2025 Pennsylvania Consolidated & Unconsolidated Statutes
Act 52 - INSURANCE COMPANY LAW OF 1921 - COVERAGE FOR MAMMOGRAPHIC EXAMINATIONS, MAGNETIC RESONANCE IMAGING AND OTHER FORMS OF BREAST IMAGING AND REPEAL
Session of 2025
No. 2025-52
SB 88
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An act relating to insurance; amending, revising, and consolidating the law providing for the incorporation of insurance companies, and the regulation, supervision, and protection of home and foreign insurance companies, Lloyds associations, reciprocal and inter-insurance exchanges, and fire insurance rating bureaus, and the regulation and supervision of insurance carried by such companies, associations, and exchanges, including insurance carried by the State Workmen's Insurance Fund; providing penalties; and repealing existing laws," in casualty insurance, repealing provisions relating to coverage for mammographic examinations and breast imaging and providing for coverage for mammographic examinations, magnetic resonance imaging and other forms of breast imaging.
The General Assembly of the Commonwealth of Pennsylvania hereby enacts as follows:
Section 1. Section 632 of the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, is repealed:
[Section 632. Coverage for Mammographic Examinations and Breast Imaging.--(a) All group or individual health or sickness or accident insurance policies providing hospital or medical/surgical coverage and all group or individual subscriber contracts or certificates issued by any entity subject to 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations), this act, the act of December 29, 1972 (P.L.1701, No.364), known as the "Health Maintenance Organization Act," the act of July 29, 1977 (P.L.105, No.38), known as the "Fraternal Benefit Society Code," or an employe welfare benefit plan as defined in section 3 of the Employee Retirement Income Security Act of 1974 (Public Law 93-406, 29 U.S.C. § 1001 et seq.) providing hospital or medical/surgical coverage shall also provide coverage for mammographic examinations. The minimum coverage required shall include all costs associated with a mammogram every year for women 40 years of age or older, with any mammogram based on a physician's recommendation for women under 40 years of age. Prior to payment for a screening mammogram, insurers shall verify that the screening mammography service provider is properly licensed by the department in accordance with the act of July 9, 1992 (P.L.449, No.93), known as the "Mammography Quality Assurance Act." Nothing in this section shall be construed to require an insurer to cover the surgical procedure known as mastectomy or to prevent application of deductible or copayment provisions contained in the policy or plan except as preempted by Federal Law.
(b) A group or individual health or sickness or accident insurance policy providing hospital or medical/surgical coverage and a group or individual subscriber contract or certificate issued by any entity subject to 40 Pa.C.S. Ch. 61 or 63, this act, the "Health Maintenance Organization Act," the "Fraternal Benefit Society Code" or an employe welfare benefit plan as defined in section 3 of the Employee Retirement Income Security Act of 1974 providing hospital or medical/surgical coverage shall also provide coverage for breast imaging. The minimum coverage required shall include all costs associated with one supplemental breast screening every year because the woman is believed to be at an increased risk of breast cancer due to:
(1) personal history of atypical breast histologies;
(2) personal history or family history of breast cancer;
(3) genetic predisposition for breast cancer;
(4) prior therapeutic thoracic radiation therapy;
(5) heterogeneously dense breast tissue based on breast composition categories with any one of the following risk factors:
(i) lifetime risk of breast cancer of greater than 20%, according to risk assessment tools based on family history;
(ii) personal history of BRCA1 or BRCA2 gene mutations;
(iii) first-degree relative with a BRCA1 or BRCA2 gene mutation but not having had genetic testing herself;
(iv) prior therapeutic thoracic radiation therapy between 10 and 30 years of age; or
(v) personal history of Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree relative with one of these syndromes; or
(6) extremely dense breast tissue based on breast composition categories.
Nothing in this subsection shall be construed as to preclude utilization review as provided under Article XXI of this act or to prevent the application of deductible, copayment or coinsurance provisions contained in the policy or plan for breast imaging in excess of the minimum coverage required.
(c) This section shall not apply to the following types of policies:
(1) Accident only.
(2) Limited benefit.
