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District of Columbia Code Division V. Local Business Affairs § 31-2902. Payable benefits.

Current as of January 01, 2024 | Updated by Findlaw Staff

(a) Any individual or group health benefit plan, including Medicaid, shall provide health insurance benefits to cover:

(1) A baseline mammogram for women, including a 3-D mammogram;

(2) An annual screening mammogram for women, including a 3-D mammogram; and

(3) Adjuvant breast cancer screening, including magnetic resonance imaging, ultrasound screening, or molecular breast imaging of the breast, if:

(A) A mammogram demonstrates a Class C or Class D breast density classification; or

(B) A woman is believed to be at an increased risk for cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications of an increased risk for cancer as determined by a woman's physician or advanced practice registered nurse.

(b) Any individual or group health benefit plan, including Medicaid, shall provide health insurance benefits to cover:

(1) Annual cervical cytologic screening for women; and

(2) Cervical cytologic screening for women upon certification by an attending physician that the test is medically necessary.

(c) Benefits provided in accordance with this section shall not be subject to an annual or coinsurance deductible.

(d) Benefits provided in accordance with this section shall not be subject to a co-payment except when an enrollee or subscriber elects to have a baseline mammogram, annual screening mammogram, annual cervical cytologic screening, and a cervical cytologic screening certified by an attending physician as being necessary, performed by an out-of-network provider in a preferred provider plan.

(e) Co-payments and coinsurance may be applicable to the enrollee's or subscriber's office visit.

(f) Subsections (d) and (e) of this section shall apply:

(1) To any insurance policy or subscriber contract delivered or issued for delivery in the District more than 120 days after April 5, 2005; and

(2) To any insurance policy or subscriber contract renewed, amended, or reissued 120 days after April 5, 2005.

(g) For the purposes of this section, the term “breast density classification” means the 4 levels of breast density identified in the Breast Imaging Reporting and Data System established by the American College of Radiology, which are:

(1) Class A, indicating fatty breast tissue;

(2) Class B, indicating scattered fibroglandular breast tissue;

(3) Class C, indicating heterogeneously dense breast tissue with fibrous and glandular tissue that are evenly distributed throughout the breast; and

(4) Class D, indicating extremely dense breast tissue.

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Cite this article: FindLaw.com - District of Columbia Code Division V. Local Business Affairs § 31-2902. Payable benefits. - last updated January 01, 2024 | https://codes.findlaw.com/dc/division-v-local-business-affairs/dc-code-sect-31-2902/

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