Prostate Cancer Screening Mandates

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Prostate Cancer Screening Mandates

Updated March 2009

(source: CNN.com)

What is prostate cancer?

The prostate is one of the male sex glands and is located just below the bladder. Prostate cancer is a common disease among older men and the second leading cause of cancer death among men in the United States. Its tumors range from small, slow-growing indolent masses to aggressive fast-growing lesions. In 2002, an estimated 30,200 men will die from prostate cancer, second only to lung cancer as the primary cause of cancer deaths among men. The prostate cancer death rate among African American men is more than twice as high as that of white men, and over three times greater than that of Hispanic men.

Prostate specific antigen (PSA) is a blood protein. Levels of the protein increase when the prostate has cancer or other diseases. The PSA test measures this protein in samples of blood drawn from men who are being screened for prostate cancer. Since the natural history of the disease is not uniform, there is some controversy over which lesions detected by screening will become clinically significant, thereby requiring treatment. More definitive answers await the completion of studies that compare, through long-term clinical trials, the survival rate of men who get the PSA blood tests to those who do not. One study currently underway is the National Cancer Institute's Prostate Cancer Screening Trial. However, conclusive data are not likely to be available from this study until 2005 at the earliest. Nevertheless, PSA testing (in combination with digital rectal examination) has increasingly become part of routine, preventive care in the United States during the past decade.

Disease highlights

For more information on prostate cancer policy, click here on the PDF link to Prostate Cancer Screening: A Matter of Routine or Patient Choice? A Discussion for Policy Makers. This booklet, developed by national experts provides helpful information on the debates surrounding prostate cancer screening and treatment.

Below is a chart that summarizes all state prostate cancer screening mandates. To date, at least 28 states have enacted laws requiring insurers to include coverage for PSA testing. In addition, the state of Utah passed a resolution encouraging private insurers to include prostate cancer screening coverage.

State

Citation

Content

Alaska

Sec.22.41.395

H 416

Health insurer shall provide coverage for the cost of prostate cancer screening tests. Minimum coverage requires annual screening for two groups of patients: 1) a person who is at least 35 but less than 40 and is in a high risk group (defined as African American or with family history) and 2) for a person who is 40 or more.

California

Sec. 1367.64

Individual or group health care service plan contract must provide coverage for the screening and diagnosis of prostate cancer including PSA and DRE.

Colorado

C.R.S. 10-16-104

All individual and all group sickness and accidental policies shall provide coverage for annual screening for the early detection of prostate cancer in men over the age of fifty years and in men over the age of forty years who are in high-risk categories. Such coverage shall be the lesser of sixty-five dollars per prostate cancer screening or the actual charge for such screening.

Connecticut

HB 7032

Public Act No.99-284

Requires specified insurers to provide coverage for prostate cancer screening and diagnostic tests and provides coverage guidelines.

Delaware

18 Del. C. 3552

All group and blanket health insurance policies which are delivered or issued for delivery in this State by any health insurer or health service corporation and which provide benefits for outpatient services shall provide to covered persons residing or having their principal place of employment in this State and being age 50 or above a benefit for prostate cancer screening,

Georgia

Official Code 33-29-3.2.

Mandates coverage for annual prostate specific antigen tests for the covered males who are 45 years of age or older, or for covered males who are 40 years of age or older, if ordered by a physician.

Illinois

HB 1881

Amends the state employees group insurance act and education employees health insurance coverage and Medicaid coverage to include annual PSA.

Indiana

SB 126

Requires group insurance for public employees, group insurers and HMOs to provide annual PSA screening to a man who is at least 40 or whose treating physician determines screening is medically necessary.

Kansas

K.S.A. 40-2, 164

Health benefit society or health maintenance organization which provides coverage for accident and health services shall provide coverage for prostate cancer screening for men 40 years of age or who are symptomatic or in a high-risk category and for all men 50 years of age or older.

Louisiana

22:215.11

Mandates coverage for detection of prostate cancer, including digital rectal examination and prostate-specific antigen testing for men over the age of fifty years and as medically necessary and appropriate for men over the age of forty years.

Maine

24 M.R.S. 2325-C

All individual and group plans must provide coverage for early detection of prostate cancer.

