Fort Wayne, IN asked in Health Care Law for Indiana

Q: Must health insurance providers pay for mammograms in Indiana?

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1 Lawyer Answer
Burton A. Padove
Burton A. Padove
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  • Highland, IN
  • Licensed in Indiana

A: Here you go:

IC 27-8-14-6

Breast cancer screening mammography; coverage

Sec. 6. (a) Except as provided in subsection (f), an insurer must

provide coverage for breast cancer screening mammography in any accident and sickness insurance policy that the insurer issues in Indiana.

(b) Except as provided in subsection (f), the coverage that an insurer must provide under this section must include the following:

(1) If the insured is at least thirty-five (35) but less than forty (40) years of age, coverage for at least one (1) baseline breast cancer screening mammography performed upon the insured before she becomes forty (40) years of age.

(2) If the insured is:

(A) less than forty (40) years of age; and

(B) a woman at risk;

one (1) breast cancer screening mammography performed upon the insured every year.

(3) If the insured is at least forty (40) years of age, one (1) breast cancer screening mammography performed upon the insured every year.

(4) Any additional mammography views that are required for proper evaluation.

(5) Ultrasound services, if determined medically necessary by the physician treating the insured.

(c) Except as provided in subsection (f), the coverage that an insurer must provide under this section must provide reimbursement for breast cancer screening mammography at a level at least as high as:

(1) the limitation on payment for screening mammography services established in 42 CFR 405.534(b)(3) according to the Medicare Economic Index at the time the breast cancer screening mammography is performed; or

(2) the rate negotiated by a contract provider according to the provisions of the insurance policy;

whichever is lower.

(d) Except as provided in subsection (f), the coverage that an insurer must provide under this section may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to the insured than the dollar limits, deductibles, or coinsurance provisions applying to physical illness generally under the accident and sickness insurance policy.

(e) Except as provided in subsection (f), the coverage that an insurer must provide is in addition to any benefits specifically provided for x-rays, laboratory testing, or wellness examinations.

(f) In the case of insurance policies that are not employer based, the insurer must offer to provide the coverage described in subsections (a) through (e).

As added by P.L.119-1991, SEC.3. Amended by P.L.170-1999, SEC.3.

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