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Sub. H. B. No. 331As Passed by the House
As Passed by the House
125th General Assembly | Regular Session | 2003-2004 |
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REPRESENTATIVES Schmidt, Schneider, Hughes, Clancy, Raga, Schlichter, Webster, T. Patton, Grendell, Flowers, Barrett, J. Stewart, Miller, Allen, DeBose, McGregor, Latta, S. Patton, Key, Kearns, Brown, Jerse, Beatty, Harwood, Kilbane, Walcher, Price, G. Smith, S. Smith, Cirelli, Hollister, Reidelbach, Aslanides, Boccieri, Book, Buehrer, Callender, Carano, Carmichael, Cates, Chandler, Collier, Daniels, DeGeeter, Distel, Domenick, C. Evans, D. Evans, Faber, Gilb, Hagan, Hartnett, Hoops, Koziura, Martin, Mason, Oelslager, Olman, Otterman, Schaffer, Seaver, Setzer, Sferra, Skindell, Slaby, D. Stewart, Strahorn, Sykes, Taylor, Ujvagi, Widener, Widowfield, Willamowski, Wilson, Woodard, Yates
A BILLTo amend sections 1751.62, 3923.52, 3923.53, and 3923.54 of the Revised Code to cap the benefits health care plans provide for the expense of screening mammographies, an examination that the plans are required to cover, at 130% of the Medicare reimbursement rate. BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1751.62, 3923.52, 3923.53, and 3923.54 of the Revised Code be amended to read as follows:
Sec. 1751.62. (A) As used in
this section, "screening: (1) "Screening mammography" means a radiologic
examination utilized to detect unsuspected breast cancer at an
early stage in an asymptomatic woman and includes the x-ray
examination of the breast using equipment that is dedicated
specifically for mammography, including, but not limited to, the x-ray tube, filter,
compression device, screens, film, and cassettes, and that has
an average radiation exposure delivery of less than one rad
mid-breast. "Screening mammography" includes two views for each
breast. The term also includes the professional interpretation
of the film. "Screening mammography" does not include diagnostic
mammography.
(2) "Medicare reimbursement rate" means the reimbursement rate paid in Ohio under the medicare program for screening mammography that does not include digitalization or computer aided detection, regardless of whether the actual benefit includes digitalization or computer aided detection. (B) Every individual or
group health insuring corporation policy, contract, or agreement
providing basic health care services that is delivered, issued for delivery,
or renewed in this state
shall provide benefits for the expenses of both of the
following: (1) Screening mammography to detect the presence of
breast cancer in adult women; (2) Cytologic screening for the presence of cervical
cancer. (C) The benefits
provided under division (B)(1)
of this section shall cover expenses in accordance with all of
the following: (1) If a woman is at least thirty-five years of age but
under forty years of age, one screening mammography; (2) If a woman is at least forty years of age but under
fifty years of age, either of the following: (a) One screening
mammography every two years; (b) If a licensed
physician has determined that the woman has risk factors to
breast cancer, one screening mammography every year. (3) If a woman is at least fifty years of age but under
sixty-five years of age, one screening mammography every
year. (D)(1) The benefits Subject to divisions (D)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (B)(1) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component. (2) Regardless of whether separate payments are made for the benefit
provided under division (B)(1)
of this section, the total benefit for a screening mammography shall not exceed eighty-five dollars per year
unless a lower amount is established pursuant to a provider
contract one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state. (2)(3) The benefit paid in accordance with division
(D)(1) of this section shall
constitute full payment. No institutional or professional provider, hospital, or other
health care provider facility shall seek or receive remuneration in
excess of the payment made in accordance with division
(D)(1) of this section, except
for approved deductibles and copayments.
(E) The benefits
provided under division (B)(1)
of this section shall be provided only for screening
mammographies that are performed in a health care facility or
mobile mammography screening unit that is accredited under the
American college of radiology
mammography accreditation program or in a hospital as defined in
section 3727.01 of the Revised
Code. (F) The benefits
provided under divisions (B)(1)
and (2) of this section shall be provided according to the terms
of the subscriber contract. (G) The benefits
provided under division (B)(2)
of this section shall be provided only for cytologic screenings
that are processed and interpreted in a laboratory certified by
the college of American
pathologists or in a hospital as defined in section 3727.01 of
the Revised
Code.