Maryland

H 1040 (1997)

SB 428

Requires annual screening coverage for men between ages 40 and 75; when used for the purpose of guiding patient management in monitoring the response to prostate cancer treatment; when used for staging in determining the need for a bone scan in patients with prostate cancer; or when used for male patients who are at high risk for prostate cancer.

Minnesota

Minn. Stat. 62Q.50

A health plan must cover prostate cancer screening for men 40 years of age or over who are symptomatic or in a high-risk category and for all men 50 years of age or older

Missouri

HB 191

Requires individual and group health insurance and self-insured group arrangements to provide coverage for a prostate examination and laboratory tests for cancer for any nonsymptomatic man in accordance with ACS guidelines.

New Jersey

17B:27-46.1o

Mandates digital rectal examination and a prostate-specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors.

New York

A 5037

Insurance Law § 3216 (indiv.)
Insurance Law § 3221 (group)
364-I - Medical assistance presumptive eligibility program.

Requires coverage of diagnostic screenings for prostate cancer.

North Carolina

NCGS 135-1

58-50-155

Requires that the standard health plan developed and approved under GS58-50-125 provide coverage for PSA. Requires benefit plans for teachers and state employees to pay 100% of allowable charges for routine diagnostic examinations and tests, including prostate exams.

North Dakota

ND S 2115 (1997)

26.1-36-09.6

Requires all health insurance policies to cover annual DRE and PSA for men 50 and over, black men 40 and over, and men 40 and over with a family history. Exempts insurers from providing coverage of PSA and other state mandates in basic health insurance policies delivered, issued, and received to employers with fewer than 50 employees

Oklahoma

36 Okl. St. 6060.8

Health benefit plans shall offer prostate cancer screening coverage for men 50 years and in men over the age of 40 who are in high-risk categories.

Rhode Island

RI H 7395 or S 2299

Requires every individual or group hospital or medical expense insurance policy or contract, nonprofit hospital or medical service plan and HMO plan to include coverage for prostate examinations and laboratory testing for all nonsymptomatic persons.

South Dakota

H 1088

Requires coverage for prostate cancer screening.

Tennessee

56-7-2354

Mandates coverage for the early detection of prostate cancer for men aged fifty (50) and over and other men if a physician determines that early detection for prostate cancer is medically necessary.

Texas

TX Ins. Code art. 26.45

Coverage for the following preventive care must be provided on an appropriate medical schedule without copayment or deductible: prostate cancer screening.

Utah

HCR 2

Encourages private health insurance companies and employers to include insurance coverage for the screening and detection of prostate cancer.

Vermont

HB 189

Established standards for health insurance coverage services including PSA.

Virginia

H 915 (1998)
§ 2.2-2818
§ 32.1-325
§ 38.2-3418.7

Requires State Health insurance plans and Medicaid to include coverage to persons age fifty and over and persons age forty and over who are at high risk for prostate cancer according to ACS guidelines.

Washington RCW 41.05.177
RCW 70.47.210
RCW 48.20.392
RCW 48.44.327
Requires State employees to have coverage.
Requires state's basic health plan to include coverage.
Requires disability insurance to include coverage.
Requires health service contracts to include coverage.

West Virginia

H 4039

Act. No. 168

Requires the Public Employees Insurance agency to establish an insurance plan that includes annual prostate cancer checkups for men age 50 and over.

Wyoming

H 26

Requires group coverage for prostate screening.

This site is made possible by program award U38/CCU814942-05 from the Centers for Disease Control and Prevention.

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In 2002, an estimated 189,000 new cases of prostate cancer will be diagnosed in the U.S.,
Prostate cancer is the leading cause of new cancer cases (excluding skin cancer) in men.
Prostate cancer is rarely diagnosed in men less than 50 years of age.
African American men are diagnosed with prostate cancer at a rate nearly 50 percent higher than white men, more than twice as high as Hispanic men, nearly three times higher than Asian/Pacific Islanders, and nearly five times higher than Native American men.
Survival rates for prostate cancer improved significantly from 1974 to 1994 for all men, and specifically for white and African American men.
Ninety-three percent of all men diagnosed with prostate cancer survive five years or more.

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