PRINTER'S NO. 103
No. 120 Session of 2005
INTRODUCED BY O'PAKE, MUSTO, KITCHEN, LAVALLE, STOUT, PILEGGI,
RHOADES, TARTAGLIONE, WOZNIAK, KASUNIC, LOGAN, COSTA, ORIE,
BOSCOLA, STACK AND MELLOW, FEBRUARY 1, 2005
REFERRED TO BANKING AND INSURANCE, FEBRUARY 1, 2005
AN ACT
1 Mandating health insurance coverage for cancer prevention and
2 early detection programs; and providing for powers and duties
3 of the Department of Health.
4 The General Assembly of the Commonwealth of Pennsylvania
5 hereby enacts as follows:
6 Section 1. Short title.
7 This act shall be known and may be cited as the Colorectal
8 Cancer Early Detection Act.
9 Section 2. Legislative intent.
10 The General Assembly finds and declares as follows:
11 (1) Colorectal cancers are the third most common cancers
12 in men and women.
13 (2) Routine examination and screening programs increase
14 the prevention and detection of early-stage cancers.
15 (3) Many cancer prevention and early detection programs
16 have proven to be cost effective and key to reducing cancer
17 morbidity and mortality.
18 (4) Current Centers for Disease Control and Prevention
1 and American Cancer Society guidelines call for a colonoscopy
2 every ten years for those 50 years of age or older and
3 recommend more frequent examinations for those at a higher
4 risk.
5 (5) Early detection of cancer may significantly increase
6 the chance of survival.
7 Section 3. Definitions.
8 The following words and phrases when used in this act shall
9 have the meanings given to them in this section unless the
10 context clearly indicates otherwise:
11 "Colonoscopy." An examination of the rectum and the entire
12 colon using a lighted instrument called a colonoscope.
13 "Colorectal cancer screening." Any of the following
14 procedures that are furnished to an individual for the purpose
15 of early detection of colorectal cancer:
16 (1) Screening fecal-occult blood test.
17 (2) Screening flexible sigmoidoscopy.
18 (3) Screening colonoscopy, in the case of a high-risk
19 individual.
20 (4) Screening barium enema, if medically necessary, as
21 an alternative to screening flexible sigmoidoscopy or
22 screening colonoscopy.
23 (5) Such other procedures as the Department of Health
24 deems appropriate in accordance with this act.
25 "Department." The Department of Health of the Commonwealth.
26 Section 4. Coverage for colorectal cancer screening.
27 (a) General rule.--All individual and group health insurance
28 policies providing coverage on an expense incurred basis,
29 individual and group service or indemnity type contracts issued
30 by a nonprofit corporation, individual and group service
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1 contracts issued by a health maintenance organization, all self-
2 insured group arrangements to the extent not preempted by
3 Federal law and all managed health care delivery entities of any
4 type or description, that are delivered, issued for delivery,
5 continued or renewed on or after the effective date of this act,
6 and providing coverage to any resident of this Commonwealth
7 shall provide benefits or coverage for colorectal cancer
8 examinations and laboratory tests for cancer for any
9 nonsymptomatic covered individual, in accordance with the most
10 recently published American Cancer Society guidelines for
11 colorectal cancer screening for a covered individual who is:
12 (1) Fifty years of age or older.
13 (2) Under 50 years of age and at high risk for
14 colorectal cancer according to the most recently published
15 colorectal cancer screening guidelines of the American Cancer
16 Society.
17 (b) Method of screening.--The group health plan or health
18 insurance issuer shall cover the method and frequency of
19 colorectal cancer screening deemed appropriate by a health care
20 provider treating a participant or beneficiary, in consultation
21 with the participant or beneficiary.
22 (c) Requirements.--The coverage required under this section
23 must meet the following requirements:
24 (1) To encourage colorectal cancer screenings, patients
25 and health care providers must not be required to meet
26 burdensome criteria or overcome significant obstacles to
27 secure such coverage.
28 (2) An individual shall not be required to pay an
29 additional deductible or coinsurance for testing that is
30 greater than an annual deductible or coinsurance established
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1 for similar benefits. If the program or contract does not
2 cover a similar benefit, a deductible or coinsurance may not
3 be set at a level that materially diminishes the value of the
4 colorectal cancer benefit required.
5 (d) Notice.--A group health plan covered under this act
6 shall comply with all relevant notice requirement rules.
7 Section 5. Insurance coverage standards.
8 (a) Referrals to participating providers.--A group health
9 plan or health insurance issuer is not required under this act
10 to provide for a referral to a nonparticipating health care
11 provider, unless the plan or issuer does not have an appropriate
12 health care provider that is available and accessible to
13 administer the screening exam and that is a participating health
14 care provider with respect to such treatment.
15 (b) Treatment of nonparticipating providers.--If a plan or
16 issuer refers an individual to a nonparticipating health care
17 provider pursuant to this section, services provided pursuant to
18 the approved screening exam or resulting treatment, if any,
19 shall be provided at no additional cost to the individual beyond
20 what the individual would otherwise pay for services received by
21 such a participating health care provider.
22 Section 6. Effective date.
23 This act shall take effect in 60 days.
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