Requires health insurance coverage for mammography by either mammogram and breast ultrasound or breast tomosynthesis for persons with heterogeneously dense or extremely dense breasts.
STATE OF NEW YORK
________________________________________________________________________
2395
2025-2026 Regular Sessions
IN SENATE
January 17, 2025
___________
Introduced by Sen. PERSAUD -- read twice and ordered printed, and when
printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to requiring health
insurance coverage for mammography by either mammogram and breast
ultrasound or breast tomosynthesis for persons with certain breast
densities
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subparagraph (A) of paragraph 11 of subsection (i) of
2 section 3216 of the insurance law, as amended by chapter 414 of the laws
3 of 2017, is amended to read as follows:
4 (A) Every policy that provides coverage for hospital, surgical or
5 medical care shall provide the following coverage for mammography
6 screening for occult breast cancer:
7 (i) upon the recommendation of a physician, a mammogram, which may be
8 provided by breast tomosynthesis, at any age for covered persons having
9 a prior history of breast cancer or who have a first degree relative
10 with a prior history of breast cancer;
11 (ii) a single baseline mammogram, which may be provided by breast
12 tomosynthesis, for covered persons aged thirty-five through thirty-nine,
13 inclusive; [and]
14 (iii) an annual mammogram, which may be provided by breast tomosynthe-
15 sis, for covered persons aged forty and older; and
16 (iv) either: a. an annual mammogram and breast ultrasound; or b.
17 breast tomosynthesis for covered persons with heterogeneously dense or
18 extremely dense breasts.
19 § 2. Subparagraph (A) of paragraph 11 of subsection (i) of section
20 3216 of the insurance law, as amended by chapter 424 of the laws of
21 2024, is amended to read as follows:
22 (A) Every policy that provides coverage for hospital, surgical or
23 medical care shall provide the following coverage for mammography
24 screening for occult breast cancer:
25 (i) upon the recommendation of a physician, a mammogram, which may be
26 provided by breast tomosynthesis, at any age for covered persons having
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD06157-01-5
S. 2395 2
1 a prior history of breast cancer or who have a first degree relative
2 with a prior history of breast cancer;
3 (ii) a single baseline mammogram, which may be provided by breast
4 tomosynthesis, for covered persons aged thirty-five through thirty-nine,
5 inclusive;
6 (iii) an annual mammogram, which may be provided by breast tomosynthe-
7 sis, for covered persons aged forty and older; [and]
8 (iv) upon the recommendation of a physician, screening and diagnostic
9 imaging, including diagnostic mammograms, breast ultrasounds, or magnet-
10 ic resonance imaging, recommended by nationally recognized clinical
11 practice guidelines for the detection of breast cancer. For the purposes
12 of this item, "nationally recognized clinical practice guidelines" means
13 evidence-based clinical practice guidelines informed by a systematic
14 review of evidence and an assessment of the benefits, and risks of
15 alternative care options intended to optimize patient care developed by
16 independent organizations or medical professional societies utilizing a
17 transparent methodology and reporting structure and with a conflict of
18 interest policy; and
19 (v) either: a. an annual mammogram and breast ultrasound; or b. breast
20 tomosynthesis for covered persons with heterogeneously dense or extreme-
21 ly dense breasts.
22 § 3. Subparagraph (A) of paragraph 11 of subsection (l) of section
23 3221 of the insurance law, as amended by chapter 143 of the laws of
24 2019, is amended to read as follows:
25 (A) Every insurer delivering a group or blanket policy or issuing a
26 group or blanket policy for delivery in this state that provides cover-
27 age for hospital, surgical or medical care shall provide the following
28 coverage for mammography screening for occult breast cancer:
29 (i) upon the recommendation of a physician, a mammogram, which may be
30 provided by breast tomosynthesis, at any age for covered persons having
31 a prior history of breast cancer or who have a first degree relative
32 with a prior history of breast cancer;
33 (ii) a single baseline mammogram, which may be provided by breast
34 tomosynthesis, for covered persons aged thirty-five through thirty-nine,
35 inclusive;
36 (iii) an annual mammogram, which may be provided by breast tomosynthe-
37 sis, for covered persons aged forty and older; [and]
38 (iv) for large group policies that provide coverage for hospital,
39 surgical or medical care, an annual mammogram for covered persons aged
40 thirty-five through thirty-nine, inclusive, upon the recommendation of a
41 physician, subject to the insurer's determination that the mammogram is
42 medically necessary; and
43 (v) either: a. an annual mammogram and breast ultrasound; or b. breast
44 tomosynthesis for covered persons with heterogeneously dense or extreme-
45 ly dense breasts.
46 § 4. Subparagraph (A) of paragraph 11 of subsection (l) of section
47 3221 of the insurance law, as amended by chapter 424 of the laws of
48 2024, is amended to read as follows:
49 (A) Every insurer delivering a group or blanket policy or issuing a
50 group or blanket policy for delivery in this state that provides cover-
51 age for hospital, surgical or medical care shall provide the following
52 coverage for mammography screening for occult breast cancer:
53 (i) upon the recommendation of a physician, a mammogram, which may be
54 provided by breast tomosynthesis, at any age for covered persons having
55 a prior history of breast cancer or who have a first degree relative
56 with a prior history of breast cancer;
S. 2395 3
1 (ii) a single baseline mammogram, which may be provided by breast
2 tomosynthesis, for covered persons aged thirty-five through thirty-nine,
3 inclusive;
4 (iii) an annual mammogram, which may be provided by breast tomosynthe-
5 sis, for covered persons aged forty and older;
6 (iv) for large group policies that provide coverage for hospital,
7 surgical or medical care, an annual mammogram for covered persons aged
8 thirty-five through thirty-nine, inclusive, upon the recommendation of a
9 physician, subject to the insurer's determination that the mammogram is
10 medically necessary; [and]
11 (v) upon the recommendation of a physician, screening and diagnostic
12 imaging, including diagnostic mammograms, breast ultrasounds, or magnet-
13 ic resonance imaging, recommended by nationally recognized clinical
14 practice guidelines for the detection of breast cancer. For the purposes
15 of this item, "nationally recognized clinical practice guidelines" means
16 evidence-based clinical practice guidelines informed by a systematic
17 review of evidence and an assessment of the benefits, and risks of
18 alternative care options intended to optimize patient care developed by
19 independent organizations or medical professional societies utilizing a
20 transparent methodology and reporting structure and with a conflict of
21 interest policy; and
22 (vi) either: a. an annual mammogram and breast ultrasound; or b.
