Senate Bill 25-296 Rerevised

A Bill for an Act

• Page 1, Line 101Concerning insurance coverage for preventive breast

• Page 1, Line 102cancer examinations.

Bill Summary

(Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://leg.colorado.gov.)

The bill makes changes to preventive care coverage by health insurers for breast cancer screening, including by:

• Relocating in statute the high-risk breast cancer screening requirements;
• Defining and creating parameters around the use of diagnostic breast examinations and supplemental breast examinations; and
• Clarifying that diagnostic and supplemental breast examinations, in addition to regular breast cancer screening, do not require cost sharing by the patient.

• Page 2, Line 1Be it enacted by the General Assembly of the State of Colorado:

• Page 2, Line 2SECTION 1.  In Colorado Revised Statutes, 10-16-104, amend (18)(b.5) and (18)(c)(III.5)(B) as follows:

• Page 2, Line 310-16-104.  Mandatory coverage provisions - definitions - rules

• Page 2, Line 4- applicability. (18)  Prevention health-care services - rules -

• Page 2, Line 5definitions. (b.5) (I)  The coverage required by pursuant to this

• Page 2, Line 6subsection (18) must include a preventive breast cancer screening study

• Page 2, Line 7that is within appropriate use guidelines as determined by the American

• Page 2, Line 8College of Radiology, the National Comprehensive Cancer Network, or

• Page 2, Line 9their successor entities. for the actual cost of an annual breast cancer

• Page 2, Line 10screening using the noninvasive imaging modality appropriate for the

• Page 2, Line 11covered person's breast health needs, as determined by the covered person's provider.

• Page 2, Line 12(II) [Similar to former section 10-16-104 (18)(b.5)(IV)] (A)  For

• Page 2, Line 13any breast imaging performed after the breast cancer screening study,

• Page 2, Line 14whether it is diagnostic breast imaging for further evaluation or

• Page 2, Line 15supplemental breast imaging within the same calendar year based on

• Page 2, Line 16factors including a high lifetime risk for breast cancer or high breast

• Page 2, Line 17density, the noninvasive imaging modality or modalities used must be the

• Page 2, Line 18same as, or comparable to, the modality or modalities used for the breast

• Page 2, Line 19cancer screening study. Notwithstanding other coverage

• Page 2, Line 20provisions of subsection (18)(b.5)(I) of this section, a policy or

• Page 2, Line 21contract subject to this subsection (18) must cover an annual

• Page 3, Line 1breast cancer screening using the appropriate noninvasive

• Page 3, Line 2imaging modality or combination of modalities recognized by the

• Page 3, Line 3American College of Radiology or the National Comprehensive

• Page 3, Line 4Cancer Network, or their successor entities, for all individuals possessing at least one risk factor for breast cancer, including:

• Page 3, Line 5(A)  A family history of breast cancer;

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

• Page 3, Line 6(C)  An increased lifetime risk of breast cancer determined

• Page 3, Line 7by a risk factor model, such as Tyrer-Cuzick, BRCAPRO, or Gail, or by other clinically appropriate risk assessment models.

• Page 3, Line 8(B)  If the noninvasive imaging modality is recommended by the

• Page 3, Line 9covered person's provider and the breast imaging is within appropriate use

• Page 3, Line 10guidelines as determined by the American College of Radiology, the

• Page 3, Line 11National Comprehensive Cancer Network, or their successor entities, the covered person is not responsible for any cost-sharing amounts.

• Page 3, Line 12(C)  If the covered person receives more than one breast imaging

• Page 3, Line 13that is in excess of what is recommended by the American College of

• Page 3, Line 14Radiology, the National Comprehensive Cancer Network, or their

• Page 3, Line 15successor entities, in a given calendar year or contract year, the other

• Page 3, Line 16benefit provisions in the policy or contract apply with respect to the additional breast imaging.

• Page 3, Line 17(III)  Benefits for preventive breast cancer screening studies and

• Page 3, Line 18breast imaging are determined on a calendar year or a contract year basis.

