing in this section shall be construed to require an insurer to cover the surgical procedure known as mastectomy or to prevent application of deductible or copayment provisions contained in the policy or plan except as preempted by Federal Law.(b) A group or individual health or sickness or accident insurance policy providing hospital or medical/surgical coverage and a group or individual subscriber contract or certificate issued by any entity subject to 40 Pa.C.S. Ch. 61 or 63, this act, the "Health Maintenance Organization Act," the "Fraternal Benefit Society Code" or an employe welfare benefit plan as defined in section 3 of the Employee Retirement Income Security Act of 1974 providing hospital or medical/surgical coverage shall also provide coverage for breast imaging. The minimum coverage required shall include all costs associated with one supplemental breast screening every year because the woman is believed to be at an increased risk of breast cancer due to: (1) Personal history of atypical breast histologies;(2) Personal history or family history of breast cancer;(3) Genetic predisposition for breast cancer;(4) Prior therapeutic thoracic radiation therapy;(5) Heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:(i) Lifetime risk of breast cancer of greater than 20%, according to risk assessment tools based on family history;(ii) Personal history of BRCA1 or BRCA2 gene mutations;(iii) First-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing herself;(iv) Prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or(v) Personal history of Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree relative with one of these syndromes; or(6) Extremely dense breast tissue based on breast composition categories. Nothing in this subsection shall be construed as to preclude utilization review as provided under Article XXI of this act or to prevent the application of deductible, copayment or coinsurance provisions contained in the policy or plan for breast imaging in excess of the minimum coverage required.
(b) A group or individual health or sickness or accident insurance policy providing hospital or medical/surgical coverage and a group or individual subscriber contract or certificate issued by any entity subject to 40 Pa.C.S. Ch. 61 or 63, this act, the "Health Maintenance Organization Act," the "Fraternal Benefit Society Code" or an employe welfare benefit plan as defined in section 3 of the Employee Retirement Income Security Act of 1974) providing hospital or medical/surgical coverage shall also provide coverage for breast imaging. The minimum coverage required shall include supplemental magnetic resonance imaging or, if such imaging is not possible, ultrasound if recommended by the treating physician because the woman is believed to be at an increased risk of breast cancer due to: (1) Personal history of atypical breast histologies;(2) Personal history or family history of breast cancer;(3) Genetic predisposition for breast cancer;(4) Prior therapeutic thoracic radiation therapy;(5) Heterogeneously dense breast tissue based on breast composition categories of the Breast Imaging and Reporting Data System established by the American College of Radiology with any one of the following risk factors:(i) Lifetime risk of breast cancer of greater than 20%, according to risk assessment tools based on family history;(ii) Personal history of BRCA1 or BRCA2 gene mutations;(iii) First-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing herself;(iv) Prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or(v) Personal history of Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree relative with one of these syndromes.(6) Extremely dense breast tissue based on breast composition categories of the Breast Imaging and Reporting Data System established by the American College of Radiology. Nothing in this subsection shall be construed to require an insurer to cover the surgical procedure known as mastectomy or to prevent the application of deductible, copayment or coinsurance provisions contained in the policy or plan.(c) This section shall not apply to the following types of policies:(8) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.(9) Long-term care or disability income.(10) Workers' compensation.(11) Automobile medical payment.(d) As used in this section: "Supplemental breast screening" means a medically necessary and clinically appropriate examination of the breast using either standard or abbreviated magnetic resonance imaging or, if such imaging is not possible, ultrasound if recommended by the treating physician to screen for breast cancer when there is no abnormality seen or suspected in the breast.
Amended by P.L. TBD 2023 No. 1, § 1, eff. 6/30/2023.Amended by P.L. TBD 2020 No. 52, § 1, eff. 8/30/2020.1921, May 17, P.L. 682, No. 284, § 632, added 1989, July 7, P.L. 755, No. 37, § 4, imd. effective. Amended 1992, Dec. 15, P.L. 1129, No. 148, § 1, effective in 60 days.