Positive Changes for Women’s Health Care – Chapter 196, P.L. 2013

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This law was approved on January 17, 2014 and becomes effective on May 1, 2014. It applies to all contracts and policies that are delivered, issued, executed, or renewed or approved for issuance or renewal in this State on or after the effective date.

The law requires the SHBP/SEHBP and other health insurers to cover breast evaluations and other additional medically necessary testing under certain circumstances and requires certain mammogram reports to contain information on breast density.

Pursuant to the provisions of this law, health insurers are to provide health benefits coverage for an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer.  The law provides that the additional risk factors include, but are not limited to, family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System, or other indications as determined by the patient’s health care provider. 

Under the law, the additional coverage required to be provided by health insurers may be subject to utilization review, including periodic review, by the health insurer of the medical necessity of the additional breast screening and diagnostic testing.

In addition, the law requires that each mammography report provided to a patient include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology.

To view the new law, click here: Chapter 196, P.L. 2013 Adobe PDF (86K)