Sec. 3923.52. (A) As used in this section and section
3923.53 of the Revised Code, "screening mammography" means a
radiologic examination utilized to detect unsuspected breast
cancer at an early stage in asymptomatic women and includes the
x-ray examination of the breast using equipment that is dedicated
specifically for mammography, including, but not limited to, the x-ray tube, filter,
compression device, screens, film, and cassettes, and that has an
average radiation exposure delivery of less than one rad
mid-breast. "Screening mammography" includes two views for each
breast. The term also includes the
professional interpretation of the film. "Screening mammography" does not include diagnostic
mammography. (B) Every policy of individual or group sickness and
accident insurance that is delivered, issued for delivery, or
renewed in this state shall offer to provide benefits for the
expenses of both of the following: (1) Screening mammography to detect the presence of breast
cancer in adult women; (2) Cytologic screening for the presence of cervical
cancer. (C) The benefits provided under division (B)(1) of this
section shall cover expenses in accordance with all of the
following: (1) If a woman is at least thirty-five years of age but
under forty years of age, one screening mammography; (2) If a woman is at least forty years of age but under
fifty years of age, either of the following: (a) One screening mammography every two years; (b) If a licensed physician has determined that the woman
has risk factors to breast cancer, one screening mammography
every year. (3) If a woman is at least fifty years of age but under
sixty-five years of age, one screening mammography every year. (D)(1) The benefits As used in this division, "medicare reimbursement rate" means the reimbursement rate paid in this state under the medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection. (1) Subject to divisions (D)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (B)(1) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component. (2) Regardless of whether separate payments are made for the benefit provided under division (B)(1) of this
section, the total benefit for a screening mammography shall not exceed eighty-five dollars per year unless a
lower amount is established pursuant to a provider contract one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state. (2)(3) The benefit paid in accordance with division (D)(1) of
this section shall constitute full payment. No institutional or
professional provider, hospital, or other health care provider facility shall seek or receive
compensation in excess of the payment made in accordance with
division (D)(1) of this section, except for approved deductibles
and copayments.
(E) The benefits provided under division (B)(1) of this
section shall be provided only for screening mammographies that
are performed in a facility or mobile mammography screening
unit that is accredited under the American
college of radiology mammography accreditation program or in a
hospital as defined in section 3727.01 of the Revised Code. (F) The benefits provided under division (B)(2) of this
section shall be provided only for cytologic screenings that are
processed and interpreted in a laboratory certified by the
college of American pathologists or in a hospital as defined in
section 3727.01 of the Revised Code. (G) This section does not apply to any policy that
provides coverage for specific diseases or accidents only, or to
any hospital indemnity, medicare supplement, or other policy that
offers only supplemental benefits.
Sec. 3923.53. (A) Every public employee benefit plan that
is established or modified in this state shall provide benefits
for the expenses of both of the following: (1) Screening mammography to detect the presence of breast
cancer in adult women; (2) Cytologic screening for the presence of cervical
cancer. (B) The benefits provided under division (A)(1) of this
section shall cover expenses in accordance with all of the
following: (1) If a woman is at least thirty-five years of age but
under forty years of age, one screening mammography; (2) If a woman is at least forty years of age but under
fifty years of age, either of the following: (a) One screening mammography every two years; (b) If a licensed physician has determined that the woman
has risk factors to breast cancer, one screening mammography
every year. (3) If a woman is at least fifty years of age but under
sixty-five years of age, one screening mammography every year. (C)(1) The benefits As used in this division, "medicare reimbursement rate" means the reimbursement rate paid in this state under the medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection. (1) Subject to divisions (C)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (B)(1) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component.
(2) Regardless of whether separate payments are made for the benefit provided under division (A)(1) of this
section, the total benefit for a screening mammography shall not exceed eighty-five dollars per year unless a
lower amount is established pursuant to a provider contract one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state. (2)(3) The benefit paid in accordance with division (C)(1) of
this section shall constitute full payment. No institutional or
professional provider, hospital, or other health care provider facility shall seek or receive
compensation in excess of the payment made in accordance with
division (C)(1) of this section, except for approved deductibles
and copayments.
