Mandated Benefits Review - Senate Bill 39 - Bill Overview

Senate Bill 39-the proposed Cancer Prevention and Early Detection Services Act-would require insurers to provide coverage for cancer screening programs. The specific benefits proposed under Senate Bill 39 are coverage of an annual digital rectal examination for men 50 years of age or older, an annual prostate specific antigen test for men 50 years of age or older as deemed medically necessary, an annual fecal occult blood test for individuals 50 years of age or older, and a sigmoidoscopy examination every four years for individuals 50 years of age or older. The Council was also asked to review an amendment which would expand coverage to include prostate cancer screening benefits to men 40 years of age or older with a family history of prostate cancer or other prostate cancer risk factors. This amendment would also exempt specific types of policies from the mandate, as well as exempting the proposed benefits from deductible provisions of health insurance policies.

Among the cancer screening procedures to which Senate Bill 39 refers are annual gynecological examinations, routine pap smears, and annual mammograms for women age 40 and over. These three procedures are already mandated by existing law (Pennsylvania Consolidated Statutes 40 P.S. § 764c and 40 P.S. § 1574). In requesting the Council to review Senate Bill 39, Senator Loeper noted "there was general consensus ... that it was unnecessary and burdensome to ask the Council to review that which is existing law." Therefore, the remainder of this report will focus exclusively on the impact of the benefits for prostate cancer screening and colorectal cancer screening proposed under Senate Bill 39.

As a state law, the measure would be preempted by the federal Employee Retirement Income Security Act of 1974 (ERISA) (PL 93-406), which precludes state laws from applying to the benefit plans of self-insured companies. According to the Pennsylvania Department of Insurance, the percentage of private payers that are preempted by ERISA is approximately 50% of all privately insureds.

Other Legislation-Federal and Other States

Council staff examined related legislation, both at the federal level and from other states.

Federal Legislation

The Health Care Financing Administration estimates that 95% of the elderly are covered by Medicare, and of those, 96% are covered by Medicare supplement Part B. This suggests that over 91% of people aged 65 and over are covered by Medicare supplement Part B.

As part of the Federal Balanced Budget Act of 1997, changes in Medicare were enacted relative to screening for prostate cancer and colorectal cancer:

Other States

Currently fourteen states and the District of Columbia have mandates for insurers to cover prostate cancer screening, including digital rectal examinations and prostate specific antigen tests. Those states mandating coverage are: Alaska, Colorado, Delaware (prostate specific antigen test only), Georgia, Illinois, Louisiana, Maryland, Minnesota, New Jersey, North Carolina, North Dakota, Tennessee, Texas, and West Virginia. Similar legislation is also pending in Virginia.

The legislation mandating coverage of prostate cancer screening in Maryland and New Jersey was reviewed by Council staff. In reviewing New Jersey's legislation, staff also noted an important difference. New Jersey's legislation excluded groups with 49 or fewer persons from the mandate. Thus, it would appear that in New Jersey, mandated coverage does not apply to small businesses and individual policy holders. Senate Bill 39 does not make such an exclusion.

The Council was not provided with copies of legislation mandating coverage for colorectal cancer screening in other states. Council staff independently contacted the National Conference of State Legislatures and inquired about such mandates. Council staff was told that after checking the resources of both a tracking service and Blue Cross/Blue Shield, the National Conference of State Legislatures did not know of any states mandating coverage for colorectal cancer screening.