SB413: Bill Text

Analysis by the Legislative Reference Bureau

This bill requires health insurance policies to cover, either fully or with a maximum out-of-pocket cost of $50, essential breast screenings beyond mammography in individuals who have had mammograms showing dense breast tissue, women who are at higher risk for cancer, or women whose health care provider considers the screenings to be medically necessary for any woman who is considered by the health care provider to have an above-average risk for breast cancer in accordance with certain guidelines. Health insurance policies are referred to in the statutes as disability insurance policies. Self-insured governmental health plans are also required to provide the coverage specified in the bill. The bill also requires coverage of those essential breast screenings by the Medical Assistance program, which is the state-administered Medicaid program that is jointly-funded by the state and federal governments and that provides health services to individuals with limited financial resources.

Health insurance policies are required under current law to cover two mammographic breast examinations to screen for breast cancer for a woman from age 45 to 49 if certain criteria are satisfied. Health insurance policies must currently cover annual mammograms for a woman once she attains the age of 50. The coverage required under current law is required whether or not the woman shows any symptoms of breast cancer and may be subject to only the same exclusions and limitations, including cost sharing, that apply to other radiological examinations under the policy. The bill does not change or eliminate the current coverage requirements for mammograms except that preferred provider plans are explicitly included in the current law and the bill's requirements.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB413,1 Section 1. 40.51 (8m) of the statutes is amended to read:

SB413,2,5 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.867, 632.885, 632.89, and 632.895 (8) and (11) to (17).

SB413,2 Section 2. 49.46 (2) (b) 6. n. of the statutes is created to read:

SB413,2,8 49.46 (2) (b) 6. n. Essential breast screenings for which coverage is required under s. 632.895 (8) (am).

SB413,3 Section 3. 66.0137 (4) of the statutes is amended to read:

SB413,2,16 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) (8) to (17), 632.896, and 767.513 (4).

SB413,4 Section 4. 120.13 (2) (g) of the statutes is amended to read:

SB413,3,4 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) (8) to (17), 632.896, and 767.513 (4).

SB413,5 Section 5. 609.80 of the statutes is amended to read:

SB413,3,10 609.80 Coverage of mammograms. Defined network plans and preferred provider plans are subject to s. 632.895 (8). Coverage of mammograms under s. 632.895 (8) may be subject to any requirements that the defined network plan or preferred provider plan imposes under s. 609.05 (2) and (3) on the coverage of other health care services obtained by enrollees.

SB413,6 Section 6. 632.895 (8) (a) 4. of the statutes is created to read:

SB413,3,13 632.895 (8) (a) 4. “Self-insured health plan” has the meaning given in s. 632.745 (24).

SB413,7 Section 7. 632.895 (8) (am) of the statutes is created to read:

SB413,3,17 632.895 (8) (am) Every disability insurance policy and self-insured health plan shall cover essential breast screenings beyond mammography, including breast ultrasound or magnetic resonance imaging, if any of the following are satisfied:

SB413,3,19 1. A mammogram has shown dense breast tissue, as defined in s. 255.065 (1) (a).

SB413,3,23 2. The woman is believed to be at higher risk for cancer due to family history, prior personal history of breast cancer, positive genetic testing, or other indications of an increased risk of breast cancer that include any of the following as determined by a woman's health care provider:

SB413,3,24 a. Personal history of atypical breast histologies

SB413,3,25 b. Genetic predisposition for breast cancer

SB413,4,1 c. Prior therapeutic thoracic radiation therapy.

SB413,4,3 d. Lifetime risk of breast cancer greater than 20 percent according to a risk assessment tool.

SB413,4,8 3. A health care provider considers these modalities to be medically necessary for the screening or evaluation of breast cancer for any woman who is considered by the health care provider to have an above-average risk for breast cancer in accordance with American College of Radiology guidelines for breast cancer screening or another generally accepted risk assessment model.

SB413,8 Section 8. 632.895 (8) (d) of the statutes is amended to read:

SB413,4,17 632.895 (8) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy. A disability insurance policy or self-insured health plan may not impose on a covered individual a cost-sharing amount that exceeds $50 for essential breast screenings beyond mammography as described in par. (am).

SB413,9 Section 9 . Initial applicability.

SB413,4,21 (1) For policies and plans containing provisions inconsistent with this act, the act first applies to policy or plan years beginning on January 1 of the year following the year in which this subsection takes effect, except as provided in sub. (2).

SB413,5,2 (2) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with this act, this act first applies to policy or plan years beginning on the effective date of this subsection or on the day on which the collective bargaining agreement is newly established, extended, modified, or renewed, whichever is later.

SB413,10 Section 10 . Effective date.

SB413,5,5 (1) This act takes effect on the first day of the 4th month beginning after publication.

SB413,5,6 (End)