GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1999

H	1 

HOUSE BILL 314

Short Title:  Insurance Covg./Bone Mass Msmt.	(Public)

─────────────────────────────────────── 
Sponsors: Representatives Boyd-McIntyre; Mosley, Wainwright, and Jeffus.
─────────────────────────────────────── 
Referred to:  Insurance.

─────────────────────────────────────── 

March 4, 1999

A BILL TO BE ENTITLED
AN ACT TO REQUIRE HEALTH AND ACCIDENT INSURANCE POLICIES, HOSPITAL OR MEDICAL SERVICES PLANS, AND HMO PLANS TO PROVIDE COVERAGE FOR BONE MASS MEASUREMENT FOR THE DIAGNOSIS AND EVALUATION OF OSTEOPOROSIS.
Whereas, osteoporosis or low bone mass is a public health hazard to over one million North Carolinians age 50 and over; and
Whereas, each year more than 13,000 North Carolinians are hospitalized for hip fractures alone resulting in more than $57 million in direct medical costs; and
Whereas, osteoporosis or low bone mass is a silent disease, typically undiagnosed until a fracture occurs and, once a fracture occurs, osteoporosis or low bone mass is already substantially advanced and has a high risk of additional fractures; and
Whereas, one of two women over age 50 and one of eight men over age 50 will suffer at least one osteoporotic fracture during late life; and
Whereas, osteoporosis or low bone mass has no cure, pharmaceutical or otherwise, but prevention, early diagnosis, and treatment can be key to reducing the prevalence of this disease as well as its negative impact on individuals; and
Whereas, osteoporosis or low bone mass not only increases the likelihood of fracture and nursing home placement but also increases the risk of depression, loss of self-esteem, anxiety, chronic pain, poor social relationships, and loss of employment; and
Whereas, it is cost-effective to mandate coverage of bone mass measurement because it leads to early diagnosis, intervention, and prevention of fracture and, therefore, reduces unnecessary health care expenditures; and
Whereas, bone mass measurement reliably detects low bone mass and helps to ascertain the extent of bone loss to determine an individual's future fracture risk which helps individuals and health care professionals to select appropriate therapies and interventions; and
Whereas, conventional X rays cannot accurately diagnose osteoporosis or low bone mass in the absence of fracture; and
Whereas, scientifically proven technologies for bone mass measurement and other services related to the diagnosis and treatment of osteoporosis or low bone mass can be used effectively to reduce the physical, emotional, social, and financial burden that this disease inflicts upon its victims; Now, therefore,
The General Assembly of North Carolina enacts:
Section 1. Effective January 1, 2000, Article 3 of Chapter 58 of the General Statutes is amended by adding the following new section to read:
"§ 58-3-174. Coverage for bone mass measurement for diagnosis and evaluation of osteoporosis or low bone mass.
(a)	Every entity providing a health benefit plan shall provide coverage for a qualified individual for scientifically proven and approved bone mass measurement for the diagnosis and evaluation of osteoporosis or low bone mass.  The same deductibles, coinsurance, and other limitations as apply to similar services covered under the plan shall apply to coverage for bone mass measurement.
(b)	A health benefit plan may provide that bone mass measurement will be covered if at least 23 months have elapsed since the last bone mass measurement was performed, except that a plan must provide coverage for follow-up bone mass measurement  performed more frequently than every 23 months if the follow-up measurement is medically necessary.  Conditions under which more frequent bone mass measurement coverage may be medically necessary include, but are not limited to:
(1)	Monitoring beneficiaries on long-term glucocorticoid therapy of more than three months.
(2)	Allowing for a confirmatory baseline bone mass measurement (either central or peripheral) to permit monitoring of beneficiaries in the future if the initial test was performed with a technique that is different from the proposed monitoring method.
(c)	As used in this section, the term:
(1)	'Bone mass measurement' means a radiological, sonographic procedure or other scientifically proven technology performed on an individual in order to identify bone mass or detect bone loss for the purpose of initiating or modifying treatment.
(2)	'Health benefit plan' means an accident and health insurance policy or certificate; a nonprofit hospital or medical service corporation contract; a health maintenance organization subscriber contract; a plan provided by a multiple employer welfare arrangement; or a plan provided by another benefit arrangement, to the extent permitted by the Employee Retirement Income Security Act of 1974, as amended, or by any waiver of or other exception to that Act provided under federal law or regulation.  'Health benefit plan' does not mean any plan implemented or administered by the North Carolina Department of Health and Human Services or the United States Department of Health and Human Services, or any successor agency, or its representatives.  'Health benefit plan' also does not mean any of the following kinds of insurance:
a.	Accident
b.	Credit
c.	Disability income
d.	Long-term care or nursing home care
e.	Medicare supplement
f.	Specified disease
g.	Dental or vision
h.	Coverage issued as a supplement to liability insurance
i.	Workers' compensation
j.	Medical payments under automobile or homeowners
k.	Hospital income or indemnity
l.	Insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability policy or equivalent self-insurance.
(3)	'Insurer' includes an insurance company subject to this Chapter, a service corporation organized under Article 65 of this Chapter, a health maintenance organization organized under Article 67 of this Chapter, and a multiple employer welfare arrangement subject to Article 49 of this Chapter.
(4)	'Qualified individual' means any one or more of the following:
a.	An individual who is estrogen-deficient and at clinical risk of osteoporosis or low bone mass.
b.	An individual with radiographic osteopenia anywhere in the skeleton.
c.	An individual who is receiving long-term glucocorticoid (steroid) therapy.
d.	An individual with primary hyperparathyroidism.
e.	An individual who is being monitored to assess the response to or efficacy of commonly accepted osteoporosis drug therapies.
f.	An individual who has a history of low trauma fractures.
g.	An individual with other conditions or on medical therapies known to cause osteoporosis or low bone mass.
(d)	Insurers subject to this section shall identify and use the most current scientifically accurate educational materials to increase awareness and knowledge by their insureds of osteoporosis or low bone mass and methods of diagnosing osteoporosis or low bone mass, including bone mass measurement, and to encourage the treatment and prevention of osteoporosis."
Section 2. Effective January 1, 2000, G.S. 58-50-155 reads as rewritten:
"§ 58-50-155.  Standard and basic health care plan coverages.
(a)	Notwithstanding G.S. 58-50-125(c), the standard health plan developed and approved under G.S. 58-50-125 shall provide coverage for 
		all of the following:
(1)	Mammograms and pap smears at least equal to the coverage required by G.S. 58-51-57.
(2)	Prostate-specific antigen (PSA) tests or equivalent tests for the presence of prostate cancer at least equal to the coverage required by G.S. 58-51-58.
(3)	Reconstructive breast surgery resulting from a mastectomy at least equal to the coverage required by G.S. 58-51-62.
(4)	For a qualified individual, scientifically proven bone mass measurement for the diagnosis and evaluation of osteoporosis or low bone mass at least equal to the coverage required by G.S. 58-3-174.
(b)	Notwithstanding G.S. 58-50-125(c), in developing and approving the plans under G.S. 58-50-125, the Committee and Commissioner shall give due consideration to cost-effective and life-saving health care services and to cost-effective health care providers. "
Section 3.  This act is effective when it becomes law and applies to health benefit plans that are delivered, issued for delivery, or renewed on and after January 1, 2000.  For purposes of this act, renewal of a health benefit plan is presumed to occur on each anniversary of the date on which coverage was first effective on the person or persons covered by the health benefit plan.