Health care coverage: diagnostic imaging.
AB 1570
California Bills
20250AB__157098AMD INTRODUCED 2026-01-12 AMENDED_ASSEMBLY 2026-04-09 REVISED 2026-05-14 2025 AB AMD Introduced by Assembly Member Wilson (Coauthors: Assembly Members Caloza, Connolly, Davies, Haney, Ortega, Pacheco, Pellerin, Quirk-Silva, Michelle Rodriguez, and Aguiar-Curry) LEAD_AUTHOR ASSEMBLY Wilson COAUTHOR ASSEMBLY Caloza COAUTHOR ASSEMBLY Connolly COAUTHOR ASSEMBLY Davies COAUTHOR ASSEMBLY Haney COAUTHOR ASSEMBLY Ortega COAUTHOR ASSEMBLY Pacheco COAUTHOR ASSEMBLY Pellerin COAUTHOR ASSEMBLY Quirk-Silva COAUTHOR ASSEMBLY Michelle Rodriguez COAUTHOR ASSEMBLY Aguiar-Curry
An act to amend
Section 1367.65 of the Health and Safety Code, and to amend
Section 10123.81 of the Insurance Code, relating to health care coverage. health care coverage Health care coverage: diagnostic imaging. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.
Existing law requires a health care service plan contract issued, amended, delivered, or renewed on or after January 1, 2000, or an individual or group policy of disability insurance or self-insured employee welfare benefit plan to provide coverage for mammography for screening or diagnostic purposes upon referral by specified professionals. Under existing law, mammography performed pursuant to those requirements or that meets the current recommendations of the United States Preventive Services Task Force is provided to an enrollee or an insured without cost sharing.
This bill would require a health care service plan contract, a health insurance policy, or a self-insured employee welfare benefit plan issued, amended, or renewed on or after January 1, 2028, to provide coverage without imposing cost sharing for, among other things, screening mammography and medically necessary diagnostic breast imaging, including diagnostic breast imaging following an abnormal mammography result and for an enrollee or insured indicated to have a risk factor associated with breast cancer, except as specified.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason. MAJORITY NO YES YES NO NO NO NO NO NO NO The people of the State of California do enact as follows:
SECTION
Section 1367.65 of the Health and Safety Code is amended to read: 1367.65. (a)
(1) A health care service plan contract issued, amended, or renewed on or after January 1, 2000, excluding a specialized health care service plan contract, shall provide coverage for mammography for screening or diagnostic purposes upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.
(2) This subdivision does not prevent application of copayment or deductible provisions in a plan, nor shall this subdivision be construed to require that a plan be extended to cover any other procedures under an individual or a group health care service plan contract. (b)
(1) A health care service plan contract issued, amended, or renewed on or after January 1, 2028, excluding a specialized health care service plan contract, shall provide coverage without imposing cost sharing for screening mammography, medically necessary diagnostic or supplemental breast examinations, diagnostic mammography, and medically necessary diagnostic breast imaging, including diagnostic breast imaging following an abnormal mammography result and for an enrollee indicated to have a risk factor associated with breast cancer, including family history or known genetic mutation.
Diagnostic breast imaging includes breast magnetic resonance imaging and breast ultrasound. Diagnostic breast imaging, diagnostic mammography, and diagnostic and supplemental breast examinations are covered under this subdivision to the extent it is consistent with nationally recognized evidence-based clinical guidelines. (2) (A) Paragraph (1) applies to a health care service plan contract that meets the definition of a “high deductible health plan” set forth in
Section 223(c)(2) of Title of the United States Code only after an enrollee’s deductible has been satisfied for the year. (
B) Notwithstanding subparagraph (A), paragraph (1) applies to a health care service plan contract that meets the definition of a “high deductible health plan” set forth in
Section 223(c)(2) of Title of the United States Code with respect to items or services that are preventative care pursuant to
Section 223(c)(2)(
C) of Title of the United States Code regardless of whether an enrollee’s deductible has been satisfied for the year. (c)
(1) This
section does not authorize an enrollee to receive the services required to be covered by this
section if those services are furnished by a nonparticipating provider, except as specified in paragraph (2).