23 breast tomosynthesis for covered persons with heterogeneously dense or
24 extremely dense breasts.
25 § 5. Paragraph 1 of subsection (p) of section 4303 of the insurance
26 law, as amended by chapter 219 of the laws of 2011, subparagraph (A) as
27 amended by chapter 414 of the laws of 2017, and subparagraphs (B), (C),
28 (D), and (E) as amended by chapter 143 of the laws of 2019, is amended
29 to read as follows:
30 (1) A medical expense indemnity corporation, a hospital service corpo-
31 ration or a health service corporation that provides coverage for hospi-
32 tal, surgical or medical care shall provide the following coverage for
33 mammography screening for occult breast cancer:
34 (A) upon the recommendation of a physician, a mammogram, which may be
35 provided by breast tomosynthesis, at any age for covered persons having
36 a prior history of breast cancer or who have a first degree relative
37 with a prior history of breast cancer;
38 (B) a single baseline mammogram, which may be provided by breast tomo-
39 synthesis, for covered persons aged thirty-five through thirty-nine,
40 inclusive;
41 (C) an annual mammogram, which may be provided by breast tomosythesis,
42 for covered persons aged forty and older;
43 (D) for large group contracts offered by a medical expense indemnity
44 corporation, a hospital service corporation or a health service corpo-
45 ration that provide coverage for hospital, surgical or medical care, an
46 annual mammogram for covered persons aged thirty-five through thirty-
47 nine, inclusive, upon the recommendation of a physician, subject to the
48 corporation's determination that the mammogram is medically necessary;
49 and
50 (E) either: (i) an annual mammogram and breast ultrasound; or (ii)
51 breast tomosynthesis for covered persons with heterogeneously dense or
52 extremely dense breasts.
53 (F) The coverage required in this paragraph or paragraph two of this
54 subsection shall not be subject to annual deductibles or coinsurance.
S. 2395 4
1 § 6. Paragraph 1 of subsection (p) of section 4303 of the insurance
2 law, as amended by chapter 424 of the laws of 2024, is amended to read
3 as follows:
4 (1) A medical expense indemnity corporation, a hospital service corpo-
5 ration or a health service corporation that provides coverage for hospi-
6 tal, surgical or medical care shall provide the following coverage for
7 mammography screening for occult breast cancer:
8 (A) upon the recommendation of a physician, a mammogram, which may be
9 provided by breast tomosynthesis, at any age for covered persons having
10 a prior history of breast cancer or who have a first degree relative
11 with a prior history of breast cancer;
12 (B) a single baseline mammogram, which may be provided by breast tomo-
13 synthesis, for covered persons aged thirty-five through thirty-nine,
14 inclusive;
15 (C) an annual mammogram, which may be provided by breast tomosythesis,
16 for covered persons aged forty and older;
17 (D) for large group contracts offered by a medical expense indemnity
18 corporation, a hospital service corporation or a health service corpo-
19 ration that provide coverage for hospital, surgical or medical care, an
20 annual mammogram for covered persons aged thirty-five through thirty-
21 nine, inclusive, upon the recommendation of a physician, subject to the
22 corporation's determination that the mammogram is medically necessary;
23 (E) upon the recommendation of a physician, screening and diagnostic
24 imaging, including diagnostic mammograms, breast ultrasounds, or magnet-
25 ic resonance imaging, recommended by nationally recognized clinical
26 practice guidelines for the detection of breast cancer. For the purposes
27 of this subparagraph, "nationally recognized clinical practice guide-
28 lines" means evidence-based clinical practice guidelines informed by a
29 systematic review of evidence and an assessment of the benefits, and
30 risks of alternative care options intended to optimize patient care
31 developed by independent organizations or medical professional societies
32 utilizing a transparent methodology and reporting structure and with a
33 conflict of interest policy; and
34 (F) either: (i) an annual mammogram and breast ultrasound; or (ii)
35 breast tomosynthesis for covered persons with heterogeneously dense or
36 extremely dense breasts.
37 (G) The coverage required in this paragraph or paragraph two of this
38 subsection shall not be subject to annual deductibles or coinsurance. If
39 under federal law, application of this requirement would result in
40 health savings account ineligibility under 26 USC 223, this requirement
41 shall apply for health savings account-qualified high deductible health
42 plans with respect to the deductible of such a plan after the enrollee
43 has satisfied the minimum deductible under 26 USC 223, except for with
44 respect to items or services that are preventive care pursuant to 26 USC
45 223(c)(2)(C), in which case the requirements of this paragraph shall
46 apply regardless of whether the minimum deductible under 26 USC 223 has
47 been satisfied.
48 § 7. This act shall take effect on the sixtieth day after it shall
49 have become a law and shall apply to all policies and contracts issued,
50 renewed, modified, altered or amended on or after such date; provided,
51 however, sections two, four, and six of this act shall take effect on
52 the same date and in the same manner as sections 1, 3 and 5, respective-
53 ly, of chapter 424 of the laws of 2024, takes effect.
