States Enact Mammography Coverage Laws Kathryn Glovier Moore State G o v e r n m e n t Relations Representative The American College of Obstetricians a n d Gynecologists W a s h i n g t o n , DC
n 1988 and 1989, mammography topped the list of new state mandates for health insurance benefits. Following the lead taken by Maryland in 1986, over half of the states now mandate insurance benefits for breast cancer screening through the use of low-dose mammography. Mammography is one of several preventive and diagnostic procedures, together with cytology screening, well-baby care, child health supervision, and colon and rectal cancer screening, that has become an increasingly popular category of mandated benefit. The number of mandated benefit laws in all categories has rapidly multiplied since the early 1970s. The earliest of these covered specific medical conditions and diseases or the services of allied health practitioners; preventive or diagnostic services, such as mammography, are more recent coverage phenomena. State governments, responding to demands for coverage from a public preoccupied with wellness and expecting the maximum health care treatment intervention to be available and accessible in all cases, are clearly willing to use their authority to regulate the insurance industry so as to expand and improve access to health care services. Despite new concerns over the cost of mandated benefits generally and budget woes in many jurisdictions, the states' interest in improving access to preventive health services, such as mammography, remains strong as we enter the 1990s.
I
WHAT ARE MANDATED BENEFIT LAWS? State-mandated benefit laws require third-party payers, such as health insurers (individual or group plans), disability insurers, Medicare supplemental insurance, or prepaid health plans (HMOs), to cover certain benefits or at least to offer the benefit to their policyholders as a condition of doing business in the state. Generally, mandated benefits comprise three categories: specific medical procedures or diseases, such as alcohol and drug abuse counseling, mental health services, well-baby care, child health care, immunizations, diabetes self-management education, Alzheimer disease, outpatient cardiac rehabilitation, cytology screening, and infertility diagnosis and treatment; services rendered by specific allied health professionals, such as podiatrists and psychologists; and specific population groups or dependents, such as newborns and handicapped children. 102
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WHI Vol. 1, No. 2 Winter 1991
Mandated benefit laws vary widely in scope and applicability. Not all states mandate benefit requirements for health insurance coverage, although most states have enacted such laws. Some states regulate benefits only for certain health insurance plans. For example, it is important to note that mandated benefit laws do not apply to companies that self-insure (those choosing to underwrite the risks of group coverage themselves rather than contract with a commercial carrier or Blue Cross and Blue Shield). The federal Employee Retirement Income Security Act of 1974 (ERISA) exempts from state regulation companies and pension plans that design and self-fund their own health plans. Finally, state mandates themselves vary, with some requiring the benefit to be provided (mandated benefit), whereas others only require that the benefit be offered (mandated offering) to policyholders.
P O L I T I C A L PRESSURES A N D REALITIES
View From the State Capitols (The Legislative Perspective) State legislators generally consider several factors in making health care policy decisions, including health outcomes and benefits. Foremost among these, however, are probably cost considerations. Legislators will weigh the positive short-term cost trade-offs and long-term cost savings. Yet, decisions are often made not on the basis of overall health cost savings but, rather, on the basis of savings that directly accrue to the state. Legislators will consider whether a proposed health service or program will require an immediate expenditure of state funds or can be funded with money saved from future expenditures. Long-term cost savings--those beyond the immediate budget period or after the next general election, which is one of the most important legislative time frames--are less likely to be considered in the legislative evaluation. Also, legislators generally are suspicious of claims of cost savings from any health service or program that broadens the population covered. Where cost savings cannot be documented, the legislator may reject the proposal, even where substantial additional health benefits or long-term cost savings may accrue. Legislators prefer mandated benefits because they are a way of extending coverage to persons in need without requiring an appropriation of additional state funds. Preventive and diagnostic coverages hold the additional appeal of presumed