(3) Credit.
(4) Dental.
(5) Vision.
(6) Specified disease.
(7) Medicare supplement.
(8) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.
(9) Long-term care or disability income.
(10) Workers' compensation.
(11) Automobile medical payment.
(12) Fixed indemnity.
(13) Hospital indemnity.
(d) As used in this section:
"Supplemental breast screening" means a medically necessary and clinically appropriate examination of the breast using either standard or abbreviated magnetic resonance imaging or, if such imaging is not possible, ultrasound if recommended by the treating physician to screen for breast cancer when there is no abnormality seen or suspected in the breast.]
Section 2. The act is amended by adding a section to read:
Section 632.1. Coverage for Mammographic Examinations, Magnetic Resonance Imaging and Other Forms of Breast Imaging.--(a) A health insurance policy offered, issued or renewed in this Commonwealth shall provide, as a minimum requirement for a covered person under the policy, coverage without cost sharing for the following services:
(1) Mammographic examinations as follows:
(i) A mammographic examination for a covered person 40 years of age or older.
(ii) A mammographic examination for a covered person under 40 years of age upon the recommendation of the covered person's physician.
(2) Supplemental breast screenings for a covered person whose risk level for breast cancer is determined to be at least average risk or higher.
(3) Diagnostic breast examinations for a covered person whose risk level for breast cancer is determined to be at least average risk or higher.
(b) The coverage required under subsection (a) shall be subject to the following:
(1) Article XXI.
(2) The terms and conditions of the health insurance policy, provided such terms and conditions are consistent with this section.
(3) Applicable Federal law and regulations.
(c) Prior to payment for a mammographic examination under this section, an insurer shall verify that the facility providing the mammogram is properly certified under 42 U.S.C. § 263b (relating to certification of mammography facilities).
(d) Nothing in this section shall be construed to:
(1) Preclude an insurer from applying utilization review under Article XXI.
(2) Prevent the application of deductible, copayment or coinsurance provisions for breast imaging services beyond the minimum coverage required under subsection (a).
(3) Require an insurer to cover a surgical procedure known as mastectomy.
(e) The following shall apply:
(1) Except as provided under paragraph (2), the terms in this section shall have the same meanings as provided in section 2102.
(2) As used in this section, the following words and phrases shall have the meanings given to them in this paragraph unless the context clearly indicates otherwise:
"Average risk" means a covered person who meets all of the following criteria:
(i) Has, based on clinical review criteria, a 15% or less lifetime risk of being diagnosed with breast cancer during the covered person's lifetime.
(ii) Has no personal history of breast cancer.
(iii) Has no family history of breast cancer.
(iv) Has no known BRCA gene mutation.
(v) Has no history of radiation therapy before 30 years of age.
(vi) Has no personal history of atypical breast histologies.
(vii) Has not undergone prior therapeutic thoracic radiation therapy.
(viii) Does not have heterogeneously dense or extremely dense breast tissue.
(ix) Does not have a personal history of Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree relative with one of these syndromes.
"Diagnostic breast examination" means a medically necessary and clinically appropriate examination of the breast using diagnostic mammography, standard or abbreviated breast magnetic resonance imaging or breast ultrasound when an abnormality is seen or suspected.
"Supplemental breast screening" means a medically necessary and clinically appropriate examination of the breast using either standard or abbreviated magnetic resonance imaging or, if such imaging is not possible, ultrasound, if recommended by the treating physician, to screen for breast cancer when no abnormality is seen or suspected.
Section 3. This act shall apply as follows:
(1) For health insurance policies for which either rates or forms are required to be filed by the Federal Government or the Insurance Department, this act shall apply to any policy for which a form or rate is first filed on or after 180 days after the effective date of this paragraph.
(2) For health insurance policies for which neither rates nor forms are required to be filed with the Federal Government or the Insurance Department, this act shall apply to any policy issued or renewed on or after 180 days after the effective date of this paragraph.
Section 4. This act shall take effect in 60 days.
APPROVED--The 24th day of November, A.D. 2025.
JOSH SHAPIRO
