Section 5-10-8-7.2 - Breast cancer; definitions; self-insurance programs; health maintenance organizations; diagnostic services(a) As used in this section, "breast cancer diagnostic service" means a procedure intended to aid in the diagnosis of breast cancer. The term includes procedures performed on an inpatient basis and procedures performed on an outpatient basis, including the following:(1) Breast cancer screening mammography.(2) Surgical breast biopsy.(3) Pathologic examination and interpretation.(b) As used in this section, "breast cancer outpatient treatment services" means procedures that are intended to treat cancer of the human breast and that are delivered on an outpatient basis. The term includes the following: (5) Other outpatient cancer treatment services prescribed by a physician.(6) Medical follow-up services related to the procedures set forth in subdivisions (1) through (5).(c) As used in this section, "breast cancer rehabilitative services" means procedures that are intended to improve the results of or to ameliorate the debilitating consequences of the treatment of breast cancer and that are delivered on an inpatient or outpatient basis. The term includes the following:(2) Psychological and social support services.(3) Reconstructive plastic surgery, including chest wall reconstruction and aesthetic flat closure (as defined by the National Cancer Institute).(d) As used in this section, "breast cancer screening mammography" means a standard, two (2) view per breast, low-dose radiographic examination of the breasts that is: (1) furnished to an asymptomatic woman; and(2) performed by a mammography services provider using equipment designed by the manufacturer for and dedicated specifically to mammography in order to detect unsuspected breast cancer. The term includes the interpretation of the results of a breast cancer screening mammography by a physician.
(e) As used in this section, "covered individual" means a female individual who is: (1) covered under a self-insurance program established under section 7(b) of this chapter to provide group health coverage; or(2) entitled to services under a contract with a health maintenance organization (as defined in IC 27-13-1-19) that is entered into or renewed under section 7(c) of this chapter.(f) As used in this section, "mammography services provider" means an individual or facility that: (1) has been accredited by the American College of Radiology;(2) meets equivalent guidelines established by the Indiana department of health; or(3) is certified by the federal Department of Health and Human Services for participation in the Medicare program (42 U.S.C. 1395 et seq.).(g) As used in this section, "woman at risk" means a woman who meets at least one (1) of the following descriptions: (1) A woman who has a personal history of breast cancer.(2) A woman who has a personal history of breast disease that was proven benign by biopsy.(3) A woman whose mother, sister, or daughter has had breast cancer.(4) A woman who is at least thirty (30) years of age and has not given birth.(h) A self-insurance program established under section 7(b) of this chapter to provide health care coverage must provide covered individuals with coverage for breast cancer diagnostic services, breast cancer outpatient treatment services, and breast cancer rehabilitative services. The coverage must provide reimbursement for breast cancer screening mammography at a level at least as high as: (1) the limitation on payment for screening mammography services established in 42 CFR 405.534(b)(3) according to the Medicare Economic Index at the time the breast cancer screening mammography is performed; or(2) the rate negotiated by a contract provider according to the provisions of the insurance policy; whichever is lower. The costs of the coverage required by this subsection may be paid by the state or by the employee or by a combination of the state and the employee.
(i) A contract with a health maintenance organization that is entered into or renewed under section 7(c) of this chapter must provide covered individuals with breast cancer diagnostic services, breast cancer outpatient treatment services, and breast cancer rehabilitative services.(j) The coverage required by subsection (h) and services required by subsection (i) may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to covered individuals than the dollar limits, deductibles, or coinsurance provisions applying to physical illness generally under the self-insurance program or contract with a health maintenance organization.(k) The coverage for breast cancer diagnostic services required by subsection (h) and the breast cancer diagnostic services required by subsection (i) must include the following: (1) In the case of a covered individual who is at least thirty-five (35) years of age but less than forty (40) years of age, at least one (1) baseline breast cancer screening mammography performed upon the individual before she becomes forty (40) years of age.(2) In the case of a covered individual who is:(A) less than forty (40) years of age; and(B) a woman at risk; at least one (1) breast cancer screening mammography performed upon the covered individual every year.
(3) In the case of a covered individual who is at least forty (40) years of age, at least one (1) breast cancer screening mammography performed upon the individual every year.(4) Any additional mammography views that are required for proper evaluation.(5) Ultrasound services, if determined medically necessary by the physician treating the covered individual.(l) The coverage for breast cancer diagnostic services required by subsection (h) and the breast cancer diagnostic services required by subsection (i) shall be provided in addition to any benefits specifically provided for x-rays, laboratory testing, or wellness examinations.Amended by P.L. 3-2024,SEC. 1, eff. 7/1/2024.Amended by P.L. 56-2023,SEC. 37, eff. 7/1/2023.As added by P.L. 35-1992, SEC.1. Amended by P.L. 26-1994, SEC.1; P.L. 170-1999, SEC.1.