Requires insurance coverage of sonograms and other diagnostic procedures used to detect breast cancer for covered persons with a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer.
Summary
S04072 amends New York’s insurance law to expand required coverage for breast cancer screening and diagnostic imaging under certain group and blanket health insurance policies, as well as large group contracts issued by medical expense indemnity corporations, hospital service corporations, and health service corporations. The bill builds on the state’s existing mammography coverage rules by adding explicit coverage for sonograms and other diagnostic procedures used to detect breast cancer for covered persons who have a prior history of breast cancer or a first-degree relative with a prior history of breast cancer, when recommended by a physician and subject to medical-necessity determinations where applicable.
The measure also clarifies and broadens coverage for baseline and annual mammograms, including breast tomosynthesis, and adds coverage for screening and diagnostic imaging recommended by nationally recognized clinical practice guidelines. In large group policies and contracts, it requires annual mammograms for all covered persons ages 35 through 39 and for those with a personal or family history of breast cancer, along with sonograms and other diagnostic procedures used to detect breast cancer. The bill is tied to the effective date and implementation framework of chapter 424 of the laws of 2024, indicating it is intended to integrate with recent prior changes to breast cancer screening coverage.
Impact
If enacted, the bill would require insurers and certain health plans in New York to cover additional breast cancer detection services, including sonograms, diagnostic mammograms, breast ultrasounds, MRI, and other guideline-based imaging, for specified covered persons. It would amend Insurance Law sections 3221 and 4303, affecting group and blanket policies and large group contracts, and would likely increase mandated benefits and insurer claims obligations for breast cancer screening and diagnostic care.
Sentiment
The available legislative record suggests generally favorable sentiment toward the bill. It was introduced, reported favorably from the Senate Insurance Committee, and advanced through multiple readings with amendment and reprinting, which indicates support for expanding breast cancer screening coverage. No opposing votes or committee objections are provided in the available materials.
Contention
The main policy issue is the scope of mandated coverage and the conditions attached to it. The bill expands coverage to additional diagnostic procedures and broader categories of covered persons, but still preserves insurer or corporation determinations of medical necessity in some instances. Potential points of contention include the cost impact on insurers and employers, the breadth of required coverage for large group plans, and whether the medical-necessity and guideline-based standards are sufficiently clear. The bill’s focus on people with a personal or first-degree family history of breast cancer suggests support from patient advocates and clinicians, while payers may be concerned about expanded utilization and mandated benefit costs.
Same As
Requires insurance coverage of sonograms and other diagnostic procedures used to detect breast cancer for covered persons with a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer.
Requires insurance coverage of sonograms and other diagnostic procedures used to detect breast cancer for covered persons with a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer.
Requires insurance coverage of sonograms and other diagnostic procedures used to detect breast cancer for covered persons with a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer.
Requires health insurance coverage for mammography by either mammogram and breast ultrasound or breast tomosynthesis for persons with heterogeneously dense or extremely dense breasts.
Requires health care professional to order bi-lateral ultrasounds concurrently when ordering mammograms; requires insurers to cover concurrent mammograms and bi-lateral ultrasounds.
Requires health care professionals to order bi-lateral ultrasounds concurrently when ordering mammograms; requires insurers to cover concurrent mammograms and bi-lateral ultrasounds.