§58‑3‑174. Coverage for bone mass measurement for diagnosis andevaluation of osteoporosis or low bone mass.
(a) Every entityproviding a health benefit plan shall provide coverage for a qualifiedindividual for scientifically proven and approved bone mass measurement for thediagnosis and evaluation of osteoporosis or low bone mass. The samedeductibles, coinsurance, and other limitations as apply to similar servicescovered under the plan shall apply to coverage for bone mass measurement.
(b) A health benefitplan may provide that bone mass measurement will be covered if at least 23months have elapsed since the last bone mass measurement was performed, exceptthat a plan must provide coverage for follow‑up bone mass measurementperformed more frequently than every 23 months if the follow‑upmeasurement is medically necessary. Conditions under which more frequent bonemass measurement coverage may be medically necessary include, but are notlimited to:
(1) Monitoringbeneficiaries on long‑term glucocorticoid therapy of more than threemonths.
(2) Allowing for acentral bone mass measurement to determine the effectiveness of adding anadditional treatment regimen for a qualified individual who is proven to havelow bone mass so long as the bone mass measurement is performed 12 to 18 monthsfrom the start date of the additional regimen.
(c) Nothing in thissection shall be construed to require health benefit plans to cover screeningfor nonqualified individuals.
(d) As used in thissection, the term:
(1) "Bone massmeasurement" means a scientifically proven radiologic, radioisotopic, orother procedure performed on a qualified individual to identify bone mass ordetect bone loss for the purpose of initiating or modifying treatment.
(2) "Health benefitplan" means an accident and health insurance policy or certificate; anonprofit hospital or medical service corporation contract; a healthmaintenance organization subscriber contract; a plan provided by a multipleemployer welfare arrangement; or a plan provided by another benefitarrangement, to the extent permitted by the Employee Retirement Income SecurityAct of 1974, as amended, or by any waiver of or other exception to that actprovided under federal law or regulation. "Health benefit plan" does notmean any plan implemented or administered by the North Carolina Department ofHealth and Human Services or the United States Department of Health and HumanServices, or any successor agency, or its representatives. "Health benefitplan" also does not mean any of the following kinds of insurance:
a. Accident
b. Credit
c. Disability income
d. Long‑term careor nursing home care
e. Medicare supplement
f. Specified disease
g. Dental or vision
h. Short‑termlimited duration coverage
i. Coverage issued asa supplement to liability insurance
j. Workers'compensation
k. Medical paymentsunder automobile or homeowners
l . Hospital income orindemnity
m. Insurance under whichbenefits are payable with or without regard to fault and that is statutorilyrequired to be contained in any liability policy or equivalent self‑insurance.
(3) "Insurer"includes an insurance company subject to this Chapter, a service corporationorganized under Article 65 of this Chapter, a health maintenance organizationorganized under Article 67 of this Chapter, and a multiple employer welfarearrangement subject to Article 49 of this Chapter.
(4) "Qualifiedindividual" means any one or more of the following:
a. An individual who isestrogen‑deficient and at clinical risk of osteoporosis or low bone mass.
b. An individual withradiographic osteopenia anywhere in the skeleton.
c. An individual who isreceiving long‑term glucocorticoid (steroid) therapy.
d. An individual withprimary hyperparathyroidism.
e. An individual who isbeing monitored to assess the response to or efficacy of commonly acceptedosteoporosis drug therapies.
f. An individual whohas a history of low‑trauma fractures.
g. An individual withother conditions or on medical therapies known to cause osteoporosis or lowbone mass. (1999‑197, s. 1.)
§58‑3‑174. Coverage for bone mass measurement for diagnosis andevaluation of osteoporosis or low bone mass.
(a) Every entityproviding a health benefit plan shall provide coverage for a qualifiedindividual for scientifically proven and approved bone mass measurement for thediagnosis and evaluation of osteoporosis or low bone mass. The samedeductibles, coinsurance, and other limitations as apply to similar servicescovered under the plan shall apply to coverage for bone mass measurement.
(b) A health benefitplan may provide that bone mass measurement will be covered if at least 23months have elapsed since the last bone mass measurement was performed, exceptthat a plan must provide coverage for follow‑up bone mass measurementperformed more frequently than every 23 months if the follow‑upmeasurement is medically necessary. Conditions under which more frequent bonemass measurement coverage may be medically necessary include, but are notlimited to:
(1) Monitoringbeneficiaries on long‑term glucocorticoid therapy of more than threemonths.
(2) Allowing for acentral bone mass measurement to determine the effectiveness of adding anadditional treatment regimen for a qualified individual who is proven to havelow bone mass so long as the bone mass measurement is performed 12 to 18 monthsfrom the start date of the additional regimen.
(c) Nothing in thissection shall be construed to require health benefit plans to cover screeningfor nonqualified individuals.
(d) As used in thissection, the term:
(1) "Bone massmeasurement" means a scientifically proven radiologic, radioisotopic, orother procedure performed on a qualified individual to identify bone mass ordetect bone loss for the purpose of initiating or modifying treatment.