long-term benefits both with respect to favorable health outcomes and reduced future health demand. Mammography clearly falls in this category and is an appealing policy option for legislators. In the last few years, state legislators have evidenced a new concern for the overall health costs and outcomes of the mandated benefits they have approved. Several states are now monitoring the impact of their own mandated benefit laws as well as the activity of other states. Washington, in 1984, was the first state to require some kind of cost-benefit analysis of proposed mandated benefit coverages as part of the legislative evaluation. Other states requiring a study of the costs and benefits of mandated benefit laws include Arizona, Florida, Hawaii, Louisiana, Maryland, Montana, Oregon, Pennsylvania, Rhode Island, and Wisconsin. The laws vary in detail and scope but generally stipulate criteria with which to assess the social and economic impact of the service or treatment. The criteria may include: the extent to which a treatment or service is used; the extent to which coverage is presently available or, if not available, the extent to which lack of coverage creates a financial hardship for those who need the treatment or service; the level of public demand; the extent to which coverage would increase cost and use or would serve as an alternative to a more expensive treatment or service; the impact WHI Vol. 1, No. 2 Winter 1991
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on insurers' administrative expenses and policyholders' premiums; and the impact on total health costs. In some states, mandate evaluation laws require those advocating the coverage to assess the social and financial impact of the proposed mandate; in others, the legislative auditor is directed to make the assessment. Before a mandated benefit bill may be considered in the Hawaii legislature, for example, lawmakers must first approve a concurrent resolution requesting the legislative auditor to make an assessment. Other state laws are more general, directing a task force or committee of the legislature to evaluate all mandated benefit laws already on the books. In some states, mandate evaluations are required only for certain coverages, such as diabetes. Still other states, such as Louisiana, require an assessment of the impact of mandated benefit laws on small businesses operating in the state.
Proponents of Mammography Mandated Benefits Proponents of mandated benefit laws generally are health professionals and patient groups that stand to benefit from the additional coverage. Health professionals typically seek equitable reimbursement for their services. They also must convince legislators of the efficacy and importance of the particular treatment or service. Patient groups seek coverage for specific illnesses or medical procedures that might be excluded from a typical insurance policy and that represent high out-of-pocket costs. Both health professionals and patients generally will argue that the coverage is humane and cost effective. Foremost among the health professionals advocating for mammography coverage are radiologists. The American College of Radiology (ACR), which supports coverage of mammography screening by government and private insurance, has mounted a vigorous advocacy campaign that has been active at the state level since about 1987. Although obstetrician-gynecologists have not been active as part of a nationally directed, cohesive campaign, individual obstetrician-gynecologists nonetheless have been visible proponents of mammography mandated benefits in some states. The American College of Obstetricians and Gynecologists supports the inclusion of coverage of mammography in appropriate government insurance and direct service programs and private insurance plans. Patients advocating mammography coverage are represented by a variety of women's organizations and constituencies operating at the local, state, and national levels including, notably, women lawmakers who have been operating under the banner of the Women's Network of the National Conference of State Legislatures (NCSL). The NCSL Women's Network identified mammography mandated benefits as its number one legislative priority in 1989 and 1990. Mammography has gained wide public support, largely as a result of favorable and sustained media coverage highlighting the medical and scientific data that demonstrate its efficacy as the optimal diagnostic tool for detecting early asymptomatic or occult breast cancer. Media accounts of women sharing their personal battles with breast cancer arouse strong public sentiment in support of widespread access to mammography. This publicity makes the pressure for government action even greater. We know that one in ten women will develop breast cancer during her lifetime. In 1988, it was projected that 135,000 women in the United States would develop breast cancer, and some 42,000 would die from this disease.
