Several states consider and advance breast cancer screening coverage measures. The West Virginia legislature advances a certificate of need bill. Kansas, Rhode Island and West Virginia introduce out-of-network billing measures. Illinois introduces and South Dakota and Virginia advance legislation affecting supervision requirements for physician assistants (PAs).
Breast Cancer Screening
In Florida, HB 743 was referred to the Committees on Appropriations and Health and Human Services and the Finance and Facilities Subcommittee. It would prohibit carriers that cover diagnostic mammograms, breast MRIs and breast ultrasounds from applying cost-sharing requirements to enrollees if the aforementioned services are ordered by the enrollee’s healthcare provider.
In Hawaii, HB 309 passed the Committee on Consumer Protection and Commerce. It would expand coverage for breast cancer screening by low-dose mammography to include an annual mammogram for women of any age with an above-average risk for breast cancer as determined using a risk-factor modeling tool.
The bill would require additional breast cancer screening coverage:
- For women ages 30 or older, a formal risk factor screening assessment informed by a risk factor modeling tool; and
- For women of any age, any additional or supplemental imaging, such as breast magnetic resonance imaging or ultrasound, deemed medically necessary by an applicable American College of Radiology® (ACR®) guideline.
Digital breast tomosynthesis would be defined as “A radiologic procedure that involves the acquisition of a projection of images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.”
Also, in Hawaii, SB 827 passed the Committee on Health. It would expand coverage for breast cancer screening by low-dose mammography as follows:
- For women ages 35 to 39, including an annual baseline mammogram;
- An annual mammogram for women over age 30, deemed by a licensed physician or clinician to have an above-average risk for breast cancer; and
- For women of any age, any additional or supplemental imaging, such as breast magnetic resonance imaging or ultrasound, deemed medically necessary by an applicable ACR guideline.
Additionally, providers of health care services specified under this section would be reimbursed at rates accurately reflecting the resource costs specific to each modality, including any increased resource cost as of Jan. 1, 2021.
The bill would expand the definition of “low-dose mammography” to include both digital mammography and digital breast tomosynthesis, and interpreting and rendering a report by a radiologist or other physician based on the screening. Digital breast tomosynthesis would be defined as: the means a radiologic procedure that allows a volumetric reconstruction of the whole breast from a finite number of low-dose two¬-dimensional projections obtained by different X-ray tube angles, creating a series of images forming a three-dimensional representation of the breast.
In Iowa, SF 136 was referred to the Commerce Committee. The bill would require carriers to cover diagnostic breast cancer examinations defined as “an examination of an abnormality, deemed medically necessary by a covered person’s healthcare professional, for the detection of breast cancer”. The examination would be conducted using a diagnostic mammogram, breast MRI or breast ultrasound.
In Minnesota, SF 989 was referred to the Health and Human Services Finance and Policy Committee. It would mandate carriers to cover additional diagnostic services or testing after a mammogram for an enrollee as determined medically necessary by a healthcare provider.
Certificate of Need
In West Virginia, HB 2264 passed the House and was referred to the Senate Health and Human Resources Committee. The bill would exempt hospital services, including diagnostic and imaging, from certificate of need requirements.
Out-of-Network Billing
In Kansas, HB 2325 was referred to the Committee on Insurance and Pensions. It would require carriers to cover enrollees at in-network rates for services ordered by an in-network healthcare provider and provided by an out-of-network provider or laboratory, including imaging services. The state insurance commissioner, in consultation with the governor, would be required to establish an independent dispute resolution (IDR) process for resolving payment disputes between carriers and out-of-network healthcare providers. The non-prevailing party would be responsible for paying all fees charged by the entity. If the parties reach a settlement prior to the completion of the IDR process, the costs of the IDR process would be divided equally between the parties.
In Minnesota, HF 1280 was introduced and referred to the Commerce Finance and Policy Committee. In the event a carrier denies coverage for a healthcare service that is a covered benefit under an enrollee's health plan for procedural reasons, including but not limited to failure to receive prior authorization, the bill would prohibit a provider from charging the enrollee more than the negotiated provider payment for the denied service. The negotiated provider payment is defined as “payment the provider agrees to accept under the contract entered into by the provider and the carrier for healthcare services provided by the provider to an enrollee.”
In Rhode Island, SB 304 was introduced and referred to the Health and Human Services Committee. The bill would prohibit carriers from imposing cost sharing to enrollees greater than the in-network rate for emergency out-of-network services. In the event of a payment dispute between an out-of-network provider and the carrier, the bill would establish an IDR process using the American Arbitration Association as the alternative dispute resolution entity. However, if the American Arbitration Association ceases to exist or ceases to be qualified, or becomes unable to perform arbitrations in connection with this section, the office of the health insurance commissioner shall specify a similarly qualified organization. In the final award, the arbitrator would determine which party is responsible for paying all administrative fees, arbitrator compensation and expenses.
In West Virginia, HB 2226 was introduced and referred to the Banking and Insurance Committee. The bill would mandate health care providers as follows:
- Disclose to patients and prospective patients, in writing or through their website, their plan and hospital affiliations prior to providing elective services and verbally at the time an appointment is scheduled.
- An out-of-network provider would inform the patient, prior to providing elective services that:
- The actual or estimated amount for the service is available upon request; and
- If requested, will be disclosed in writing with a warning that costs could go up if unanticipated complications occur.
Physicians would be required to provide a patient and the inpatient or outpatient hospital in which the patient is scheduled for admission with the name, practice name, mailing address and phone number of any other physician scheduled to treat the patient, and information as to how to determine the health plan in which the provider participates.
Carriers would be mandated to have a process to assure that an enrollee obtains a covered benefit at an in-network level from an out-of-network provider, or would make other arrangements acceptable to the commissioner when:
- The carrier has a sufficient network, but has determined that it does not have a type of provider available to provide the covered benefit to the enrollee or it does not have an in-network provider available to provide the covered benefit without unreasonable travel or delay; or
- The carrier has an insufficient number or type of in-network providers available to provide the covered benefit to the enrollee without unreasonable travel or delay.
Scope of Practice
In Illinois, HB 1826 and SB 145 seek to change the practice agreement between a physician assistant and physician from a supervising to a collaborating agreement. The physician in the collaborative agreement would not be liable for the actions or inactions of the PA.
The House bill was introduced and referred to the Rules Committee. The Senate companion bill was assigned to the Licensed Activities Committee.
In South Dakota, HB 1163 passed the Health and Human Services Committee. The bill seeks to change the practice agreement between a physician assistant and physician from a supervising to a collaborating agreement. PAs would also be permitted to delegate and assign therapeutic measures to assistive personnel.
In Virginia, HB 2039 passed the Senate Education and Health Committee. The measure seeks to change the practice agreement between a physician assistant and physician to a collaborative agreement. Additionally, the physician in the collaborative agreement would not be liable for the actions or inactions of the PA.
To stay abreast of state legislative developments relevant to radiology, view our policy map.