(2) "Health benefitplan" means an accident and health insurance policy or certificate; anonprofit hospital or medical service corporation contract; a healthmaintenance organization subscriber contract; a plan provided by a multipleemployer welfare arrangement; or a plan provided by another benefitarrangement, to the extent permitted by the Employee Retirement Income SecurityAct of 1974, as amended, or by any waiver of or other exception to that actprovided under federal law or regulation. "Health benefit plan" does notmean any plan implemented or administered by the North Carolina Department ofHealth and Human Services or the United States Department of Health and HumanServices, or any successor agency, or its representatives. "Health benefitplan" also does not mean any of the following kinds of insurance:
a. Accident
b. Credit
c. Disability income
d. Long‑term careor nursing home care
e. Medicare supplement
f. Specified disease
g. Dental or vision
h. Short‑termlimited duration coverage
i. Coverage issued asa supplement to liability insurance
j. Workers'compensation
k. Medical paymentsunder automobile or homeowners
l . Hospital income orindemnity
m. Insurance under whichbenefits are payable with or without regard to fault and that is statutorilyrequired to be contained in any liability policy or equivalent self‑insurance.
(3) "Insurer"includes an insurance company subject to this Chapter, a service corporationorganized under Article 65 of this Chapter, a health maintenance organizationorganized under Article 67 of this Chapter, and a multiple employer welfarearrangement subject to Article 49 of this Chapter.
(4) "Qualifiedindividual" means any one or more of the following:
a. An individual who isestrogen‑deficient and at clinical risk of osteoporosis or low bone mass.
b. An individual withradiographic osteopenia anywhere in the skeleton.
c. An individual who isreceiving long‑term glucocorticoid (steroid) therapy.
d. An individual withprimary hyperparathyroidism.
e. An individual who isbeing monitored to assess the response to or efficacy of commonly acceptedosteoporosis drug therapies.
f. An individual whohas a history of low‑trauma fractures.
g. An individual withother conditions or on medical therapies known to cause osteoporosis or lowbone mass. (1999‑197, s. 1.)
§58‑3‑174. Coverage for bone mass measurement for diagnosis andevaluation of osteoporosis or low bone mass.
(a) Every entityproviding a health benefit plan shall provide coverage for a qualifiedindividual for scientifically proven and approved bone mass measurement for thediagnosis and evaluation of osteoporosis or low bone mass. The samedeductibles, coinsurance, and other limitations as apply to similar servicescovered under the plan shall apply to coverage for bone mass measurement.
(b) A health benefitplan may provide that bone mass measurement will be covered if at least 23months have elapsed since the last bone mass measurement was performed, exceptthat a plan must provide coverage for follow‑up bone mass measurementperformed more frequently than every 23 months if the follow‑upmeasurement is medically necessary. Conditions under which more frequent bonemass measurement coverage may be medically necessary include, but are notlimited to:
(1) Monitoringbeneficiaries on long‑term glucocorticoid therapy of more than threemonths.
(2) Allowing for acentral bone mass measurement to determine the effectiveness of adding anadditional treatment regimen for a qualified individual who is proven to havelow bone mass so long as the bone mass measurement is performed 12 to 18 monthsfrom the start date of the additional regimen.
(c) Nothing in thissection shall be construed to require health benefit plans to cover screeningfor nonqualified individuals.
(d) As used in thissection, the term:
(1) "Bone massmeasurement" means a scientifically proven radiologic, radioisotopic, orother procedure performed on a qualified individual to identify bone mass ordetect bone loss for the purpose of initiating or modifying treatment.
(2) "Health benefitplan" means an accident and health insurance policy or certificate; anonprofit hospital or medical service corporation contract; a healthmaintenance organization subscriber contract; a plan provided by a multipleemployer welfare arrangement; or a plan provided by another benefitarrangement, to the extent permitted by the Employee Retirement Income SecurityAct of 1974, as amended, or by any waiver of or other exception to that actprovided under federal law or regulation. "Health benefit plan" does notmean any plan implemented or administered by the North Carolina Department ofHealth and Human Services or the United States Department of Health and HumanServices, or any successor agency, or its representatives. "Health benefitplan" also does not mean any of the following kinds of insurance:
a. Accident
b. Credit
c. Disability income
d. Long‑term careor nursing home care
e. Medicare supplement
f. Specified disease
g. Dental or vision
h. Short‑termlimited duration coverage
i. Coverage issued asa supplement to liability insurance
j. Workers'compensation
k. Medical paymentsunder automobile or homeowners
l . Hospital income orindemnity
m. Insurance under whichbenefits are payable with or without regard to fault and that is statutorilyrequired to be contained in any liability policy or equivalent self‑insurance.
(3) "Insurer"includes an insurance company subject to this Chapter, a service corporationorganized under Article 65 of this Chapter, a health maintenance organizationorganized under Article 67 of this Chapter, and a multiple employer welfarearrangement subject to Article 49 of this Chapter.
(4) "Qualifiedindividual" means any one or more of the following:
a. An individual who isestrogen‑deficient and at clinical risk of osteoporosis or low bone mass.
b. An individual withradiographic osteopenia anywhere in the skeleton.
c. An individual who isreceiving long‑term glucocorticoid (steroid) therapy.
d. An individual withprimary hyperparathyroidism.
e. An individual who isbeing monitored to assess the response to or efficacy of commonly acceptedosteoporosis drug therapies.
f. An individual whohas a history of low‑trauma fractures.
g. An individual withother conditions or on medical therapies known to cause osteoporosis or lowbone mass. (1999‑197, s. 1.)
