Subject: Proposed Legislation Mandating Health Insurer Coverage for Preventative Prostate Cancer Screenings for High-Risk Men in Ohio
Source: Ohio House Bill No. 33 (As Introduced), 136th General Assembly
1. Executive Summary:
Ohio House Bill No. 33 (HB 33) proposes to enact Section 3902.66 of the Ohio Revised Code, requiring health benefit plans in Ohio to cover the costs associated with preventive prostate cancer screenings for men who are at least 40 years of age and considered at high risk for developing the disease. The bill defines “high risk” based on a family history of prostate cancer or the diagnosis of the covered person or a first-degree relative with a genetic alteration or cancer associated with increased prostate cancer risk. Notably, the bill aims to eliminate cost-sharing for these screenings, although an exception is made to preserve health savings account (HSA) eligibility under federal law. The Superintendent of Insurance would be responsible for implementing and administering the new section, including specifying covered PSA tests and screening intervals (not greater than one year).
2. Main Themes and Important Ideas:
- Mandated Coverage for High-Risk Men: The central theme of HB 33 is to mandate health insurers to cover preventive prostate cancer screenings for a specific demographic: men aged 40 and older identified as being at high risk for prostate cancer. This is explicitly stated in Section 3902.66(B): “a health benefit plan issued, renewed, or modified in this state on or after the effective date of this section shall provide coverage for all expenses associated with prostate cancer screenings for covered persons who are male, at least forty years of age, and are at high risk of developing prostate cancer based on one or both of the following factors…”
- Definition of “High Risk”: The bill clearly defines what constitutes “high risk” for the purpose of this coverage mandate. It identifies two key criteria:
- “(1) Diagnosis of the covered person or a first-degree relative with a genetic alteration or cancer associated with increased risk of prostate cancer;”
- “(2) A family history of prostate cancer.” The bill further clarifies “family history of prostate cancer” as meaning “that a first-degree relative of a covered person was diagnosed with, developed, or died as a result of prostate cancer” and defines “first-degree relative” as “a biological parent, full biological sibling, or biological child.”
- Scope of “Prostate Cancer Screening”: The legislation defines “prostate cancer screening” broadly to include “any evidence-based preventive care or screening procedure performed for the purpose of identifying prostate cancer, including prostate-specific antigen tests and digital rectal examination.”
- Elimination of Cost-Sharing: A significant aspect of the bill is the provision to eliminate cost-sharing (e.g., co-pays, deductibles) for the mandated screenings: “(C) Subject to division (E) of this section, no health benefit plan issued, renewed, or modified in this state on or after the effective date of this section shall impose a cost-sharing requirement for the coverage required by division (B) of this section.”
- Rulemaking Authority for the Superintendent of Insurance: The bill delegates authority to the Superintendent of Insurance to establish rules for the implementation and administration of this section. This includes specifying the types of PSA tests that must be covered and the allowable interval between screenings: “(D) The superintendent of insurance shall adopt rules in accordance with Chapter 119. of the Revised Code for the purposes of implementing and administering this section, including rules that specify both of the following: (1) The types of prostate-specific antigen tests for which coverage is required by this section; (2) The interval between prostate cancer screenings covered in accordance with this section, which shall not be greater than one year.”
- Exception for HSA Eligibility: The bill includes a provision to ensure compliance with federal law regarding Health Savings Account eligibility. If the no cost-sharing requirement would jeopardize HSA eligibility under 26 U.S.C. 223, then the cost-sharing prohibition applies to HSA-qualified high deductible health plans only after the enrollee has met the minimum deductible: “(E) If, under federal law, the application of the requirement in division (C) of this section would result in health savings account ineligibility under 26 U.S.C. 223, then the requirement of division (C) of this section applies for health savings account-qualified high deductible health plans with respect to the deductible of such a plan after the enrollee has satisfied the minimum deductible under 26 U.S.C. 223.”
- Applicability to Health Benefit Plans: The requirements of this bill apply to health benefit plans issued, renewed, or modified in Ohio on or after the effective date of the section. It explicitly states it acts “[n]otwithstanding section 3901.71 of the Revised Code,” which likely deals with existing regulations regarding health benefit plans.
3. Potential Implications and Considerations:
- Increased Access to Preventative Care: This bill, if enacted, could significantly increase access to potentially life-saving prostate cancer screenings for men at higher risk, potentially leading to earlier detection and improved treatment outcomes.
- Financial Impact on Insurers: Mandating coverage without cost-sharing could have financial implications for health insurance companies in Ohio. However, the potential for reduced long-term healthcare costs associated with late-stage cancer diagnoses could offset these initial expenses.
- Impact on Employers: Employers offering health benefit plans in Ohio would need to ensure their plans comply with these new requirements.
- Public Health Benefits: Early detection of prostate cancer through increased screening among high-risk individuals could lead to a reduction in morbidity and mortality associated with the disease.
- Implementation Challenges: The Superintendent of Insurance will need to develop clear and comprehensive rules regarding the specific PSA tests to be covered and the appropriate screening intervals to ensure effective implementation.
- Coordination with Federal Guidelines: It will be important for the state regulations to align with evolving federal guidelines and recommendations regarding prostate cancer screening.
4. Notable Quotes:
- “a health benefit plan issued, renewed, or modified in this state on or after the effective date of this section shall provide coverage for all expenses associated with prostate cancer screenings for covered persons who are male, at least forty years of age, and are at high risk of developing prostate cancer based on one or both of the following factors: (1) Diagnosis of the covered person or a first-degree relative with a genetic alteration or cancer associated with increased risk of prostate cancer; (2) A family history of prostate cancer.” (Section 3902.66(B))
- “‘Prostate cancer screening’ means any evidence-based preventive care or screening procedure performed for the purpose of identifying prostate cancer, including prostate-specific antigen tests and digital rectal examination.” (Section 3902.66(A)(3))
- “Subject to division (E) of this section, no health benefit plan issued, renewed, or modified in this state on or after the effective date of this section shall impose a cost-sharing requirement for the coverage required by division (B) of this section.” (Section 3902.66(C))
5. Next Steps:
This bill has been introduced in the Ohio House of Representatives and will need to go through the legislative process, including committee hearings and votes in both the House and Senate, before it can potentially become law. Stakeholders, including healthcare providers, insurance companies, patient advocacy groups, and the public, may have opportunities to provide input during this process.convert_to_textConvert to source