Section 304.17-316 - [Effective 1/1/2025] Coverage for mammograms(1) As used in this section: (a) "Cost-sharing requirements" means any: 1. Deductible, coinsurance, or copayment; or 2. Out-of-pocket expense imposed upon an insured that is similar to an expense referenced in subparagraph 1. of this paragraph; (b)1."Diagnostic breast examination" means a medically necessary and appropriate examination of the breast that is used to evaluate an abnormality seen or suspected from, or detected by, a screening examination for breast cancer or another means of examination. 2. As used in subparagraph 1. of this paragraph, "examination of the breast" includes but is not limited to an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound; (c)1. "Mammogram" means an X-ray examination of the breast, with at least two (2) views of each breast and with an average radiation exposure at the current recommended level as set forth in guidelines of the American College of Radiology, using equipment dedicated specifically for mammography, including but not limited to: a.The X-ray tube, filter, compression device, screens, film, and cassettes; b.Digital mammography; and 2. As used in subparagraph 1. of this paragraph, "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; and (d)1. "Supplemental breast examination" means a medically necessary and appropriate examination of the breast that is: a. Used to screen for breast cancer when there is no abnormality seen or suspected; and b. Based on personal or family medical history, or additional factors, that may increase the individual's risk of breast cancer. 2. As used in subparagraph 1. of this paragraph, "examination of the breast" includes but is not limited to: b. An examination using breast magnetic resonance imaging or breast ultrasound.(2) Subject to subsection (3) of this section and except as otherwise provided in subsection (4) of this section, a health insurance policy, plan, certificate, or contract issued, renewed, or delivered in this Commonwealth: (a)That provides coverage on an expense-incurred basis for surgical services for a mastectomy shall also provide coverage for: 1.a.Low-dose mammography screening for persons who have no sign or symptom of breast cancer upon self-referral or referral by a health care practitioner acting within the scope of the practitioner's licensure.b.The coverage required under this subparagraph may be limited to the following: i.One (1) mammogram for persons ages thirty-five (35) years through thirty-nine (39) years;ii.One (1) mammogram every two (2) years for persons ages forty (40) years through forty-nine (49) years;iii.One (1) mammogram per year for persons ages fifty (50) years and over; andiv.A benefit of fifty dollars ($50) per screening mammogram.c. The coverage required under this subparagraph shall be subject to deductibles and coinsurance that are no less favorable than the deductibles and coinsurance for coverage for physical illness generally; and 2.a. Mammograms for any insured , regardless of age, who has been diagnosed with breast disease upon referral by a health care practitioner acting within the scope of the practitioner's licensure.b.The coverage required under this subparagraph shall be subject to the same annual deductibles or coinsurance established for other coverages within the policy; (b) Shall not impose any cost-sharing requirements for any diagnostic breast examination or supplemental breast examination that is covered under the policy, plan, certificate, or contract; and (c) Shall provide any coverage not otherwise required under this section, including coverage with respect to restrictions on cost-sharing requirements, for breast examinations, including mammograms, that is required for that policy, plan, certificate, or contract under federal law.(3) The coverage required under subsection (2)(a) of this section shall be limited to mammograms: (a)Performed by a radiographer: 1. Licensed under KRS Chapter 311B; or2. Certified by the American Registry of Radiologic Technologists; (b)Interpreted by a qualified radiologist; (c)Performed under the direction of a person licensed to practice medicine and certified by the American Board of Radiology; (d) Performed by a facility and ordered by a health care practitioner that follow federal laws relating to the notification of mammography exam results and maintaining medical records; (e) Performed by a facility that meets current criteria of the American College of Radiology Mammography Accreditation Program; and (f) Performed on dedicated equipment that meets the guidelines established by the American College of Radiology.(4) If the application of any requirement of subsection (2) of this section would be the sole cause of a health insurance policy's, plan's, certificate's, or contract's failure to qualify as a Health Savings Account-qualified High Deductible Health Plan under 26 U.S.C. sec. 223, as amended, then the requirement shall not apply to that policy, plan, certificate, or contract until the minimum deductible under 26 U.S.C. sec. 223, as amended, is satisfied. Amended by 2024 Ky. Acts ch. 97,§ 1, eff. 1/1/2025, app. to policies, plans, certificates, and contracts issued or renewed on or after January 1, 2025.Amended by 2017 Ky. Acts ch. 183,§ 2, eff. 6/29/2017.Effective:7/14/2000
Amended 2000, Ky. Acts ch. 18, sec. 1, effective7/14/2000. -- Created 1990 Ky. Acts ch. 46, sec. 1, effective 7/13/1990.This section is set out more than once due to postponed, multiple, or conflicting amendments.