Iowa Code § 514C.4A — IA Code / Title XIII / Chapter 514C / Section 514C.4A
Supplemental and diagnostic breast examinations.
Status: in_force

(1) As used in this section, unless the context otherwise requires:

(1) (a) “Breast magnetic resonance imaging” or “breast MRI” means an examination of a breast, following administration of intravenous contrast, using a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.

(1) (b) “Breast ultrasound” means a noninvasive examination of a breast using high-frequency sound waves to produce detailed images of the breast.

(1) (c) “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.

(1) (d) “Diagnostic breast examination” means a medically necessary and appropriate examination of the breast that may include a diagnostic mammogram, breast magnetic resonance imaging, breast ultrasound, or other breast imaging, and that is performed for any of the following reasons:

(1) (d) To evaluate an abnormality seen or suspected during a screening examination for breast cancer.

(1) (d) To evaluate an abnormality detected by another means of examination.

(1) (e) “Diagnostic mammogram” means a detailed examination of a breast abnormality using X ray.

(1) (f) “Health care professional” means the same as defined in section 514J.102.

(1) (g) “Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

(1) (h) “Screening mammogram” means an examination of a breast that aids in the early detection and diagnosis of breast abnormalities including breast cancer.

(1) (i) “Supplemental breast examination” means a medically necessary and appropriate examination of the breast that may include breast magnetic resonance imaging, breast ultrasound, contrast-enhanced mammography, or examination for dense breast tissue as described by the breast imaging reporting and data system of the American college of radiology, and that is performed to screen for breast cancer when there is no abnormality seen or suspected and based on an individual’s personal or family medical history, or additional factors that may increase the individual’s risk of breast cancer.

(2) (a) Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall provide coverage for supplemental breast examinations and diagnostic breast examinations.

(2) (b) Coverage required under this section shall not be less favorable than coverage a health carrier offers for screening mammograms.

(3) (a) This section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2025:

(3) (a) Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.

(3) (a) An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.

(3) (a) An individual or group health maintenance organization contract regulated under chapter 514B.

(3) (a) A plan established for public employees pursuant to chapter 509A.

(3) (b) This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.

(4) The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.

2024 Acts, ch 1115, §1