Required Coverage for Tomosynthesis

STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-114 JULY 7, 2016 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE INDIVIDUAL AND GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT RE: NEW OR MODIFIED BENEFITS REQUIRED TO BE PROVIDED FOR TOMOSYNTHESIS- PUBLIC ACT 16-82 In June 2016, the Governor signed into law PA 16-82, An Act Concerning Health Insurance Coverage for Tomosynthesis for Breast Cancer Screenings. This public act impacts individual and group health insurance policies delivered or issued for delivery in Connecticut. All entities are reminded that all policy forms are subject to prior approval. Policies are reviewed in the order of date received by the Insurance Department. • For policy forms that are already approved, you are asked to file an endorsement or amendatory rider to be attached to the approved policy in order to expedite the review process. • For new benefits on policies that require rates be filed, a rate filing should be made at the same time as the form filing even if there is no adjustment to the rates. The rate filing shall provide the per member per month (PMPM) cost separately for each newly required benefit. Public Act 16-82 provides in relevant part: Each individual or group health insurance policy providing coverage of the type specified in subdivisions (1 ), (2) , ( 4 ), (1 0), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2017 shall provide benefits for a baseline mammogram, that may be provided by breast tomosynthesis at the option of the woman covered under the policy, for any woman who is thirty-five to thirty-nine years of age, inclusive; and a mammogram, that may be provided by breast tomosynthesis at the option of the woman covered under the policy, every year for any woman who is forty years of age or older. Accordingly, companies must cover a baseline mammogram and a yearly mammogram for women subject to the age requirements and other conditions set forth in Connecticut General Statutes 38a-503 and 38a-530; or at the option of the woman, they must instead cover these services by use of breast tomosynthesis. Requests for mammograms or breast tomosynthesis outside the requirements of CGS 38a-503 and 38a-530 may be subject to reasonable medical management including pre-authorization and medical necessity review. Section 1001 of the ACA which amends§ 2713 of the Public Health Service Act, requires that all non-grandfathered group health plans and health insurance issuers offering group or individual coverage must provide coverage of certain preventive services with no cost sharing requirements. While neither the statute nor associated regulation, 45 CFR § 147.130, set the www.ct.gov/cld P.O. Box 816 • Hartford, CT 061 42 -0816 An Equal Opportunity Employer specifics for what is actually required they instead refer to the Health Resources and Service Administration Agency ("HRSA") of HHS and the United States Preventive Services Task Force ("USPSTF") as the entities charged with identifying the appropriate benefits. When referring to USPSTF, the ACA requires only compliance with A and B recommendations. The USPSTF A and B recommendations are updated as the organization sees appropriate. For the designated preventive services identified in the HRSA guidelines and USPSTF A and B recommendations, there is no cost sharing allowed W1der the ACA, nor are limits permitted, except where those guidelines/recommendations identify such explicit limits. On January 12, 2016, the USPSTF 1 changed its recommendations for preventative mammograms for women age 40 to age 74 to preventative mammograms for women age 50 to 74. Per the USPSTF, mammograms for women age 50-74 is a B recommendation, meaning they must be covered with no cost sharing. All other mammography services are rated either I or C, and therefore cost sharing is permitted . • Per Connecticut law, coverage of mammograms is required for women starting at age 35. • In Accordance with federal regulations2 , currently, insurers may use cost sharing on benefits for mammography services for women age 35 to 39 and age 75 and older. • For plan years beginning on or after February 1, 2017, health insurers may use cost sharing on benefits for mammography services for women age 35 to 49 and age 75 and older. Breast tomosynthesis is not currently considered a mammogram by the USPSTF. It is broken out in a separate category and is rated I. Therefore, Breast tomosynthesis is not subject to the ACA requirement for no cost sharing and may be covered with a cost sharing requirement for women of all ages. If cost sharing is imposed for Breast Tomosynthesis, all Summary Plan Descriptions and Summary of Benefit Coverage should clearly identify the cost share differences between ACA preventative mammography and Breast Tomosynthesis. Any cost share should be consistent with the requirements set forth in Bulletin HC-109. QUESTIONS Please contact the Insurance Department Life and Health Division at cid.lh@ ct.gov with any questions about the Public Acts in this notice. Katharine L. Wade, Insurance Commissioner Katharine L. Wade Insurance Commissioner 1http: //www.uspreventiveservicestaskforce .org/Page/Document!UpdateSummaryFinaVbreast-cancer-screeningl 2 https://www.gpo.gov/fdsys/pkg/FR-2010-07-19/pdf/2010-17242.pdf Vol. 75 , No. 137 Fed. Reg. 41726 (July 19, 201 0).