Senate Bill 25-296

BY SENATOR(S) Michaelson Jenet, Rich, Amabile, Ball, Carson, Cutter, Danielson, Daugherty, Exum, Frizell, Gonzales J., Hinrichsen, Jodeh, Kipp, Marchman, Mullica, Roberts, Snyder, Wallace, Weissman, Winter F., Coleman;

also REPRESENTATIVE(S) Bird and Stewart K., Rydin, Stewart R., Bacon, Boesenecker, Brown, Caldwell, Camacho, Carter, Clifford, Duran, Froelich, Gonzalez R., Hamrick, Jackson, Joseph, Lieder, Lindsay, Lindstedt, Lukens, McCormick, Paschal, Rutinel, Sirota, Smith, Soper, Story, Titone, McCluskie.

Concerning insurance coverage for preventive breast cancer examinations.

Be it enacted by the General Assembly of the State of Colorado:

SECTION 1.  In Colorado Revised Statutes, 10-16-104, amend (18)(b.5) and (18)(c)(III.5)(B) as follows:

10-16-104.  Mandatory coverage provisions - definitions - rules - applicability. (18)  Prevention health-care services - rules - definitions. (b.5) (I)  The coverage required bypursuant to this subsection (18) must include a preventive breast cancer screening study that is within appropriate use guidelines as determined by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities. for the actual cost of an annual breast cancer screening using the noninvasive imaging modality appropriate for the covered person's breast health needs, as determined by the covered person's provider.

(II) [Similar to former section 10-16-104 (18)(b.5)(IV)] (A)  For any breast imaging performed after the breast cancer screening study, whether it is diagnostic breast imaging for further evaluation or supplemental breast imaging within the same calendar year based on factors including a high lifetime risk for breast cancer or high breast density, the noninvasive imaging modality or modalities used must be the same as, or comparable to, the modality or modalities used for the breast cancer screening study.Notwithstanding other coverage provisions of subsection (18)(b.5)(I) of this section, a policy or contract subject to this subsection (18) must cover an annual breast cancer screening using the appropriate noninvasive imaging modality or combination of modalities recognized by the American College of Radiology or the National Comprehensive Cancer Network, or their successor entities, for all individuals possessing at least one risk factor for breast cancer, including:

(A)  A family history of breast cancer;

(B)  Being forty years of age or older; or

(C)  An increased lifetime risk of breast cancer determined by a risk factor model, such as Tyrer-Cuzick, BRCAPRO, or Gail, or by other clinically appropriate risk assessment models.

(B)  If the noninvasive imaging modality is recommended by the covered person's provider and the breast imaging is within appropriate use guidelines as determined by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, the covered person is not responsible for any cost-sharing amounts.

(C)  If the covered person receives more than one breast imaging that is in excess of what is recommended by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, in a given calendar year or contract year, the other benefit provisions in the policy or contract apply with respect to the additional breast imaging.

(III)  Benefits for preventive breast cancer screening studies and breast imaging are determined on a calendar year or a contract year basis. The preventive and diagnostic coverages provided pursuant to this subsection (18)(b.5) do not diminish or limit diagnostic benefits otherwise allowable under a policy or contract.The coverage required pursuant to this subsection (18)(b.5) must include:

(A)  A medically necessary and appropriate diagnostic examination of the breast that is used to evaluate an abnormality seen or suspected from a screening examination for breast cancer or used to evaluate an abnormality detected by another means of examination; and

(B)  A medically necessary and appropriate supplemental examination of the breast that is used to screen for breast cancer when there is no abnormality seen or suspected and that is based on personal or family medical history or additional factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.

(IV)  Notwithstanding the other coverage provisions of this subsection (18)(b.5), a policy or contract subject to this subsection (18) must cover an annual breast cancer screening using the appropriate noninvasive imaging modality or combination of modalities recognized by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, for all individuals possessing at least one risk factor for breast cancer, includingThe coverage required pursuant to this subsection (18)(b.5) must cover the following services, without cost-sharing requirements, including deductibles, coinsurance, copayments, or any maximum limitation on the application of such deductibles, coinsurance, or copayments or similar out-of-pocket expenses:

(A)  A family history of breast cancerBreast cancer screening studies;

(B)  Being forty years of age or older; orDiagnostic examinations of the breast that are medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network guidelines, including such an examination using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging; and

(C)  An increased lifetime risk of breast cancer determined by a risk factor model such as Tyrer-Cuzick, BRCAPRO, or GAIL or by other clinically appropriate risk assessment modelsSupplemental examinations of the breast that are medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network guidelines, including such an examination using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging.

(V)  If application of this subsection (18) would make a covered person's health savings account contributions ineligible under section 223 of the federal "Internal Revenue Code of 1986", 26 U.S.C. sec. 223, this subsection (18) applies to the deductible applicable to the covered person's health benefit plan after the covered person has satisfied the minimum deductible amount under 26 U.S.C. sec. 223; except that, with respect to items or services that are preventive care pursuant to 26 U.S.C. sec. 223 (c)(2)(C), this subsection (18) applies, regardless of whether the minimum deductible under 26 U.S.C. sec. 223 has been satisfied.

(c)  As used in this subsection (18):

(III.5)  "Breast cancer screening study" and "breast imaging" mean:

(B)  A mammogram using aor other noninvasive imaging modality or modalities, as recommended by the medical provider; or

SECTION 2.  Act subject to petition - effective date. This act takes effect at 12:01 a.m. on the day following the expiration of the ninety-day period after final adjournment of the general assembly; except that, if a referendum petition is filed pursuant to section 1 (3) of article V of the state constitution against this act or an item, section, or part of this act within such period, then the act, item, section, or part will not take effect unless approved by the people at the general election to be held in November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.