Opponents of Mammography Mandated Benefits Opposition to mandated benefits, whether for mammography or any other treatment or service, is rooted in cost concerns. Opponents--primarily the 104
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insurance industry and businesses buying group coverage for their emp l o y e e s - a r g u e that mandated benefits are costly and unduly interfere with the ability to tailor insurance packages for policyholders. Insurers argue that they, rather than the government, should decide which benefits to include in a particular plan. Businesses claim that mandated benefit laws are unfair because companies choosing to self-insure are immune. Both insurers and businesses have opposed mammography mandated benefits as they have other coverages. There has also been opposition from the medical community. Some state medical societies, for example, have opposed mammography mandated benTable 1. STATE MAMMOGRAPHY LAWS*
Year Enacted
State
Arizona Arkansas California Colorado Connecticut Florida Georgia Hawaii Illinois Iowa Kansas Kentucky Maine Maryland Massachusetts Michigan Minnesota Missouri Nevada New Hampshire New Jersey New Mexico New York North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Dakota Tennessee Texas Virginia Washington West Virginia Wisconsin
1988 1989"* 1987 1989"* 1988, 1989"* 1988 1990 1990 1989 1989 1988 1990"* 1990"* 1986"* 1987 1989"* 1988 1990 1989 1988"* pending legislation 1990"* 1988, 1989"* 1989 pending legislation 1988, 1989"* 1989 1988, 1989 1990"* 1989, 1990"* 1987, 1989"* 1989, 1990"* 1989"* 1989 1990
Mandatory Optional Age and Sets a QualityInsurance Insurance Frequency Ceilingon Assurance Coverage Coverage Requirements Payment Requirements
X X X X X X X X X X X X X
X X X X X X X X X X X X X X X
X X X X X X
X ($60)
X X
X ($100) X
X X X
X X X
X X X
X X X
X X X X X X X
X X X X X X X
X
X
X
X ($75) X
X ($50)
X
X X
* As of N o v e m b e r 1990. ** See Table 2 for explanation.
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Table 2. EXPLANATION OF STATE MAMMOGRAPHY LAWS
State Arkansas
Colorado
Connecticut
Kentucky
Maine Maryland
Michigan New Hampshire
New Mexico
106
Clarification The 1989 optional coverage law applies only to group insurance policies. Additionally, benefit payments may not be less than $50 for a mammogram. Radiologic standards, quality-assurance programs, and standards for accreditation of facilities will be established and administered by the state health department. Mammograms may only be performed in facilities accredited by the state. Apart from the 1989 mandatory coverage law, a 1988 law establishes a breast cancer screening fund to support the purchase and operation of a mobile vehicle to make mammography more widely accessible to asymptomatic women. The law also provides for the creation and operation of a referral service for women needing further examination or treatment following a baseline screening. The 1988 mandatory coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The 1989 law broadens this mandate to include group health insurance policies provided by out-of-state employers if 51% or more of covered employees are employed in Connecticut. Mammograms may only be performed on dedicated equipment. Apart from the mandatory coverage law, a second law enacted in 1990 establishes a breast cancer screening program and fund within the Department of Health Services. The Department is authorized to purchase, maintain, and staff a mobile vehicle equipped to perform mammograms; screening services may be done by private contract or by the Department. The Department is also authorized to provide a referral service for women needing further examination or treatment. Providers must meet standards for radiation protection as established by the state human services department. The 1986 law applies only to Medicare supplemental insurance policies. Additionally, the law sets a maximum benefit of $100 for an annual mammogram. Mammograms may only be performed on dedicated equipment. The 1988 mandatory coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The law also establishes a committee to examine the need for uniform regulation of persons who operate x-ray equipment, including mammography equipment. Beginning July 1, 1992, mammograms may only be performed on dedicated equipment in facilities that have met the American College of Radiology accreditation standards for mammography.
