S 2395: Requires health insurance coverage for mammography by either mammogram and breast ultrasound or breast tomosynthesis for persons with heterogeneously dense or extremely dense breasts.

  
  STATE OF NEW YORK ________________________________________________________________________ 2395 2025-2026 Regular Sessions  IN SENATE January 17, 2025 ___________ Introduced by Sen. PERSAUD -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law, in relation to requiring health insurance coverage for mammography by either mammogram and breast ultrasound or breast tomosynthesis for persons with certain breast densities The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subparagraph (A) of paragraph 11 of subsection (i) of 2 section 3216 of the insurance law, as amended by chapter 414 of the laws 3 of 2017, is amended to read as follows: 4 (A) Every policy that provides coverage for hospital, surgical or 5 medical care shall provide the following coverage for mammography 6 screening for occult breast cancer: 7 (i) upon the recommendation of a physician, a mammogram, which may be 8 provided by breast tomosynthesis, at any age for covered persons having 9 a prior history of breast cancer or who have a first degree relative 10 with a prior history of breast cancer; 11 (ii) a single baseline mammogram, which may be provided by breast 12 tomosynthesis, for covered persons aged thirty-five through thirty-nine, 13 inclusive; [and] 14 (iii) an annual mammogram, which may be provided by breast tomosynthe- 15 sis, for covered persons aged forty and older; and 16 (iv) either: a. an annual mammogram and breast ultrasound; or b. 17 breast tomosynthesis for covered persons with heterogeneously dense or 18 extremely dense breasts. 19 § 2. Subparagraph (A) of paragraph 11 of subsection (i) of section 20 3216 of the insurance law, as amended by chapter 424 of the laws of 21 2024, is amended to read as follows: 22 (A) Every policy that provides coverage for hospital, surgical or 23 medical care shall provide the following coverage for mammography 24 screening for occult breast cancer: 25 (i) upon the recommendation of a physician, a mammogram, which may be 26 provided by breast tomosynthesis, at any age for covered persons having EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD06157-01-5 
 S. 2395 2 1 a prior history of breast cancer or who have a first degree relative 2 with a prior history of breast cancer; 3 (ii) a single baseline mammogram, which may be provided by breast 4 tomosynthesis, for covered persons aged thirty-five through thirty-nine, 5 inclusive; 6 (iii) an annual mammogram, which may be provided by breast tomosynthe- 7 sis, for covered persons aged forty and older; [and] 8 (iv) upon the recommendation of a physician, screening and diagnostic 9 imaging, including diagnostic mammograms, breast ultrasounds, or magnet- 10 ic resonance imaging, recommended by nationally recognized clinical 11 practice guidelines for the detection of breast cancer. For the purposes 12 of this item, "nationally recognized clinical practice guidelines" means 13 evidence-based clinical practice guidelines informed by a systematic 14 review of evidence and an assessment of the benefits, and risks of 15 alternative care options intended to optimize patient care developed by 16 independent organizations or medical professional societies utilizing a 17 transparent methodology and reporting structure and with a conflict of 18 interest policy; and 19 (v) either: a. an annual mammogram and breast ultrasound; or b. breast 20 tomosynthesis for covered persons with heterogeneously dense or extreme- 21 ly dense breasts. 22 § 3. Subparagraph (A) of paragraph 11 of subsection (l) of section 23 3221 of the insurance law, as amended by chapter 143 of the laws of 24 2019, is amended to read as follows: 25 (A) Every insurer delivering a group or blanket policy or issuing a 26 group or blanket policy for delivery in this state that provides cover- 27 age for hospital, surgical or medical care shall provide the following 28 coverage for mammography screening for occult breast cancer: 29 (i) upon the recommendation of a physician, a mammogram, which may be 30 provided by breast tomosynthesis, at any age for covered persons having 31 a prior history of breast cancer or who have a first degree relative 32 with a prior history of breast cancer; 33 (ii) a single baseline mammogram, which may be provided by breast 34 tomosynthesis, for covered persons aged thirty-five through thirty-nine, 35 inclusive; 36 (iii) an annual mammogram, which may be provided by breast tomosynthe- 37 sis, for covered persons aged forty and older; [and] 38 (iv) for large group policies that provide coverage for hospital, 39 surgical or medical care, an annual mammogram for covered persons aged 40 thirty-five through thirty-nine, inclusive, upon the recommendation of a 41 physician, subject to the insurer's determination that the mammogram is 42 medically necessary; and 43 (v) either: a. an annual mammogram and breast ultrasound; or b. breast 44 tomosynthesis for covered persons with heterogeneously dense or extreme- 45 ly dense breasts. 46 § 4. Subparagraph (A) of paragraph 11 of subsection (l) of section 47 3221 of the insurance law, as amended by chapter 424 of the laws of 48 2024, is amended to read as follows: 49 (A) Every insurer delivering a group or blanket policy or issuing a 50 group or blanket policy for delivery in this state that provides cover- 51 age for hospital, surgical or medical care shall provide the following 52 coverage for mammography screening for occult breast cancer: 53 (i) upon the recommendation of a physician, a mammogram, which may be 54 provided by breast tomosynthesis, at any age for covered persons having 55 a prior history of breast cancer or who have a first degree relative 56 with a prior history of breast cancer; 
