SB 88 — An Act amending the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, 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.

PRINTER'S NO.   915

                     THE GENERAL ASSEMBLY OF PENNSYLVANIA



                        SENATE BILL
                        No. 88
                                               Session of
                                                 2025

     INTRODUCED BY FARRY, K. WARD, PENNYCUICK, ROBINSON, BARTOLOTTA,
        LAUGHLIN, SANTARSIERO, J. WARD, COSTA, HAYWOOD, FONTANA,
        COMITTA, STEFANO, ARGALL, CULVER, HUTCHINSON, BAKER, ROTHMAN,
        LANGERHOLC, MASTRIANO, TARTAGLIONE, BROWN, STREET, BROOKS,
        SAVAL, PICOZZI, L. WILLIAMS, KANE, PHILLIPS-HILL, FLYNN,
        MARTIN, SCHWANK, GEBHARD, KIM, VOGEL, KEARNEY, YAW AND
        BOSCOLA, JUNE 6, 2025

     REFERRED TO BANKING AND INSURANCE, JUNE 6, 2025


                                    AN ACT
 1   Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
 2      act relating to insurance; amending, revising, and
 3      consolidating the law providing for the incorporation of
 4      insurance companies, and the regulation, supervision, and
 5      protection of home and foreign insurance companies, Lloyds
 6      associations, reciprocal and inter-insurance exchanges, and
 7      fire insurance rating bureaus, and the regulation and
 8      supervision of insurance carried by such companies,
 9      associations, and exchanges, including insurance carried by
10      the State Workmen's Insurance Fund; providing penalties; and
11      repealing existing laws," in casualty insurance, repealing
12      provisions relating to coverage for mammographic examinations
13      and breast imaging and providing for coverage for
14      mammographic examinations, magnetic resonance imaging and
15      other forms of breast imaging.
16      The General Assembly of the Commonwealth of Pennsylvania
17   hereby enacts as follows:
18      Section 1.    Section 632 of the act of May 17, 1921 (P.L.682,
19   No.284), known as The Insurance Company Law of 1921, is
20   repealed:
21      [Section 632.    Coverage for Mammographic Examinations and
22   Breast Imaging.--(a)    All group or individual health or sickness
 1   or accident insurance policies providing hospital or
 2   medical/surgical coverage and all group or individual subscriber
 3   contracts or certificates issued by any entity subject to 40
 4   Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63
 5   (relating to professional health services plan corporations),
 6   this act, the act of December 29, 1972 (P.L.1701, No.364), known
 7   as the "Health Maintenance Organization Act," the act of July
 8   29, 1977 (P.L.105, No.38), known as the "Fraternal Benefit
 9   Society Code," or an employe welfare benefit plan as defined in
10   section 3 of the Employee Retirement Income Security Act of 1974
11   (Public Law 93-406, 29 U.S.C. § 1001 et seq.) providing hospital
12   or medical/surgical coverage shall also provide coverage for
13   mammographic examinations. The minimum coverage required shall
14   include all costs associated with a mammogram every year for
15   women 40 years of age or older, with any mammogram based on a
16   physician's recommendation for women under 40 years of age.
17   Prior to payment for a screening mammogram, insurers shall
18   verify that the screening mammography service provider is
19   properly licensed by the department in accordance with the act
20   of July 9, 1992 (P.L.449, No.93), known as the "Mammography
21   Quality Assurance Act." Nothing in this section shall be
22   construed to require an insurer to cover the surgical procedure
23   known as mastectomy or to prevent application of deductible or
24   copayment provisions contained in the policy or plan except as
25   preempted by Federal Law.
26      (b)   A group or individual health or sickness or accident
27   insurance policy providing hospital or medical/surgical coverage
28   and a group or individual subscriber contract or certificate
29   issued by any entity subject to 40 Pa.C.S. Ch. 61 or 63, this
30   act, the "Health Maintenance Organization Act," the "Fraternal

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 1   Benefit Society Code" or an employe welfare benefit plan as
 2   defined in section 3 of the Employee Retirement Income Security
 3   Act of 1974 providing hospital or medical/surgical coverage
 4   shall also provide coverage for breast imaging. The minimum
 5   coverage required shall include all costs associated with one
 6   supplemental breast screening every year because the woman is
 7   believed to be at an increased risk of breast cancer due to:
 8      (1)     personal history of atypical breast histologies;
 9      (2)     personal history or family history of breast cancer;
10      (3)     genetic predisposition for breast cancer;
11      (4)     prior therapeutic thoracic radiation therapy;
12      (5)     heterogeneously dense breast tissue based on breast
13   composition categories with any one of the following risk
14   factors:
15      (i)     lifetime risk of breast cancer of greater than 20%,
16   according to risk assessment tools based on family history;
17      (ii)     personal history of BRCA1 or BRCA2 gene mutations;
18      (iii)     first-degree relative with a BRCA1 or BRCA2 gene
19   mutation but not having had genetic testing herself;
20      (iv)     prior therapeutic thoracic radiation therapy between 10
21   and 30 years of age; or
22      (v)     personal history of Li-Fraumeni syndrome, Cowden
23   syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree
24   relative with one of these syndromes; or
25      (6)     extremely dense breast tissue based on breast
26   composition categories.
27      Nothing in this subsection shall be construed as to preclude
28   utilization review as provided under Article XXI of this act or
29   to prevent the application of deductible, copayment or
30   coinsurance provisions contained in the policy or plan for