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Table 2. EXPLANATION OF STATE MAMMOGRAPHY LAWS (Continued) State New York
Oklahoma
Rhode Island
South Dakota
Tennessee
Texas
Virginia
Washington
Clarification The 1988 law applies only to Medicare supplemental policies. However, the 1988 mandate was broadened a year later to extend coverage to women aged 35 and older. The 1988 mandatory coverage law covers women aged 45 years and older. The 1989 law broadens the age requirements for coverage to include women aged 35 years and older. Payment is limited to $75 for a mammogram. All facilities performing mammograms and all licensed physicians interpreting mammograms must meet state-approved quality-assurance standards as promulgated by the state health director. The 1990 optional coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The 1990 mandatory coverage law exempts Medicare supplemental policies and limited benefit insurance policies from the requirements for coverage. The 1987 mandatory coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The 1989 law authorizes the newly created Center for Rural Health to establish a breast cancer screening program in sparsely populated counties (having a population of 50,000 or less). The Center is directed to contract with public or private entities to provide mobile units and on-site screening services. The $50 benefit is suggested as an optional limit on payment for a mammogram. Mammograms must be ordered by a licensed health care practitioner and interpreted by a qualified radiologist. Mammography equipment must meet the standards of the Virginia Department of Health, and radiologic film must be retained in accordance with American College of Radiology guidelines or state law. The 1990 law extended mammography coverage benefits to state employees. The 1989 mandatory coverage law specifically exempts Medicare supplemental policies from the requirements for coverage.
efits based on a policy of longstanding philosophical objection to insurance mandates generally as cost inflationary. The South Dakota Medical Association unsuccessfully opposed a mammography mandated benefit bill last year; the bill was enacted.
OVERVIEW OF M A M M O G R A P H Y M A N D A T E D BENEFIT LAWS This section and Tables 1 and 2 provide an overview of laws enacted to date. As of November 1990, 33 states have adopted legislation. The majority of mammography mandated benefit laws apply to all health insurers, although there are exceptions, and stipulate mandatory WHI Vol. I, No. 2 Winter 1991
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rather than optional coverage. Some states exempt certain types of insurance, such as Medicare supplemental policies (Washington), or apply to Medicare supplemental policies exclusively (Maryland). A few states require coverage only under insurance policies that provide coverage for mastectomy (Kentucky and Tennessee), and some require coverage only if ordered by a physician (Tennessee) or by a physician or an advanced registered nurse practitioner (Washington). Age and frequency requirements vary, as do payment and co-payment levels. Whereas the majority of states follow the guidelines of the American Cancer Society and the ACR, a few states are silent as to frequency and age requirements or leave this to the discretion of the referring physician. With most states, however, insurers are required to cover a baseline mammogram for women aged 35 to 39, biannual mammograms (or more often, based on the recommendation of a physician) for women aged 40 to 49, and an annual mammogram for women aged 50 and older. A few states also require coverage for women at any age where there is a prior history or family history of breast cancer (Arkansas and New York). Some states set payment limits on the mammography benefit policyholders may be entitled to (Colorado, Maryland, Oklahoma, and Virginia). Quality-assurance requirements are incorporated in the more recent laws, such as those enacted last year in Arkansas, Kentucky, Michigan, New Hampshire, Rhode Island, and Virginia. Typically, a state will require the development of quality-assurance guidelines, usually by the state health department, and may condition insurance reimbursement on compliance with state-approved quality-assurance standards. States may allow only certified radiographers and radiologists to perform and interpret mammograms, require equipment to meet ACR accreditation standards, or may require mammograms to be performed on dedicated equipment that is designed and used exclusively for mammography examinations.
SOURCES American College of Radiology, Division of Government Relations. State mammography legislation. Reston, VA: American College of Radiology, 1988. American College of Radiology, Division of Government Relations. State mammography legislation. Reston, VA: American College of Radiology, 1989. Bruner CS. Slicing the health care pie: A legislator's view of state health care allocation choices. Des Moines: State Public Policy Group. Washington DC: The National Center for Policy Alternatives, October 1987. Fisher RS, Donohoe E. Emerging trends in clinical preventive services: State health care laws and employee wellness benefits. Washington DC: The Intergovernmental Health Policy Project at the George Washington University, September 1988.
