Ohio’s Screening Mammography Reimbursement to Increase

After 14 Years Since Original Rates Were Created

(By: N. Victor Goodman Esq and Billie J. Fiore )

Currently, Ohio law requires every health insuring corporation policy, contract, or agreement providing basic health care services that is delivered, issued for delivery, or renewed; every public employee benefit plan; and every policy of sickness and accident insurance provided by an employer that is established or modified to provide benefits for screening mammography to detect the presence of breast cancer in adult women. Preexisting law also requires every policy of individual or group sickness and accident insurance delivered, issued for delivery, or renewed in Ohio to offer to provide such benefits.

On December 21, 2004 Ohio’s Governor Bob Taft signed Sub. H.B. 331, Screening Mammography Reimbursement Increase. H.B. 331 (“The Act”) becomes effective on March 22, 2005. The Act raises the reimbursement rate for mammography screening from the $85 cap that applies under certain health insurance policies and plans for screening mammography, and instead provides that the total benefit is not to exceed 130% of the Medicare reimbursement rate in Ohio for screening mammography, which put the new rate at approximately $106.* The current rate has not been adjusted since it was created by the legislature in 1992.

Under the Act, the benefit amount is required to be calculated according to the lowest Medicare reimbursement rate when more than one rate applies in Ohio for a screening mammography or a component of a screening mammography. The Act defines "Medicare reimbursement rate" as the reimbursement rate paid in Ohio under the Medicare program for screening mammography that does not include digitization or computer-aided detection, regardless of whether the actual benefit includes digitization or computer-aided detection.

When separate claims are submitted by the provider, hospital, or health care facility, the Act specifies that, if a provider, hospital, or facility provides a service that is a component of the screening mammography benefit and submits a separate claim for that component, a separate payment must be made to the provider, hospital, or other health care facility in an amount that corresponds to the ratio paid by Medicare in Ohio for that component. Regardless of whether separate payments are made for the benefit, the total benefit for a screening mammography shall not exceed 130% of the Medicare reimbursement rate in Ohio for screening mammography.

(O.R.C. §§1751.62, 3923.52, 3923.53, and 3923.54)

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* COMMENT

The total Medicare reimbursement rate for screening mammography in Ohio (CPT code 76092) is $81.57. The technical component reimbursement rate is $46.88 while the professional component reimbursement rate is $35.69. (Health Insurance Specialist, Centers for Medicare and Medicaid Services (May 17, 2004).