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PRIOR PRINTER'S NO. 915 PRINTER'S NO. 981
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No. 88
Session of
2025
INTRODUCED BY FARRY, K. WARD, PENNYCUICK, ROBINSON, BARTOLOTTA,
LAUGHLIN, SANTARSIERO, J. WARD, COSTA, HAYWOOD, FONTANA,
COMITTA, STEFANO, ARGALL, CULVER, HUTCHINSON, BAKER, ROTHMAN,
LANGERHOLC, MASTRIANO, TARTAGLIONE, BROWN, STREET, BROOKS,
SAVAL, PICOZZI, L. WILLIAMS, KANE, PHILLIPS-HILL, FLYNN,
MARTIN, SCHWANK, GEBHARD, KIM, VOGEL, KEARNEY, YAW, BOSCOLA,
HUGHES, COLLETT, PISCIOTTANO, CAPPELLETTI AND MALONE,
JUNE 6, 2025
AS AMENDED ON THIRD CONSIDERATION, JUNE 23, 2025
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in casualty insurance, repealing
provisions relating to coverage for mammographic examinations
and breast imaging and providing for coverage for
mammographic examinations, magnetic resonance imaging and
other forms of breast imaging.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 632 of the act of May 17, 1921 (P.L.682,
No.284), known as The Insurance Company Law of 1921, is
repealed:
[Section 632. Coverage for Mammographic Examinations and
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Breast Imaging.--(a) All group or individual health or sickness
or accident insurance policies providing hospital or
medical/surgical coverage and all group or individual subscriber
contracts or certificates issued by any entity subject to 40
Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63
(relating to professional health services plan corporations),
this act, the act of December 29, 1972 (P.L.1701, No.364), known
as the "Health Maintenance Organization Act," the act of July
29, 1977 (P.L.105, No.38), known as the "Fraternal Benefit
Society Code," or an employe welfare benefit plan as defined in
section 3 of the Employee Retirement Income Security Act of 1974
(Public Law 93-406, 29 U.S.C. § 1001 et seq.) providing hospital
or medical/surgical coverage shall also provide coverage for
mammographic examinations. The minimum coverage required shall
include all costs associated with a mammogram every year for
women 40 years of age or older, with any mammogram based on a
physician's recommendation for women under 40 years of age.
Prior to payment for a screening mammogram, insurers shall
verify that the screening mammography service provider is
properly licensed by the department in accordance with the act
of July 9, 1992 (P.L.449, No.93), known as the "Mammography
Quality Assurance Act." Nothing in this section shall be
construed to require an insurer to cover the surgical procedure
known as mastectomy or to prevent application of deductible or
copayment provisions contained in the policy or plan except as
preempted by Federal Law.
(b) A group or individual health or sickness or accident
insurance policy providing hospital or medical/surgical coverage
and a group or individual subscriber contract or certificate
issued by any entity subject to 40 Pa.C.S. Ch. 61 or 63, this
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act, the "Health Maintenance Organization Act," the "Fraternal
Benefit Society Code" or an employe welfare benefit plan as
defined in section 3 of the Employee Retirement Income Security
Act of 1974 providing hospital or medical/surgical coverage
shall also provide coverage for breast imaging. The minimum
coverage required shall include all costs associated with one
supplemental breast screening every year because the woman is
believed to be at an increased risk of breast cancer due to:
(1) personal history of atypical breast histologies;
(2) personal history or family history of breast cancer;
(3) genetic predisposition for breast cancer;
(4) prior therapeutic thoracic radiation therapy;
(5) heterogeneously dense breast tissue based on breast
composition categories with any one of the following risk
factors:
(i) lifetime risk of breast cancer of greater than 20%,
according to risk assessment tools based on family history;
(ii) personal history of BRCA1 or BRCA2 gene mutations;
(iii) first-degree relative with a BRCA1 or BRCA2 gene
mutation but not having had genetic testing herself;
(iv) prior therapeutic thoracic radiation therapy between 10
and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden
syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree
relative with one of these syndromes; or
(6) extremely dense breast tissue based on breast
composition categories.
Nothing in this subsection shall be construed as to preclude
utilization review as provided under Article XXI of this act or
to prevent the application of deductible, copayment or
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coinsurance provisions contained in the policy or plan for
breast imaging in excess of the minimum coverage required.
