GENERAL ASSEMBLY OF NORTH CAROLINA
1991 SESSION

CHAPTER 490
HOUSE BILL 347

AN ACT TO REQUIRE MAMMOGRAM AND PAP SMEAR COVERAGE IN HEALTH AND ACCIDENT INSURANCE POLICIES, IN HOSPITAL OR MEDICAL SERVICES PLANS, AND IN HMO PLANS.

The General Assembly of North Carolina enacts:

Section 1.  Chapter 58 of the General Statutes is amended by adding the following new section to read:
"§ 58-51-57. Coverage for mammograms and pap smears.
(a)	Every policy or contract of accident or health insurance, and every preferred provider contract, policy, or plan as defined and regulated under G.S. 58-50-50 and G.S. 58-50-55, that is issued, renewed, or amended on or after January 1, 1992, shall provide coverage for pap smears and for low-dose screening mammography.  The same deductibles, coinsurance, and other limitations as apply to similar services covered under the policy, contract, or plan shall apply to coverage for pap smears and low-dose screening mammography.
(b)	As used in this section, 'low-dose screening mammography' means a radiologic procedure for the early detection of breast cancer provided to an asymptomatic woman using equipment dedicated specifically for mammography, including a physician's interpretation of the results of the procedure.
(c)	Coverage for low-dose screening mammography shall be provided as follows:
(1)	One or more mammograms a year, as recommended by a physician, for any woman who is at risk for breast cancer.  For purposes of this subdivision, a woman is at risk for breast cancer if any one or more of the following is true:
a.	The woman has a personal history of breast cancer;
b.	The woman has a personal history of biopsy-proven benign breast disease;
c.	The woman's mother, sister, or daughter has or has had breast cancer; or
d.	The woman has not given birth prior to the age of 30;
(2)	One baseline mammogram for any woman 35 through 39 years of age, inclusive;
(3)	A mammogram every other year for any woman 40 through 49 years of age, inclusive, or more frequently upon recommendation of a physician; and
(4)	A mammogram every year for any woman 50 years of age or older.
(d)	Reimbursement for a mammogram authorized under this section shall be made only if the facility in which the mammogram was performed meets mammography accreditation standards.  Mammography accreditation standards shall be those established by the North Carolina Medical Care Commission unless such standards are not in effect, in which case standards established by the United States Department of Health and Human Services for Medicare/Medicaid coverage of screening mammography shall apply until Medical Care Commission standards become effective.  Facilities that do not meet required mammography accreditation standards shall so inform the patient or the patient's legally responsible person prior to performing the mammogram.
(e)	Coverage for pap smears shall be provided for pap smears obtained once a year, or more frequently if recommended by a physician.  Coverage shall include the examination, the laboratory fee, and the physician's interpretation of the laboratory results.  When the screening pap smear accreditation standards adopted by the North Carolina Medical Care Commission become effective, reimbursement for laboratory fees shall be made only if the laboratory meets those standards.  Facilities utilizing services of laboratories that do not meet accreditation standards for screening pap smears shall, prior to performing the pap smear examination, inform the patient or the patient's legally responsible person that such laboratory fees will not be covered."
Sec. 2.  Chapter 58 of the General Statutes is amended by adding the following new section to read:
"§ 58-65-92. Coverage for mammograms and pap smears.
(a)	Every insurance certificate or subscriber contract under any hospital service plan or medical service plan governed by this Article and Article 66 of this Chapter, and every preferred provider contract, policy, or plan as defined and regulated under G.S. 58-50-50 and G.S. 58-50-55, that is issued, renewed, or amended on or after January 1, 1992, shall provide coverage for pap smears and for low-dose screening mammography.  The same deductibles, coinsurance, and other limitations as apply to similar services covered under the certificate or contract shall apply to coverage for pap smears and low-dose screening mammography.
(b)	As used in this section, 'low-dose screening mammography' means a radiologic procedure for the early detection of breast cancer provided to an asymptomatic woman using equipment dedicated specifically for mammography, including a physician's interpretation of the results of the procedure.
(c)	Coverage for low-dose screening mammography shall be provided as follows:
(1)	One or more mammograms a year, as recommended by a physician, for any woman who is at risk for breast cancer.  For purposes of this subdivision, a woman is at risk for breast cancer if any one or more of the following is true:
a.	The woman has a personal history of breast cancer;
b.	The woman has a personal history of biopsy-proven benign breast disease;
c.	The woman's mother, sister, or daughter has or has had breast cancer; or
d.	The woman has not given birth prior to the age of 30;
(2)	One baseline mammogram for any woman 35 through 39 years of age, inclusive;
(3)	A mammogram every other year for any woman 40 through 49 years of age, inclusive, or more frequently upon recommendation of a physician; and
(4)	A mammogram every year for any woman 50 years of age or older.
(d)	Reimbursement for a mammogram authorized under this section shall be made only if the facility in which the mammogram was performed meets mammography accreditation standards.  Mammography accreditation standards shall be those established by the North Carolina Medical Care Commission unless such standards are not in effect, in which case standards established by the United States Department of Health and Human Services for Medicare/Medicaid coverage of screening mammography shall apply until Medical Care Commission standards become effective.  Facilities that do not meet required mammography accreditation standards shall so inform the patient or the patient's legally responsible person prior to performing the mammogram.