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n 1988 and 1989, mammography topped the list of new state mandates for health insurance benefits. Following the lead taken by Maryland in 1986, over half of the states now mandate insurance benefits for breast cancer screening through the use of low-dose mammography. Mammography is one of several preventive and diagnostic procedures, together with cytology screening, well-baby care, child health supervision, and colon and rectal cancer screening, that has become an increasingly popular category of mandated benefit. The number of mandated benefit laws in all categories has rapidly multiplied since the early 1970s. The earliest of these covered specific medical conditions and diseases or the services of allied health practitioners; preventive or diagnostic services, such as mammography, are more recent coverage phenomena. State governments, responding to demands for coverage from a public preoccupied with wellness and expecting the maximum health care treatment intervention to be available and accessible in all cases, are clearly willing to use their authority to regulate the insurance industry so as to expand and improve access to health care services. Despite new concerns over the cost of mandated benefits generally and budget woes in many jurisdictions, the states' interest in improving access to preventive health services, such as mammography, remains strong as we enter the 1990s.
I
WHAT ARE MANDATED BENEFIT LAWS? State-mandated benefit laws require third-party payers, such as health insurers (individual or group plans), disability insurers, Medicare supplemental insurance, or prepaid health plans (HMOs), to cover certain benefits or at least to offer the benefit to their policyholders as a condition of doing business in the state. Generally, mandated benefits comprise three categories: specific medical procedures or diseases, such as alcohol and drug abuse counseling, mental health services, well-baby care, child health care, immunizations, diabetes self-management education, Alzheimer disease, outpatient cardiac rehabilitation, cytology screening, and infertility diagnosis and treatment; services rendered by specific allied health professionals, such as podiatrists and psychologists; and specific population groups or dependents, such as newborns and handicapped children. 102
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© 1991 by The Jacobs Institute of Women's Health 1049-3867/91/53.50
WHI Vol. 1, No. 2 Winter 1991
Mandated benefit laws vary widely in scope and applicability. Not all states mandate benefit requirements for health insurance coverage, although most states have enacted such laws. Some states regulate benefits only for certain health insurance plans. For example, it is important to note that mandated benefit laws do not apply to companies that self-insure (those choosing to underwrite the risks of group coverage themselves rather than contract with a commercial carrier or Blue Cross and Blue Shield). The federal Employee Retirement Income Security Act of 1974 (ERISA) exempts from state regulation companies and pension plans that design and self-fund their own health plans. Finally, state mandates themselves vary, with some requiring the benefit to be provided (mandated benefit), whereas others only require that the benefit be offered (mandated offering) to policyholders.
P O L I T I C A L PRESSURES A N D REALITIES
View From the State Capitols (The Legislative Perspective) State legislators generally consider several factors in making health care policy decisions, including health outcomes and benefits. Foremost among these, however, are probably cost considerations. Legislators will weigh the positive short-term cost trade-offs and long-term cost savings. Yet, decisions are often made not on the basis of overall health cost savings but, rather, on the basis of savings that directly accrue to the state. Legislators will consider whether a proposed health service or program will require an immediate expenditure of state funds or can be funded with money saved from future expenditures. Long-term cost savings--those beyond the immediate budget period or after the next general election, which is one of the most important legislative time frames--are less likely to be considered in the legislative evaluation. Also, legislators generally are suspicious of claims of cost savings from any health service or program that broadens the population covered. Where cost savings cannot be documented, the legislator may reject the proposal, even where substantial additional health benefits or long-term cost savings may accrue. Legislators prefer mandated benefits because they are a way of extending coverage to persons in need without requiring an appropriation of additional state funds. Preventive and diagnostic coverages hold the additional appeal of presumed long-term benefits both with