(c) This section shall not apply to the following types of
policies:
(1) Accident only.
(2) Limited benefit.
(3) Credit.
(4) Dental.
(5) Vision.
(6) Specified disease.
(7) Medicare supplement.
(8) Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) supplement.
(9) Long-term care or disability income.
(10) Workers' compensation.
(11) Automobile medical payment.
(12) Fixed indemnity.
(13) Hospital indemnity.
(d) As used in this section:
"Supplemental breast screening" means a medically necessary
and clinically appropriate examination of the breast using
either standard or abbreviated magnetic resonance imaging or, if
such imaging is not possible, ultrasound if recommended by the
treating physician to screen for breast cancer when there is no
abnormality seen or suspected in the breast.]
Section 2. The act is amended by adding a section to read:
Section 632.1. Coverage for Mammographic Examinations,
Magnetic Resonance Imaging and Other Forms of Breast Imaging.--
(a) A health insurance policy offered, issued or renewed in
this Commonwealth shall provide, as a minimum requirement for a
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covered person under the policy, coverage without cost sharing
for the following services:
(1) Mammographic examinations as follows:
(i) An annual A mammographic examination for a covered
person 40 years of age or older.
(ii) A mammographic examination for a covered person under
40 years of age upon the recommendation of the covered person's
physician.
(2) Supplemental breast screenings for a covered person
whose risk level for breast cancer is determined to be at least
average risk or higher.
(3) Diagnostic breast examinations for a covered person
whose risk level for breast cancer is determined to be at least
average risk or higher.
(b) The coverage required under subsection (a) shall be
subject to the following:
(1) Article XXI of this act.
(2) The terms and conditions of the health insurance policy,
provided such terms and conditions are consistent with this
section.
(3) Applicable Federal law and regulations.
(c) Prior to payment for a mammographic examination under
this section, an insurer shall verify that the facility
prov iding the mammogram is properly certified under 42 U.S.C. §
263b (relating to certification of mammography facilities).
(d) Nothing in this section shall be construed to:
(1) Preclude an insurer from applying utilization review
under Article XXI of this act.
(2) Prevent the application of deductible, copayment or
coinsurance provisions for breast imaging services beyond the
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minimum coverage required under subsection (a).
(3) Require an insurer to cover a surgical procedure known
as mastectomy.
(4) Prohibit the application of deductible or copayment
provisions contained in a policy or plan, except as preempted by
Federal law.
(e) The following shall apply:
(1) Except as provided under paragraph (2), the terms in
this section shall have the same meanings as provided in section
2102.
(2) As used in this section, the following words and phrases
shall have the meanings given to them in this paragraph unless
the context clearly indicates otherwise:
"Average risk" means a covered person who meets all of the
following criteria:
(i) Has, based on clinical review criteria, a 15% or less
lifetime risk of being diagnosed with breast cancer during the
covered person's lifetime.
(ii) Has no personal history of breast cancer.
(iii) Has no family history of breast cancer.
(iv) Has no known BRCA gene mutation.
(v) Has no history of radiation therapy before 30 years of
age.
(vi) Has no personal history of atypical breast histologies.
(vii) Has not undergone prior therapeutic thoracic radiation
therapy.
(viii) Does not have heterogeneously dense or extremely
dense breast tissue.
(ix) Does not have a personal history of Li-Fraumeni
syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome
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or a first-degree relative with one of these syndromes.
"Diagnostic breast examination" means a medically necessary
and clinically appropriate examination of the breast using
diagnostic mammography, standard or abbreviated breast magnetic
resonance imaging or breast ultrasound when an abnormality is
seen or suspected.
"Supplemental breast screening" means a medically necessary
and clinically appropriate examination of the breast using
either standard or abbreviated magnetic resonance imaging or, if
such imaging is not possible, ultrasound, if recommended by the
treating physician, to screen for breast cancer when no
abnormality is seen or suspected.
Section 3. This act shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed by the Federal Government
or the Insurance Department, this act shall apply to any
policy for which a form or rate is first filed on or after
180 days after the effective date of this paragraph.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, this act shall apply
to any policy issued or renewed on or after 180 days after
the effective date of this paragraph.
Section 4. This act shall take effect in 60 days.
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