(2) A plan shall arrange for the provision of services required by this
section from providers outside the plan’s network if those services are unavailable within the network to ensure timely access to covered health care services consistent with
Section 1367.03. (
d) Subdivision (
b) does not preclude a health care service plan that provides coverage for out-of-network benefits from imposing cost-sharing requirements for the items or services described in this
section that are delivered by an out-of-network provider, except in the situation described in paragraph (2) of subdivision (
c) and as otherwise required by law. (
e) For the purposes of this section: (1) “Breast magnetic resonance imaging” means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast. (2) “Breast ultrasound” means a noninvasive diagnostic tool that uses high-frequency sound. (3) “Cost sharing” means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense. (4) “Diagnostic breast examination” means a medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network Guidelines, examination of the breast, including an examination using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is either of the following: (
A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer. (
B) Used to evaluate an abnormality detected by another means of examination. (5) “Diagnostic mammography” means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast. (6) “Supplemental breast examination” means a medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network Guidelines, examination of the breast, including an examination using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is either of the following: (
A) Used to screen for breast cancer when an abnormality is not seen or suspected. (
B) Based on personal or family medical history or additional factors that increase the individual’s risk of breast cancer, including heterogeneously or extremely dense breasts.
SEC.
Section 10123.81 of the Insurance Code is amended to read: 10123.81. (a)
(1) A disability insurance policy or self-insured employee welfare benefit plan shall be deemed to provide coverage for mammography for screening or diagnostic purposes upon the referral of a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant, or participating physician, providing care to the patient and operating within the scope of practice provided under existing law.
(2) This subdivision does not prevent the application of copayment or deductible provisions in a policy, nor does this
section require that a policy be extended to cover any other procedures under an individual or a group policy. (b)
(1) A health insurance policy or a self-insured employee welfare benefit plan issued, amended, or renewed on or after January 1, 2028, shall provide coverage without imposing cost sharing for screening mammography, medically necessary diagnostic or supplemental breast examinations, diagnostic mammography, and medically necessary diagnostic breast imaging, including diagnostic breast imaging following an abnormal mammography result and for an insured indicated to have a risk factor associated with breast cancer, including family history or known genetic mutation.
Diagnostic breast imaging includes breast magnetic resonance imaging and breast ultrasound. Diagnostic breast imaging, diagnostic mammography, and diagnostic and supplemental breast examinations are covered under this subdivision to the extent it is consistent with nationally recognized evidence-based clinical guidelines. (2) (A) Paragraph (1) applies to a health insurance policy that meets the definition of a “high deductible health plan” set forth in
Section 223(c)(2) of Title of the United States Code only after an insured’s deductible has been satisfied for the year. (
B) Notwithstanding subparagraph (A), paragraph (1) applies to a health insurance policy that meets the definition of a “high deductible health plan” set forth in
Section 223(c)(2) of Title of the United States Code with respect to items or services that are preventative care pursuant to
Section 223(c)(2)(
C) of Title of the United States Code regardless of whether an insured’s deductible has been satisfied for the year. (c)
(1) This
section does not authorize an insured to receive the services required to be covered by this
section if those services are furnished by a nonparticipating provider, except as specified in paragraph (2).
(2) An insurer shall arrange for the provision of services required by this
section from providers outside the insurer’s contracted network if those services are unavailable within the network to ensure timely access to covered health care services consistent with Sections and 10133.54. (
d) This
section does not apply to specialized health insurance, Medicare supplement insurance, CHAMPUS supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance. (
e) Subdivision (
b) does not preclude a disability insurer that provides coverage for out-of-network benefits from imposing cost-sharing requirements for the items or services described in this
section that are delivered by an out-of-network provider, except in the situation described in paragraph (2) of subdivision (
c) and as otherwise required by law. (
f) For the purposes of this section: (1) “Breast magnetic resonance imaging” means a diagnostic tool that uses a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast. (2) “Breast ultrasound” means a noninvasive diagnostic tool that uses high-frequency sound. (3) “Cost sharing” means a deductible, coinsurance, or copayment, and any maximum limitation on the application of that deductible, coinsurance, or copayment, or a similar out-of-pocket expense. (4) “Diagnostic breast examination” means a medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network Guidelines, examination of the breast, including an examination using contrast-enhanced mammography, diagnostic mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is either of the following: (
A) Used to evaluate an abnormality seen or suspected from a screening examination for breast cancer. (
B) Used to evaluate an abnormality detected by another means of examination. (5) “Diagnostic mammography” means a diagnostic tool that uses x-ray and is designed to evaluate an abnormality in the breast. (6) “Supplemental breast examination” means a medically necessary and appropriate, in accordance with the National Comprehensive Cancer Network Guidelines, examination of the breast, including an examination using contrast-enhanced mammography, breast magnetic resonance imaging, breast ultrasound, or molecular breast imaging, that is either of the following: (
A) Used to screen for breast cancer when an abnormality is not seen or suspected. (
B) Based on personal or family medical history or additional factors that increase the individual’s risk of breast cancer, including heterogeneously or extremely dense breasts.
SEC. 3. No reimbursement is required by this act pursuant to
Section of
Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of