respect to favorable health outcomes and reduced future health demand. Mammography clearly falls in this category and is an appealing policy option for legislators. In the last few years, state legislators have evidenced a new concern for the overall health costs and outcomes of the mandated benefits they have approved. Several states are now monitoring the impact of their own mandated benefit laws as well as the activity of other states. Washington, in 1984, was the first state to require some kind of cost-benefit analysis of proposed mandated benefit coverages as part of the legislative evaluation. Other states requiring a study of the costs and benefits of mandated benefit laws include Arizona, Florida, Hawaii, Louisiana, Maryland, Montana, Oregon, Pennsylvania, Rhode Island, and Wisconsin. The laws vary in detail and scope but generally stipulate criteria with which to assess the social and economic impact of the service or treatment. The criteria may include: the extent to which a treatment or service is used; the extent to which coverage is presently available or, if not available, the extent to which lack of coverage creates a financial hardship for those who need the treatment or service; the level of public demand; the extent to which coverage would increase cost and use or would serve as an alternative to a more expensive treatment or service; the impact WHI Vol. 1, No. 2 Winter 1991
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on insurers' administrative expenses and policyholders' premiums; and the impact on total health costs. In some states, mandate evaluation laws require those advocating the coverage to assess the social and financial impact of the proposed mandate; in others, the legislative auditor is directed to make the assessment. Before a mandated benefit bill may be considered in the Hawaii legislature, for example, lawmakers must first approve a concurrent resolution requesting the legislative auditor to make an assessment. Other state laws are more general, directing a task force or committee of the legislature to evaluate all mandated benefit laws already on the books. In some states, mandate evaluations are required only for certain coverages, such as diabetes. Still other states, such as Louisiana, require an assessment of the impact of mandated benefit laws on small businesses operating in the state.
Proponents of Mammography Mandated Benefits Proponents of mandated benefit laws generally are health professionals and patient groups that stand to benefit from the additional coverage. Health professionals typically seek equitable reimbursement for their services. They also must convince legislators of the efficacy and importance of the particular treatment or service. Patient groups seek coverage for specific illnesses or medical procedures that might be excluded from a typical insurance policy and that represent high out-of-pocket costs. Both health professionals and patients generally will argue that the coverage is humane and cost effective. Foremost among the health professionals advocating for mammography coverage are radiologists. The American College of Radiology (ACR), which supports coverage of mammography screening by government and private insurance, has mounted a vigorous advocacy campaign that has been active at the state level since about 1987. Although obstetrician-gynecologists have not been active as part of a nationally directed, cohesive campaign, individual obstetrician-gynecologists nonetheless have been visible proponents of mammography mandated benefits in some states. The American College of Obstetricians and Gynecologists supports the inclusion of coverage of mammography in appropriate government insurance and direct service programs and private insurance plans. Patients advocating mammography coverage are represented by a variety of women's organizations and constituencies operating at the local, state, and national levels including, notably, women lawmakers who have been operating under the banner of the Women's Network of the National Conference of State Legislatures (NCSL). The NCSL Women's Network identified mammography mandated benefits as its number one legislative priority in 1989 and 1990. Mammography has gained wide public support, largely as a result of favorable and sustained media coverage highlighting the medical and scientific data that demonstrate its efficacy as the optimal diagnostic tool for detecting early asymptomatic or occult breast cancer. Media accounts of women sharing their personal battles with breast cancer arouse strong public sentiment in support of widespread access to mammography. This publicity makes the pressure for government action even greater. We know that one in ten women will develop breast cancer during her lifetime. In 1988, it was projected that 135,000 women in the United States would develop breast cancer, and some 42,000 would die from this disease.