(e)	Coverage for pap smears shall be provided for pap smears obtained once a year, or more frequently if recommended by a physician.  Coverage shall include the examination, the laboratory fee, and the physician's interpretation of the laboratory results.  When the screening pap smear accreditation standards adopted by the North Carolina Medical Care Commission become effective, reimbursement for laboratory fees shall be made only if the laboratory meets those standards.  Facilities utilizing services of laboratories that do not meet accreditation standards for screening pap smears shall, prior to performing the pap smear examination, inform the patient or the patient's legally responsible person that such laboratory fees will not be covered."
Sec. 3.  Chapter 58 of the General Statutes is amended by adding the following new section to read:
"§ 58-67-76.  Coverage for mammograms and pap smears.
(a)	Every health care plan written by a health maintenance organization and in force, issued, renewed, or amended on or after January 1, 1992, that is subject to this Article, shall provide coverage for pap smears and for low-dose screening mammography.  The same deductibles, coinsurance, and other limitations as apply to similar services covered under the plan shall apply to coverage for pap smears and low-dose screening mammography.
(b)	As used in this section, 'low-dose screening mammography' means a radiologic procedure for the early detection of breast cancer provided to an asymptomatic woman using equipment dedicated specifically for mammography, including a physician's interpretation of the results of the procedure.
(c)	Coverage for low-dose screening mammography shall be provided as follows:
(1)	One or more mammograms a year, as recommended by a physician, for any woman who is determined to be at risk for breast cancer.  For purposes of this subdivision, a woman is at risk for breast cancer if any one or more of the following is true:
a.	The woman has a personal history of breast cancer;
b.	The woman has a personal history of biopsy-proven benign breast disease;
c.	The woman's mother, sister, or daughter has or has had breast cancer; or
d.	The woman has not given birth prior to the age of 30;
(2)	One baseline mammogram for any woman 35 through 39 years of age, inclusive;
(3)	A mammogram every other year for any woman 40 through 49 years of age, inclusive, or more frequently upon recommendation of a physician; and
(4)	A mammogram every year for any woman 50 years of age or older.
(d)	Reimbursement for a mammogram authorized under this section shall be made only if the facility in which the mammogram was performed meets mammography accreditation standards.  Mammography accreditation standards shall be those established by the North Carolina Medical Care Commission unless such standards are not in effect, in which case standards established by the United States Department of Health and Human Services for Medicare/Medicaid coverage of screening mammography shall apply until Medical Care Commission standards become effective.  Facilities that do not meet required mammography accreditation standards shall so inform the patient or the patient's legally responsible person prior to performing the mammogram.
(e)	Coverage for pap smears shall be provided for pap smears obtained once a year, or more frequently if recommended by a physician.  Coverage shall include the examination, the laboratory fee, and the physician's interpretation of the laboratory results.  When the screening pap smear accreditation standards adopted by the North Carolina Medical Care Commission become effective, reimbursement for laboratory fees shall be made only if the laboratory meets those standards.  Facilities utilizing services of laboratories that do not meet accreditation standards for screening pap smears shall, prior to performing the pap smear examination, inform the patient or the patient's legally responsible person that such laboratory fees will not be covered."
Sec. 4. G.S. 143B-165 is amended by adding the following new subdivision to read:
"(12)	The Commission shall adopt rules, including temporary rules pursuant to G.S. 150B-13, providing for the accreditation of facilities that perform mammography procedures and for laboratories evaluating screening pap smears.  Mammography accreditation standards shall address, but are not limited to, the quality of mammography equipment used and the skill levels and other qualifications of personnel who administer mammographies and personnel who interpret mammogram results.  The Commission's standards shall be no less stringent than those established by the United States Department of Health and Human Services for Medicare/Medicaid coverage of screening mammography.  These rules shall also specify procedures for waiver of these accreditation standards on an individual basis for any facility providing screening mammography to a significant number of patients, but only if there is no accredited facility located nearby.  The Commission may grant a waiver subject to any conditions it deems necessary to protect the health and safety of patients, including requiring the facility to submit a plan to meet accreditation standards."
Sec. 5.  If House Bill 1037, 1991 Session, is ratified Chapter 58 of the General Statutes is amended by adding the following new section to read:
"§ 58-50-155.  Standard and basic health care plan coverages.
(a)	Notwithstanding G.S. 58-50-125(c), the standard health plan developed and approved under G.S. 58-50-125 shall provide coverage for mammograms and pap smears at least equal to the coverage required by G.S. 58-51-57.
(b)	Notwithstanding G.S. 58-50-125(c), in developing and approving the plans under G.S. 58-50-125, the Committee and Commissioner shall give due consideration to cost-effective and life-saving health care services and to cost-effective health care providers.  This section shall be effective after the ratification date of H.B. 1037."
Sec. 6.  G.S. 58-54-10 is amended by adding the following new subsection to read:
"(e)	Notwithstanding coverage provided by Medicare for mammograms and pap smears, every policy in force in this State shall provide coverage at least equal to the coverage required by G.S. 58-51-57."
Sec. 7.  Nothing in this act shall apply to specified accident, specified disease, hospital indemnity, or long-term care health insurance policies.
Sec. 8.  Section 5 of this act becomes effective January 1, 1992.  The remainder of this act is effective upon ratification.
In the General Assembly read three times and ratified this the 2nd day of July, 1991.

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James C. Gardner
President of the Senate

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Daniel Blue, Jr.
Speaker of the House of Representatives