KRS 304.17-316: Coverage for mammograms -- Prohibition on cost -sharing

requirements for covered diagnostic breast examinations or supplemental

breast examinations.

(1) As used in this section:

(a) "Cost-sharing requirements" means any:

1. Deductible, coinsurance, or copayment; or

2. Out-of-pocket expense imposed upon an insured that is similar to an

expense referenced in subparagraph 1. of this paragraph;

(b) 1. "Diagnostic breast examination" means a medically necessary and

appropriate examination o f the breast that is used to evaluate an

abnormality seen or suspected from, or detected by, a screening

examination for breast cancer or another means of examination.

2. As used in subparagraph 1. of this paragraph, "examination of the

breast" includes bu t is not limited to an examination using diagnostic

mammography, breast magnetic resonance imaging, or breast

ultrasound;

(c) 1. "Mammogram" means an X -ray examination of the breast, with at least

two (2) views of each breast and with an average radiation exposure at

the current recommended level as set forth in guidelines of the

American College of Radiology, using equipment dedicated specifically

for mammography, including but not limited to:

a. The X -ray tube, filter, compression device, screens, film, and

cassettes;

b. Digital mammography; and

c. Breast tomosynthesis.

2. As used in subparagraph 1. of this paragraph, "breast tomosynthesis"

means a radiologic procedure that involves the acquisitio n of projection

images over the stationary breast to produce cross -sectional digital

three-dimensional images of the breast; and

(d) 1. "Supplemental breast examination" means a medically necessary and

appropriate examination of the breast that is:

a. Used to screen for breast cancer when there is no abnormality seen

or suspected; and

b. Based on personal or family medical history, or additional factors,

that may increase the individual's risk of breast cancer.

2. As used in subparagraph 1. of this paragrap h, "examination of the

breast" includes but is not limited to:

a. A mammogram; and

b. An examination using breast magnetic resonance imaging or

breast ultrasound.

(2) Subject to subsection (3) of this section and except as otherwise provided in

subsection (4) of this section, a health insurance policy, plan, certificate, or contract

issued, renewed, or delivered in this Commonwealth:

(a) That provides coverage on an expense -incurred basis for surgical services for

a mastectomy shall also provide coverage for:

1. a. Low-dose mammography screening for persons who have no sign

or symptom of breast cancer upon self -referral or referral by a

health care practitioner acting within the scope of the practitioner's

licensure.

b. The coverage required under this subpa ragraph may be limited to

the following:

i. One (1) mammogram for persons ages thirty -five (35) years

through thirty-nine (39) years;

ii. One (1) mammogram every two (2) years for persons ages

forty (40) years through forty-nine (49) years;

iii. One (1) ma mmogram per year for persons ages fifty (50)

years and over; and

iv. A benefit of fifty dollars ($50) per screening mammogram.

c. The coverage required under this subparagraph shall be subject to

deductibles and coinsurance that are no less favorable than the

deductibles and coinsurance for coverage for physical illness

generally; and

2. a. Mammograms for any insured, regardless of age, who has been

diagnosed with breast disease upon referral by a health care

practitioner acting within the scope of the practitioner's licensure.

b. The coverage required under this subparagraph shall be subject to

the same annual deductibles or coinsurance established for other

coverages within the policy;

(b) Shall not impose any cost -sharing requirements for any diagnostic b reast

examination or supplemental breast examination that is covered under the

policy, plan, certificate, or contract; and

(c) Shall provide any coverage not otherwise required under this section,

including coverage with respect to restrictions on cost -sharing requirements,

for breast examinations, including mammograms, that is required for that

policy, plan, certificate, or contract under federal law.

(3) The coverage required under subsection (2)(a) of this section shall be limited to

mammograms:

(a) Performed by a radiographer:

1. Licensed under KRS Chapter 311B; or

2. Certified by the American Registry of Radiologic Technologists;

(b) Interpreted by a qualified radiologist;

(c) Performed under the direction of a person licensed to practice medicine and

certified by the American Board of Radiology;

(d) Performed by a facility and ordered by a health care practitioner that follow

federal laws relating to th e notification of mammography exam results and

maintaining medical records;

(e) Performed by a facility that meets current criteria of the American College of

Radiology Mammography Accreditation Program; and

(f) Performed on dedicated equipment that meets the guidelines established by

the American College of Radiology.

(4) If the application of any requirement of subsection (2) of this section would be the

sole cause of a health insurance policy's, plan's, certificate's, or contract's failure to

qualify as a Health Savings Account -qualified High Deductible Health Plan under

26 U.S.C. sec. 223, as amended, then the requirement shall not apply to that policy,

plan, certificate, or contract until the minimum deductible under 26 U.S.C. sec. 223,

as amended, is satisfied.