• Page 3, Line 19The preventive and diagnostic coverages provided pursuant to this

• Page 3, Line 20subsection (18)(b.5) do not diminish or limit diagnostic benefits otherwise

• Page 3, Line 21allowable under a policy or contract. The coverage required

• Page 3, Line 22pursuant to this subsection (18)(b.5) must include:

• Page 4, Line 1(A)  A medically necessary and appropriate diagnostic

• Page 4, Line 2examination of the breast that is used to evaluate an

• Page 4, Line 3abnormality seen or suspected from a screening examination for

• Page 4, Line 4breast cancer or used to evaluate an abnormality detected by another means of examination; and

• Page 4, Line 5(B)  A medically necessary and appropriate supplemental

• Page 4, Line 6examination of the breast that is used to screen for breast

• Page 4, Line 7cancer when there is no abnormality seen or suspected and that

• Page 4, Line 8is based on personal or family medical history or additional

• Page 4, Line 9factors that increase the individual's risk of breast cancer, including heterogeneously or extremely dense breasts.

• Page 4, Line 10(IV)  Notwithstanding the other coverage provisions of this

• Page 4, Line 11subsection (18)(b.5), a policy or contract subject to this subsection (18)

• Page 4, Line 12must cover an annual breast cancer screening using the appropriate

• Page 4, Line 13noninvasive imaging modality or combination of modalities recognized

• Page 4, Line 14by the American College of Radiology, the National Comprehensive

• Page 4, Line 15Cancer Network, or their successor entities, for all individuals possessing

• Page 4, Line 16at least one risk factor for breast cancer, including The coverage

• Page 4, Line 17required pursuant to this subsection (18)(b.5) must cover the

• Page 4, Line 18following services, without cost-sharing requirements,

• Page 4, Line 19including deductibles, coinsurance, copayments, or any

• Page 4, Line 20maximum limitation on the application of such deductibles, coinsurance, or copayments or similar out-of-pocket expenses:

• Page 4, Line 21(A)  A family history of breast cancer Breast cancer screening studies;

• Page 4, Line 22(B)  Being forty years of age or older; or Diagnostic

• Page 4, Line 23examinations of the breast that are medically necessary and

• Page 5, Line 1appropriate, in accordance with the National Comprehensive

• Page 5, Line 2Cancer Network guidelines, including such an examination using

• Page 5, Line 3contrast-enhanced mammography, diagnostic mammography,

• Page 5, Line 4breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging; and

• Page 5, Line 5(C)  An increased lifetime risk of breast cancer determined by a

• Page 5, Line 6risk factor model such as Tyrer-Cuzick, BRCAPRO, or GAIL or by other

• Page 5, Line 7clinically appropriate risk assessment models Supplemental

• Page 5, Line 8examinations of the breast that are medically necessary and

• Page 5, Line 9appropriate, in accordance with the National Comprehensive

• Page 5, Line 10Cancer Network guidelines, including such an examination using

• Page 5, Line 11contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging.

• Page 5, Line 12(V)  If application of this subsection (18) would make a

• Page 5, Line 13covered person's health savings account contributions

• Page 5, Line 14ineligible under section 223 of the federal "Internal Revenue

• Page 5, Line 15Code of 1986", 26 U.S.C. sec. 223, this subsection (18) applies to the

• Page 5, Line 16deductible applicable to the covered person's health benefit

• Page 5, Line 17plan after the covered person has satisfied the minimum

• Page 5, Line 18deductible amount under 26 U.S.C. sec. 223; except that, with

• Page 5, Line 19respect to items or services that are preventive care pursuant

• Page 5, Line 20to 26 U.S.C. sec. 223 (c)(2)(C), this subsection (18) applies,

• Page 5, Line 21regardless of whether the minimum deductible under 26 U.S.C. sec. 223 has been satisfied.

• Page 5, Line 22(c)  As used in this subsection (18):

• Page 5, Line 23(III.5)  "Breast cancer screening study" and "breast imaging"

• Page 5, Line 24mean:

• Page 6, Line 1(B)  A mammogram using a or other noninvasive imaging modality or modalities, as recommended by the medical provider; or

• Page 6, Line 2SECTION 2.  Act subject to petition - effective date. This act

• Page 6, Line 3takes effect at 12:01 a.m. on the day following the expiration of the

• Page 6, Line 4ninety-day period after final adjournment of the general assembly; except

• Page 6, Line 5that, if a referendum petition is filed pursuant to section 1 (3) of article V

• Page 6, Line 6of the state constitution against this act or an item, section, or part of this

• Page 6, Line 7act within such period, then the act, item, section, or part will not take

• Page 6, Line 8effect unless approved by the people at the general election to be held in

• Page 6, Line 9November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.