June 04, 2020

Pennsylvania Considers Mandated Coverage for Breast MRI, Ultrasound

While out-of-network billing and scope of practice remain hot topics in several states, legislation under consideration in Pennsylvania would mandate private insurance coverage of supplemental breast MRI and ultrasound for at-risk women.

SB 595 recently passed the Pennsylvania House Insurance Committee. It would require carriers to include supplemental MRI or ultrasound, if recommended by the treating physician, because the woman is determined to be at an increased risk of breast cancer due to:

  • Personal history of atypical breast histology
  • Personal or family history of breast cancer
  • Genetic predisposition for breast cancer, or
  • Prior therapeutic thoracic radiation therapy.

Out-Of-Network Billing

In Louisiana, SB 7a was introduced and referred to the Senate Insurance Committee. The bill would require health insurance carriers to ensure that out-of-network costs for emergency services would not be greater than the in-network rates for enrollees. The amount billed would not exceed 120 percent of the usual and customary cost, defined as the 80th percentile of all charges for the particular healthcare service performed by a provider in the same specialty and provided in the same geographical area as reported in a benchmarking database maintained by a nonprofit organization specified by the insurance commissioner.

In the event of a payment dispute, when the independent dispute resolution entity determines the health insurance issuer's payment is reasonable, payment for the dispute resolution process shall be the responsibility of the nonparticipating physician. When the independent dispute resolution entity determines the nonparticipating physician's fee is reasonable, payment for the dispute resolution process shall be the responsibility of the carrier. When a good faith negotiation directed by the independent dispute resolution entity results in a settlement between the carrier and nonparticipating physician, the carrier and the nonparticipating physician would evenly divide and share the prorated cost for the dispute resolution process.

In Maryland, outgoing Insurance Commissioner Alfred Redmer signed a notice of emergency action, 20-098-E on May 22, 2020. The notice amends the state’s out-of-network billing regulation to waive any cost sharing, including copayments, coinsurance, deductibles, laboratory fees and vaccinations, for visits to test for COVID-19.

A health carrier shall evaluate a request to use an out-of-network provider to perform diagnostic testing of COVID-19 solely on whether the use of the out of network provider is medically necessary or appropriate.

The amendments do not apply to Medicare patients nor enrollees covered under a high-deductible health plan if the waiver of the deductible would disqualify the plan from being considered a high-deductible health plan under federal law.

The emergency action will expire on October 12, 2020.

Scope of Practice

Minnesota’s Gov. Tim Walz signed SB 13 into law. It removes the mandatory physician supervision of physician assistants (PAs). It would also change the current delegation agreement where the supervising physician delegates the PA’s duties and scope of practice to a collaboration agreement where a PA would consult with a physician. 

The PA’s scope of practice is expanded to include reviewing diagnostic procedures, including the use of radiographic imaging systems but excluding interpreting computed tomography scans, magnetic resonance imaging scans, positron emission tomography scans, nuclear scans and mammography.