Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 79 - INSURANCE POLICIES GENERALLY (§§ 23-79-101 — 23-79-2802) › Subchapter 1 - GENERAL PROVISIONS (§§ 23-79-101 — 23-79-168) › Section 23-79-140 - Coverage for mammograms and breast ultrasounds - Definitions

(a)
As used in this section:
(1)
"Breast magnetic resonance imaging" means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast;
(2)
"Breast ultrasound" means a noninvasive, diagnostic imaging technique that uses high-frequency sound waves to produce detailed images of the breast;
(3)
"Cost-sharing requirement" means a deductible, coinsurance, copayment, and any maximum limitation on the application of a deductible, coinsurance, copayment, or similar out-of-pocket expense under a health benefit plan;
(4)
"Diagnostic examination for breast cancer" means a medically necessary and appropriate examination, as determined by a clinician who is evaluating the individual for breast cancer, to evaluate the abnormality in the breast that is:
(A)
Seen or suspected from a screening examination for breast cancer;
(B)
Detected by another means of examination; or
(C)
Suspected based on the medical history or family medical history of the individual;
(5)
"Diagnostic mammography" means a diagnostic tool that:
(A)
Uses X-ray; and
(B)
Is designed to evaluate an abnormality in a breast;
(6)
"Examination for breast cancer" means an examination used to evaluate an abnormality in a breast using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound;
(7)
(A)
"Health benefit plan" means an individual, blanket, or any group plan, policy, or contract for healthcare services issued, renewed, or extended in this state by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state.
(B)
"Health benefit plan" includes:
(i)
Indemnity and managed care plans; and
(ii)
Plans providing health benefits to state and public school employees under §
21-5-401
et seq.
(C)
"Health benefit plan" does not include:
(i)
A plan that provides only dental benefits or eye and vision care benefits;
(ii)
A disability income plan;
(iii)
A credit insurance plan;
(iv)
Insurance coverage issued as a supplement to liability insurance;
(v)
Medical payments under an automobile or homeowners insurance plan;
(vi)
A health benefit plan provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, §
11-9-101
et seq., and the Public Employee Workers' Compensation Act, §
21-5-601
et seq.;
(vii)
A plan that provides only indemnity for hospital confinement;
(viii)
An accident-only plan; or
(ix)
A specified disease plan;
(8)
(A)
"Healthcare insurer" means any insurance company, hospital and medical service corporation, or health maintenance organization that issues or delivers health benefit plans in this state and is subject to any of the following laws:
(i)
The insurance laws of this state;
(ii)
Section
23-75-101
et seq., pertaining to hospital and medical service corporations; or
(iii)
Section
23-76-101
et seq., pertaining to health maintenance organizations.
(B)
"Healthcare insurer" does not include an entity that provides only dental benefits or eye and vision care benefits;
(9)
"Mammography" means radiography of the breast; and
(10)
(A)
"Screening mammography", including digital breast tomosynthesis, means a radiologic procedure provided to a woman, who has no signs or symptoms of breast cancer, for the purpose of early detection of breast cancer.
(B)
The procedure entails at least two (2) views of each breast and includes a radiologist's interpretation of the results of the procedure.
(b)
(1)
Every healthcare insurer in this state shall offer as an essential health benefit, coverage for screening mammography for the diagnosis of breast disease such as cancer and the evaluation of dense breast tissue:
(A)
A baseline mammogram for an insured woman who is thirty-five to forty (35-40) years of age;
(B)
An annual mammogram for an insured woman who is forty (40) years of age or older;
(C)
Upon recommendation of a woman's physician, without regard to age, when the woman has had a prior history of breast cancer, when the woman's mother, sister, or any first- or second-degree female relative of the woman has had a history of breast cancer, positive genetic testing, or other risk factors; and
(D)
A complete breast ultrasound if a mammogram screening demonstrates heterogeneously dense or extremely dense breast tissue and the woman's primary healthcare provider or radiologist determines an ultrasound screening is medically necessary.
(2)
Insurance coverage for screening mammograms under a health benefit plan, including digital breast tomosynthesis, and breast ultrasounds shall not prejudice coverage for diagnostic mammograms or breast ultrasounds, as recommended by the woman's physician.
(3)
A fully insured large group insurer that issues, renews, or extends a health benefit plan in this state shall also provide coverage for an optional screening mammography and breast ultrasound benefit as described under subdivision (b)(1) of this section.
(c)
A healthcare insurer shall not pay for mammographies performed in an unaccredited facility after January 1, 1990.
(d)
(1)
After January 1, 2014, a healthcare insurer shall use the Healthcare Common Procedure Coding System G code for digital mammography services or the Current Procedural Terminology code as established for digital mammography and listed in the most recent annual edition of Current Procedural Terminology published by the American Medical Association.
(2)
The codes used for digital mammography services described in subdivision (d)(1) of this section shall be reimbursed at a minimum of one and five-tenths (1.5) times the Medicare reimbursement rate.
(e)
(1)
Benefits under this section are subject to any health benefit plan provisions that apply to other services covered by the health benefit plan, except that a health benefit plan shall not impose a copayment or deductible for a screening mammogram.
(2)
A breast ultrasound shall not be subject to a deductible or any applicable copayment.
(3)
A healthcare insurer shall ensure that an individual's cost-sharing requirement under a health benefit plan that is applicable to a diagnostic examination for breast cancer, including breast magnetic resonance imaging, is no less favorable than the cost-sharing requirement that is applicable to a screening examination for breast cancer.
Amended by Act 2021, No. 553,§ 1, eff. 7/28/2021.
Amended by Act 2019, No. 477,§ 1, eff. 7/24/2019.
Amended by Act 2017, No. 708,§ 5, eff. 8/1/2017.
Amended by Act 2017, No. 708,§ 4, eff. 8/1/2017.
Amended by Act 2017, No. 708,§ 3, eff. 8/1/2017.
Amended by Act 2017, No. 708,§ 2, eff. 8/1/2017.
Amended by Act 2017, No. 708,§ 1, eff. 8/1/2017.
Amended by Act 2017, No. 500,§ 2, eff. 3/15/2017.
Amended by Act 2013, No. 1259,§ 2, eff. 8/16/2013.
Acts 1989, No. 292, §§ 2-4, 6; 1995, No. 508, § 2; 2001, No. 1604, § 104.