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 1   breast imaging in excess of the minimum coverage required.
 2         (c)    This section shall not apply to the following types of
 3   policies:
 4         (1)    Accident only.
 5         (2)    Limited benefit.
 6         (3)    Credit.
 7         (4)    Dental.
 8         (5)    Vision.
 9         (6)    Specified disease.
10         (7)    Medicare supplement.
11         (8)    Civilian Health and Medical Program of the Uniformed
12   Services (CHAMPUS) supplement.
13         (9)    Long-term care or disability income.
14         (10)    Workers' compensation.
15         (11)    Automobile medical payment.
16         (12)    Fixed indemnity.
17         (13)    Hospital indemnity.
18         (d)    As used in this section:
19         "Supplemental breast screening" means a medically necessary
20   and clinically appropriate examination of the breast using
21   either standard or abbreviated magnetic resonance imaging or, if
22   such imaging is not possible, ultrasound if recommended by the
23   treating physician to screen for breast cancer when there is no
24   abnormality seen or suspected in the breast.]
25         Section 2.    The act is amended by adding a section to read:
26         Section 632.1.    Coverage for Mammographic Examinations,
27   Magnetic Resonance Imaging and Other Forms of Breast Imaging.--
28   (a)    A health insurance policy offered, issued or renewed in
29   this Commonwealth shall provide, as a minimum requirement for a
30   covered person under the policy, coverage without cost sharing

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 1   for the following services:
 2      (1)     Mammographic examinations as follows:
 3      (i)     An annual mammographic examination for a covered person
 4   40 years of age or older.
 5      (ii)     A mammographic examination for a covered person under
 6   40 years of age upon the recommendation of the covered person's
 7   physician.
 8      (2)     Supplemental breast screenings for a covered person
 9   whose risk level for breast cancer is determined to be at least
10   average risk or higher.
11      (3)     Diagnostic breast examinations for a covered person
12   whose risk level for breast cancer is determined to be at least
13   average risk or higher.
14      (b)     The coverage required under subsection (a) shall be
15   subject to the following:
16      (1)     Article XXI of this act.
17      (2)     The terms and conditions of the health insurance policy,
18   provided such terms and conditions are consistent with this
19   section.
20      (3)     Applicable Federal law and regulations.
21      (c)     Prior to payment for a mammographic examination under
22   this section, an insurer shall verify that the facility
23   providing the mammogram is properly certified under 42 U.S.C. §
24   263b (relating to certification of mammography facilities).
25      (d)     Nothing in this section shall be construed to:
26      (1)     Preclude an insurer from applying utilization review
27   under Article XXI of this act.
28      (2)     Prevent the application of deductible, copayment or
29   coinsurance provisions for breast imaging services beyond the
30   minimum coverage required under subsection (a).

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 1      (3)     Require an insurer to cover a surgical procedure known
 2   as mastectomy.
 3      (4)     Prohibit the application of deductible or copayment
 4   provisions contained in a policy or plan, except as preempted by
 5   Federal law.
 6      (e)     The following shall apply:
 7      (1)     Except as provided under paragraph (2), the terms in
 8   this section shall have the same meanings as provided in section
 9   2102.
10      (2)     As used in this section, the following words and phrases
11   shall have the meanings given to them in this paragraph unless
12   the context clearly indicates otherwise:
13      "Average risk" means a covered person who meets all of the
14   following criteria:
15      (i)     Has, based on clinical review criteria, a 15% or less
16   lifetime risk of being diagnosed with breast cancer during the
17   covered person's lifetime.
18      (ii)     Has no personal history of breast cancer.
19      (iii)     Has no family history of breast cancer.
20      (iv)     Has no known BRCA gene mutation.
21      (v)     Has no history of radiation therapy before 30 years of
22   age.
23      (vi)     Has no personal history of atypical breast histologies.
24      (vii)     Has not undergone prior therapeutic thoracic radiation
25   therapy.
26      (viii)     Does not have heterogeneously dense or extremely
27   dense breast tissue.
28      (ix)     Does not have a personal history of Li-Fraumeni
29   syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome
30   or a first-degree relative with one of these syndromes.

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 1      "Diagnostic breast examination" means a medically necessary
 2   and clinically appropriate examination of the breast using
 3   diagnostic mammography, standard or abbreviated breast magnetic
 4   resonance imaging or breast ultrasound when an abnormality is
 5   seen or suspected.
 6      "Supplemental breast screening" means a medically necessary
 7   and clinically appropriate examination of the breast using
 8   either standard or abbreviated magnetic resonance imaging or, if
 9   such imaging is not possible, ultrasound, if recommended by the
10   treating physician, to screen for breast cancer when no
11   abnormality is seen or suspected.
12      Section 3.   This act shall apply as follows:
13          (1)   For health insurance policies for which either rates
14      or forms are required to be filed by the Federal Government
15      or the Insurance Department, this act shall apply to any
16      policy for which a form or rate is first filed on or after
17      180 days after the effective date of this paragraph.
18          (2)   For health insurance policies for which neither
19      rates nor forms are required to be filed with the Federal
20      Government or the Insurance Department, this act shall apply
21      to any policy issued or renewed on or after 180 days after
22      the effective date of this paragraph.
23      Section 4.   This act shall take effect in 60 days.




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