Opponents of Mammography Mandated Benefits Opposition to mandated benefits, whether for mammography or any other treatment or service, is rooted in cost concerns. Opponents--primarily the 104
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insurance industry and businesses buying group coverage for their emp l o y e e s - a r g u e that mandated benefits are costly and unduly interfere with the ability to tailor insurance packages for policyholders. Insurers argue that they, rather than the government, should decide which benefits to include in a particular plan. Businesses claim that mandated benefit laws are unfair because companies choosing to self-insure are immune. Both insurers and businesses have opposed mammography mandated benefits as they have other coverages. There has also been opposition from the medical community. Some state medical societies, for example, have opposed mammography mandated benTable 1. STATE MAMMOGRAPHY LAWS*
Year Enacted
State
Arizona Arkansas California Colorado Connecticut Florida Georgia Hawaii Illinois Iowa Kansas Kentucky Maine Maryland Massachusetts Michigan Minnesota Missouri Nevada New Hampshire New Jersey New Mexico New York North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Dakota Tennessee Texas Virginia Washington West Virginia Wisconsin
1988 1989"* 1987 1989"* 1988, 1989"* 1988 1990 1990 1989 1989 1988 1990"* 1990"* 1986"* 1987 1989"* 1988 1990 1989 1988"* pending legislation 1990"* 1988, 1989"* 1989 pending legislation 1988, 1989"* 1989 1988, 1989 1990"* 1989, 1990"* 1987, 1989"* 1989, 1990"* 1989"* 1989 1990
Mandatory Optional Age and Sets a QualityInsurance Insurance Frequency Ceilingon Assurance Coverage Coverage Requirements Payment Requirements
X X X X X X X X X X X X X
X X X X X X X X X X X X X X X
X X X X X X
X ($60)
X X
X ($100) X
X X X
X X X
X X X
X X X
X X X X X X X
X X X X X X X
X
X
X
X ($75) X
X ($50)
X
X X
* As of N o v e m b e r 1990. ** See Table 2 for explanation.
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Table 2. EXPLANATION OF STATE MAMMOGRAPHY LAWS
State Arkansas
Colorado
Connecticut
Kentucky
Maine Maryland
Michigan New Hampshire
New Mexico
106
Clarification The 1989 optional coverage law applies only to group insurance policies. Additionally, benefit payments may not be less than $50 for a mammogram. Radiologic standards, quality-assurance programs, and standards for accreditation of facilities will be established and administered by the state health department. Mammograms may only be performed in facilities accredited by the state. Apart from the 1989 mandatory coverage law, a 1988 law establishes a breast cancer screening fund to support the purchase and operation of a mobile vehicle to make mammography more widely accessible to asymptomatic women. The law also provides for the creation and operation of a referral service for women needing further examination or treatment following a baseline screening. The 1988 mandatory coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The 1989 law broadens this mandate to include group health insurance policies provided by out-of-state employers if 51% or more of covered employees are employed in Connecticut. Mammograms may only be performed on dedicated equipment. Apart from the mandatory coverage law, a second law enacted in 1990 establishes a breast cancer screening program and fund within the Department of Health Services. The Department is authorized to purchase, maintain, and staff a mobile vehicle equipped to perform mammograms; screening services may be done by private contract or by the Department. The Department is also authorized to provide a referral service for women needing further examination or treatment. Providers must meet standards for radiation protection as established by the state human services department. The 1986 law applies only to Medicare supplemental insurance policies. Additionally, the law sets a maximum benefit of $100 for an annual mammogram. Mammograms may only be performed on dedicated equipment. The 1988 mandatory coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The law also establishes a committee to examine the need for uniform regulation of persons who operate x-ray equipment, including mammography equipment. Beginning July 1, 1992, mammograms may only be performed on dedicated equipment in facilities that have met the American College of Radiology accreditation standards for mammography.