(D) The benefits provided under division (A)(1) of this
section shall be provided only for screening mammographies that
are performed in a facility or mobile mammography screening unit
that is accredited under the American
college of radiology mammography accreditation program or in a
hospital as defined in section 3727.01 of the Revised Code. (E) The benefits provided under division (A)(2) of this
section shall be provided only for cytologic screenings that are
processed and interpreted in a laboratory certified by the
college of American pathologists or in a hospital as defined in
section 3727.01 of the Revised Code.
Sec. 3923.54. (A) As used in this section, "screening
mammography" means a radiologic examination utilized to detect
unsuspected breast cancer at an early stage in asymptomatic women
and includes the x-ray examination of the breast using equipment
that is dedicated specifically for mammography including, but not
limited to, the x-ray tube, filter, compression device, screens,
film, and cassettes, and that has an average radiation exposure
delivery of less than one rad mid-breast. "Screening
mammography" includes two views for each breast.
The term also includes the professional
interpretation of the film. "Screening mammography" does not include diagnostic mammography. (B) Each employer in this state that provides, in whole or
in part, health care benefits for its employees under a policy of
sickness and accident insurance issued in accordance with Chapter
3923. of the Revised Code shall also provide to its employees
benefits for the expenses of both of the following: (1) Screening mammography to detect the presence of breast
cancer in adult women; (2) Cytologic screening for the presence of cervical
cancer. (C) An employer may comply with division (B) of this
section in any of the following ways: (1) By providing the benefits under a health insuring corporation
contract issued in accordance
with Chapter 1751. of
the Revised Code or a policy of sickness and accident insurance
issued in accordance with Chapter 3923. of the Revised Code; (2) By reimbursing the employee for the direct health care
provider charges associated with receipt of the covered service; (3) By making any other arrangement that provides the
benefits described in division (B) of this section. (D) The benefits provided under division (B)(1) of this
section shall cover expenses in accordance with all of the
following: (1) If a woman is at least thirty-five years of age but
under forty years of age, one screening mammography; (2) If a woman is at least forty years of age but under
fifty years of age, either of the following: (a) One screening mammography every two years; (b) If a licensed physician has determined that the woman
has risk factors to breast cancer, one screening mammography
every year. (3) If a woman is at least fifty years of age but under
sixty-five years of age, one screening mammography every year. (E)(1) The benefits As used in this division, "medicare reimbursement rate" means the reimbursement rate paid in this state under the medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection. (1) Subject to divisions (E)(2) and (3) of this section, if a provider, hospital, or other health care facility provides a service that is a component of the screening mammography benefit in division (B)(1) of this section and submits a separate claim for that component, a separate payment shall be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by medicare in this state for that component. (2) Regardless of whether separate payments are made for the benefit provided under division (B)(1) of this
section, the total benefit for a screening mammography need not exceed eighty-five dollars per year one hundred thirty per cent of the medicare reimbursement rate in this state for screening mammography. If there is more than one medicare reimbursement rate in this state for screening mammography or a component of a screening mammography, the reimbursement limit shall be one hundred thirty per cent of the lowest medicare reimbursement rate in this state. (2)(3) The benefit paid in accordance with division (E)(1) of
this section shall constitute full payment. No institutional or
professional provider, hospital, or other health care provider facility shall seek or receive
compensation in excess of the payment made in accordance with
division (E)(1) of this section, except for approved deductibles
and copayments.
(F) The benefits provided under division (B)(1) of this
section shall be provided only for screening mammographies that
are performed in a facility or mobile mammography screening unit
that is accredited under the American
college of radiology mammography accreditation program or in a
hospital as defined in section 3727.01 of the Revised Code. (G) The benefits provided under division (B)(2) of this
section shall be provided only for cytologic screenings that are
processed and interpreted in a laboratory certified by the
college of American pathologists or in a hospital as defined in
section 3727.01 of the Revised Code.
Section 2. That existing sections 1751.62, 3923.52, 3923.53, and 3923.54 of the Revised Code are hereby repealed.
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