2025 SESSION

INTRODUCED

25102295D

HOUSE BILL NO. 2133

Offered January 13, 2025

Prefiled January 7, 2025

A BILL to amend the Code of Virginia by adding a section numbered 38.2-3418.1:3, relating to health insurance; coverage for breast examinations for high-risk individuals.

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Patrons—Keys-Gamarra, Askew, Clark, Cousins, Feggans, Hernandez, Hope, LeVere Bolling, Martinez and Shin

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Referred to Committee on Labor and Commerce

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Be it enacted by the General Assembly of Virginia:

1. That the Code of Virginia is amended by adding a section numbered 38.2-3418.1:3 as follows:

§ 38.2-3418.1:3. Coverage for breast examinations for high-risk individuals.

A. Notwithstanding the provisions of § 38.2-3419 or subdivision A 1 of § 38.2-6506, and in addition to the coverage required by § 38.2-3418.1, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, each corporation providing individual or group accident and sickness subscription contracts, and each health maintenance organization providing a health care plan for health care services shall provide coverage without cost sharing for diagnostic breast examinations and supplemental breast examinations based on sound medical practices for any high-risk individual under such policy, contract, or plan delivered, issued for delivery, or renewed in the Commonwealth.

B. As used in this section:

"Cost sharing" means any coinsurance, copayment, or deductible.

"Diagnostic breast examination" means a medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network Guidelines, examination of the breast, including such an examination using a health care provider's choice of diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound, that is used to evaluate (i) an abnormality seen or suspected from a screening for the detection of breast cancer or (ii) an abnormality detected by another means of examination.

"High-risk individual" means an individual who (i) is at increased risk of breast cancer, as determined in accordance with the most recent applicable American College of Radiology Appropriateness Criteria or the most recent applicable National Comprehensive Cancer Network Guidelines, (ii) is diagnosed with heterogeneously or extremely dense breast tissue, as defined by the Breast Imaging Reporting and Data System established by the American College of Radiology, or (iii) is not described in clauses (i) or (ii) and is determined by a health care provider, in accordance with such applicable criteria or guidelines, to require diagnostic or supplemental breast examination due to factors including age, race, ethnicity, or personal or family medical history.

"Supplemental breast examination" means a medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network Guidelines, examination of the breast, including such an examination using a health care provider's choice of diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound, that is (i) used to screen for breast cancer when there is no abnormality seen or suspected and (ii) based on personal or family medical history or additional factors that may increase the individual's risk of breast cancer.

C. The provisions of this section shall not apply to short-term travel, accident-only, or limited or specified disease policies, or to short-term nonrenewable policies of not more than six months' duration.

2. That the provisions of this act shall apply to any individual or group accident and sickness insurance policy, any individual or group accident and sickness subscription contract, and any health care plan for health care services delivered, issued for delivery, or renewed in the Commonwealth on and after January 1, 2026.