July 01, 2021

Breast Cancer Screening Introduced; OON Legislation Advances

Wisconsin introduces a bill to expand breast cancer screening coverage provisions. Massachusetts deliberates and New Jersey advances legislation to modify health insurance out-of-network provisions.

Breast Cancer Screening
In Wisconsin, Assembly Bill 416 was introduced in the Assembly. The bill would require preferred provider health insurance plans to cover, either fully or with a $50 maximum out-of-pocket cost, essential breast screenings beyond mammography in:
• Individuals with dense breast tissue.
• Women with a higher risk for cancer.
• Women believed to be at higher risk for cancer due to family history, prior personal history of breast cancer, positive genetic testing or other indications of an increased risk of breast cancer.

Out-of-Network Billing
In Massachusetts, House Bill 1066 will be heard before the Joint Committee on Financial Services. The bill would require the state’s Health Policy Commission recommend the out-of-network rate for emergency services and the out-of-network rate for nonemergency services for a period of five years. Prior to recommending the rates, the commission would hold a public hearing. The hearing would examine current rates paid for in- and out-of-network services and the impact of those rates on the operation of the healthcare delivery system, and determine an appropriate out-of-network rate for emergency services and out-of-network rate for nonemergency services based on testimony, information and data.

The Massachusetts Radiological Society is opposed to the bill.

In New Jersey, Senate Bill 3458 passed the senate. The bill would modify out-of-network provisions by permitting the arbitrator to determine a usual, reasonable and customary fee that would be one of the two amounts submitted by the parties in arbitration. To determine the fee, the out-of-network provider would submit the provider’s usual and customary fee by means of explanations of benefits from enrollees showing the provider’s billed and paid fee. The arbitrator would determine the reasonableness of the provider’s fee by comparison of the provider’s experience to providers in the area. When using a database as evidence of the reasonableness of a fee, the provider and carrier would both identify the database used, the edition date, the geo-zip and the percentile. The arbitrator also would consider prior arbitration awards submitted by either party as evidence of reasonableness.

For more information, please contact Tina Getachew or Eugenia Brandt. To stay current on state legislative developments relevant to radiology, view the American College of Radiology® policy map.