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Table 2. EXPLANATION OF STATE MAMMOGRAPHY LAWS (Continued) State New York
Oklahoma
Rhode Island
South Dakota
Tennessee
Texas
Virginia
Washington
Clarification The 1988 law applies only to Medicare supplemental policies. However, the 1988 mandate was broadened a year later to extend coverage to women aged 35 and older. The 1988 mandatory coverage law covers women aged 45 years and older. The 1989 law broadens the age requirements for coverage to include women aged 35 years and older. Payment is limited to $75 for a mammogram. All facilities performing mammograms and all licensed physicians interpreting mammograms must meet state-approved quality-assurance standards as promulgated by the state health director. The 1990 optional coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The 1990 mandatory coverage law exempts Medicare supplemental policies and limited benefit insurance policies from the requirements for coverage. The 1987 mandatory coverage law applies both to individual and group insurance policies and to Medicare supplemental policies. The 1989 law authorizes the newly created Center for Rural Health to establish a breast cancer screening program in sparsely populated counties (having a population of 50,000 or less). The Center is directed to contract with public or private entities to provide mobile units and on-site screening services. The $50 benefit is suggested as an optional limit on payment for a mammogram. Mammograms must be ordered by a licensed health care practitioner and interpreted by a qualified radiologist. Mammography equipment must meet the standards of the Virginia Department of Health, and radiologic film must be retained in accordance with American College of Radiology guidelines or state law. The 1990 law extended mammography coverage benefits to state employees. The 1989 mandatory coverage law specifically exempts Medicare supplemental policies from the requirements for coverage.
efits based on a policy of longstanding philosophical objection to insurance mandates generally as cost inflationary. The South Dakota Medical Association unsuccessfully opposed a mammography mandated benefit bill last year; the bill was enacted.
OVERVIEW OF M A M M O G R A P H Y M A N D A T E D BENEFIT LAWS This section and Tables 1 and 2 provide an overview of laws enacted to date. As of November 1990, 33 states have adopted legislation. The majority of mammography mandated benefit laws apply to all health insurers, although there are exceptions, and stipulate mandatory WHI Vol. I, No. 2 Winter 1991
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rather than optional coverage. Some states exempt certain types of insurance, such as Medicare supplemental policies (Washington), or apply to Medicare supplemental policies exclusively (Maryland). A few states require coverage only under insurance policies that provide coverage for mastectomy (Kentucky and Tennessee), and some require coverage only if ordered by a physician (Tennessee) or by a physician or an advanced registered nurse practitioner (Washington). Age and frequency requirements vary, as do payment and co-payment levels. Whereas the majority of states follow the guidelines of the American Cancer Society and the ACR, a few states are silent as to frequency and age requirements or leave this to the discretion of the referring physician. With most states, however, insurers are required to cover a baseline mammogram for women aged 35 to 39, biannual mammograms (or more often, based on the recommendation of a physician) for women aged 40 to 49, and an annual mammogram for women aged 50 and older. A few states also require coverage for women at any age where there is a prior history or family history of breast cancer (Arkansas and New York). Some states set payment limits on the mammography benefit policyholders may be entitled to (Colorado, Maryland, Oklahoma, and Virginia). Quality-assurance requirements are incorporated in the more recent laws, such as those enacted last year in Arkansas, Kentucky, Michigan, New Hampshire, Rhode Island, and Virginia. Typically, a state will require the development of quality-assurance guidelines, usually by the state health department, and may condition insurance reimbursement on compliance with state-approved quality-assurance standards. States may allow only certified radiographers and radiologists to perform and interpret mammograms, require equipment to meet ACR accreditation standards, or may require mammograms to be performed on dedicated equipment that is designed and used exclusively for mammography examinations.
SOURCES American College of Radiology, Division of Government Relations. State mammography legislation. Reston, VA: American College of Radiology, 1988. American College of Radiology, Division of Government Relations. State mammography legislation. Reston, VA: American College of Radiology, 1989. Bruner CS. Slicing the health care pie: A legislator's view of state health care allocation choices. Des Moines: State Public Policy Group. Washington DC: The National Center for Policy Alternatives, October 1987. Fisher RS, Donohoe E. Emerging trends in clinical preventive services: State health care laws and employee wellness benefits. Washington DC: The Intergovernmental Health Policy Project at the George Washington University, September 1988.
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