§1028. Early screening and detection requirements; examination; coverage

            A.(1) Any health coverage plan which is delivered or issued for delivery in this state shall include benefits payable for an annual Pap test and minimum mammography examination as provided in this Subsection.

            (2) In this Subsection, "minimum mammography examination" means mammographic examinations, including but not limited to digital breast tomosynthesis (DBT), performed no less frequently than the following schedule and criteria of the American Society of Breast Surgeons provides:

            (a)(i) Except as provided in this Subparagraph, one baseline mammogram for any woman who is thirty-five through thirty-nine years of age.

            (ii) For women with a hereditary susceptibility from pathogenic mutation carrier status or prior chest wall radiation, an annual MRI starting at age twenty-five and annual mammography (DBT preferred modality) starting at age thirty. Such examinations shall be in accordance with recommendations by National Comprehensive Cancer Network guidelines or the American Society of Breast Surgeons Position Statement on Screening Mammography no later than the following policy or plan year following changes in the recommendations.

            (iii) Annual mammography (DBT preferred modality) and access to supplemental imaging (MRI preferred modality) starting at age thirty-five upon recommendation by her physician if the woman has a predicted lifetime risk greater than twenty percent by any validated model published in peer reviewed medical literature.

            (b) Annual mammography (DBT preferred modality) for any woman who is forty years of age or older.

            (i) Consideration given to supplemental imaging (breast ultrasound initial preferred modality, followed by MRI if inconclusive), if recommended by her physician, for women with increased breast density (C and D density).

            (ii) Access to annual supplemental imaging (MRI preferred modality), if recommended by her physician, for women with a prior history of breast cancer below the age of fifty or with a prior history of breast cancer at any age and dense breast (C and D density).

            (iii) Any coverage provided pursuant to this Subsection may be subject to the health coverage plan's utilization review using guidelines published in peer reviewed medical literature consistent with this Section.

            (3) The annual Pap test for cervical cancer and the minimum mammography examination shall be covered when rendered or prescribed by a physician or other appropriate health care provider licensed in this state and received in any licensed hospital or in any other licensed public or private facility, or portion thereof, including but not limited to clinics and mobile screening units.

            (4) In this Subsection, "digital breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.

            (5) No health coverage plan which is delivered or issued for delivery in this state shall prevent any insured, beneficiary, enrollee, or subscriber from having direct access, without any requirement for specialty referral, to the minimum mammography examination required to be covered by this Subsection.

            B.(1) Any health coverage plan which is delivered or issued for delivery in the state shall provide coverage for detection of prostate cancer, including digital rectal examination and prostate-specific antigen testing for men over the age of fifty years and as medically necessary and appropriate for men over the age of forty years.

            (2) "Routine prostate preventative care" as used in this Subsection, shall mean a minimum of one routine annual visit, provided that a second visit shall be permitted based upon medical need and follow-up treatment within sixty days after either visit if related to a condition diagnosed or treated during the visits.

            (3) Repealed by Acts 2018, No. 494, §4. eff. Jan. 1, 2019.

            C. As used in this Section, "health coverage plan" shall mean any hospital, health, or medical expense insurance policy, hospital or medical service contract, health and accident insurance policy, or any other contract of this type, including a group insurance plan, or any policy of family group, blanket, or association health and accident insurance, a self-insurance plan, an employee welfare benefit plan, and a health maintenance organization subscriber agreement. Unless otherwise specifically provided in the policy of insurance, nothing in this Section shall apply to high deductible coverage as defined under the Internal Revenue Code of 1986, or similar coverage with a greater deductible amount, limited benefit and supplemental health insurance policies including individually underwritten high deductible coverage as defined under the Internal Revenue Code of 1986, or similar coverage with a greater deductible amount limited benefit and supplemental health insurance policies.

            D. For the purposes of this Section, a health coverage plan shall include the office of group benefits programs.

            E. Any coverage required under the provisions of this Section shall not be subject to any policy or health coverage plan deductible amount.

            F. Any provision in a health insurance policy, benefit program, or health coverage plan under this Section which is delivered, renewed, issued for delivery, or otherwise contracted for in this state which is contrary to this Section shall, to the extent of the conflict, be void.

            G. The provisions of this Section shall not apply to limited benefit health insurance policies or contracts authorized to be issued in this state.

            Acts 1991, No. 387, §1; Acts 1991, No. 994, §1; Acts 1992, No. 462, §1; Acts 1995, No. 593, §1; Acts 1997, No. 1439, §1, eff. July 15, 1997; Acts 2001, No. 1116, §1; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2003, No. 129, §1, eff. May 28, 2003; Redesignated from R.S. 22:215.11 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2018, No. 494, §§1, 4, eff. Jan. 1, 2019; Acts 2021, No. 45, §1.

NOTE: Former R.S. 22:1028 redesignated as R.S. 22:808 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.