 S. 2395 3 1 (ii) a single baseline mammogram, which may be provided by breast 2 tomosynthesis, for covered persons aged thirty-five through thirty-nine, 3 inclusive; 4 (iii) an annual mammogram, which may be provided by breast tomosynthe- 5 sis, for covered persons aged forty and older; 6 (iv) for large group policies that provide coverage for hospital, 7 surgical or medical care, an annual mammogram for covered persons aged 8 thirty-five through thirty-nine, inclusive, upon the recommendation of a 9 physician, subject to the insurer's determination that the mammogram is 10 medically necessary; [and] 11 (v) upon the recommendation of a physician, screening and diagnostic 12 imaging, including diagnostic mammograms, breast ultrasounds, or magnet- 13 ic resonance imaging, recommended by nationally recognized clinical 14 practice guidelines for the detection of breast cancer. For the purposes 15 of this item, "nationally recognized clinical practice guidelines" means 16 evidence-based clinical practice guidelines informed by a systematic 17 review of evidence and an assessment of the benefits, and risks of 18 alternative care options intended to optimize patient care developed by 19 independent organizations or medical professional societies utilizing a 20 transparent methodology and reporting structure and with a conflict of 21 interest policy; and 22 (vi) either: a. an annual mammogram and breast ultrasound; or b. 23 breast tomosynthesis for covered persons with heterogeneously dense or 24 extremely dense breasts. 25 § 5. Paragraph 1 of subsection (p) of section 4303 of the insurance 26 law, as amended by chapter 219 of the laws of 2011, subparagraph (A) as 27 amended by chapter 414 of the laws of 2017, and subparagraphs (B), (C), 28 (D), and (E) as amended by chapter 143 of the laws of 2019, is amended 29 to read as follows: 30 (1) A medical expense indemnity corporation, a hospital service corpo- 31 ration or a health service corporation that provides coverage for hospi- 32 tal, surgical or medical care shall provide the following coverage for 33 mammography screening for occult breast cancer: 34 (A) upon the recommendation of a physician, a mammogram, which may be 35 provided by breast tomosynthesis, at any age for covered persons having 36 a prior history of breast cancer or who have a first degree relative 37 with a prior history of breast cancer; 38 (B) a single baseline mammogram, which may be provided by breast tomo- 39 synthesis, for covered persons aged thirty-five through thirty-nine, 40 inclusive; 41 (C) an annual mammogram, which may be provided by breast tomosythesis, 42 for covered persons aged forty and older; 43 (D) for large group contracts offered by a medical expense indemnity 44 corporation, a hospital service corporation or a health service corpo- 45 ration that provide coverage for hospital, surgical or medical care, an 46 annual mammogram for covered persons aged thirty-five through thirty- 47 nine, inclusive, upon the recommendation of a physician, subject to the 48 corporation's determination that the mammogram is medically necessary; 49 and 50 (E) either: (i) an annual mammogram and breast ultrasound; or (ii) 51 breast tomosynthesis for covered persons with heterogeneously dense or 52 extremely dense breasts. 53 (F) The coverage required in this paragraph or paragraph two of this 54 subsection shall not be subject to annual deductibles or coinsurance. 
 S. 2395 4 1 § 6. Paragraph 1 of subsection (p) of section 4303 of the insurance 2 law, as amended by chapter 424 of the laws of 2024, is amended to read 3 as follows: 4 (1) A medical expense indemnity corporation, a hospital service corpo- 5 ration or a health service corporation that provides coverage for hospi- 6 tal, surgical or medical care shall provide the following coverage for 7 mammography screening for occult breast cancer: 8 (A) upon the recommendation of a physician, a mammogram, which may be 9 provided by breast tomosynthesis, at any age for covered persons having 10 a prior history of breast cancer or who have a first degree relative 11 with a prior history of breast cancer; 12 (B) a single baseline mammogram, which may be provided by breast tomo- 13 synthesis, for covered persons aged thirty-five through thirty-nine, 14 inclusive; 15 (C) an annual mammogram, which may be provided by breast tomosythesis, 16 for covered persons aged forty and older; 17 (D) for large group contracts offered by a medical expense indemnity 18 corporation, a hospital service corporation or a health service corpo- 19 ration that provide coverage for hospital, surgical or medical care, an 20 annual mammogram for covered persons aged thirty-five through thirty- 21 nine, inclusive, upon the recommendation of a physician, subject to the 22 corporation's determination that the mammogram is medically necessary; 23 (E) upon the recommendation of a physician, screening and diagnostic 24 imaging, including diagnostic mammograms, breast ultrasounds, or magnet- 25 ic resonance imaging, recommended by nationally recognized clinical 26 practice guidelines for the detection of breast cancer. For the purposes 27 of this subparagraph, "nationally recognized clinical practice guide- 28 lines" means evidence-based clinical practice guidelines informed by a 29 systematic review of evidence and an assessment of the benefits, and 30 risks of alternative care options intended to optimize patient care 31 developed by independent organizations or medical professional societies 32 utilizing a transparent methodology and reporting structure and with a 33 conflict of interest policy; and 34 (F) either: (i) an annual mammogram and breast ultrasound; or (ii) 35 breast tomosynthesis for covered persons with heterogeneously dense or 36 extremely dense breasts. 37 (G) The coverage required in this paragraph or paragraph two of this 38 subsection shall not be subject to annual deductibles or coinsurance. If 39 under federal law, application of this requirement would result in 40 health savings account ineligibility under 26 USC 223, this requirement 41 shall apply for health savings account-qualified high deductible health 42 plans with respect to the deductible of such a plan after the enrollee 43 has satisfied the minimum deductible under 26 USC 223, except for with 44 respect to items or services that are preventive care pursuant to 26 USC 45 223(c)(2)(C), in which case the requirements of this paragraph shall 46 apply regardless of whether the minimum deductible under 26 USC 223 has 47 been satisfied. 48 § 7. This act shall take effect on the sixtieth day after it shall 49 have become a law and shall apply to all policies and contracts issued, 50 renewed, modified, altered or amended on or after such date; provided, 51 however, sections two, four, and six of this act shall take effect on 52 the same date and in the same manner as sections 1, 3 and 5, respective- 53 ly, of chapter 424 of the laws of 2024, takes effect.