2018 -- H 7002 SUBSTITUTE A

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LC003302/SUB A

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2018

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Shekarchi, Ajello, Tanzi, Fogarty, and Lima

     Date Introduced: January 03, 2018

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-18-39 of the General Laws in Chapter 27-18 entitled "Accident

and Sickness Insurance Policies" is hereby amended to read as follows:

     27-18-39. Mastectomy treatment.

     (a) All individual or group health insurance coverage and health benefit plans delivered,

issued for delivery or renewed in this state on or after January 1, 2005, which provides medical

and surgical benefits with respect to mastectomy excluding supplemental policies which only

provide coverage for specified diseases or other supplemental policies, shall provide, in a case of

any person covered in the individual market or covered by a group health plan coverage for:

     (1) Reconstruction of the breast on which the mastectomy has been performed;

     (2) Surgery and reconstruction of the other breast to produce a symmetrical appearance;

and

     (3) Prostheses and treatment of physical complications, including lymphademas, at all

stages of mastectomy; in a manner determined in consultation with the attending physician,

physician assistant as defined in § 5-54-2, or an advance practice registered nurse as defined in §

5-34-3, and the patient. Such coverage may be subject to annual deductibles and coinsurance

provisions applied to the mastectomy and consistent with those established for other benefits

under the plan or coverage. As used in this section, "mastectomy" means the removal of all or

part of a breast. Written notice of the availability of such coverage shall be delivered to the

participant upon enrollment and annually thereafter.

     (b) As used in this section, "prosthetic devices" means and includes the provision of

initial and subsequent prosthetic devices pursuant to an order of the patient's physician, physician

assistant, advance practice registered nurse, or surgeon.

     (c) Nothing in this section shall be construed to require an individual or group policy to

cover the surgical procedure known as mastectomy or to prevent application of deductible or co-

payment provisions contained in the policy or plan, nor shall this section be construed to require

that coverage under an individual or group policy be extended to any other procedures.

     (d) Nothing in this section shall be construed to prevent a group health plan or a health

insurance carrier offering health insurance coverage from negotiating the level and type of

reimbursement with a provider for care provided in accordance with this section.

     (e) Nothing in this section shall preclude the conducting of managed care reviews and

medical necessity reviews, by an insurer, hospital or medical service corporation or health

maintenance organization.

     (f) Notice. A group health plan, and a health insurance issuer providing health insurance

coverage in connection with a group health plan, shall provide notice to each participant and

beneficiary under such plan regarding the coverage required by this section in accordance with

regulations promulgated by the United States Secretary of Health and Human Services. Such

notice shall be in writing and prominently positioned in any literature or correspondence made

available or distributed by the plan or issuer and shall be transmitted as part of any yearly

informational packet sent to the participant or beneficiary.

     (g) Prohibitions. A group health plan and a health insurance carrier offering group or

individual health insurance coverage may not:

     (1) Deny to a patient eligibility, or continued eligibility, to enroll or renew coverage

under the terms of the plan, solely for the purpose of avoiding the requirements of this section;

nor

     (2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or

provide incentives (monetary or otherwise) to an attending provider, to induce such provider to

provide care to an individual participant or beneficiary in a manner inconsistent with this section.

     SECTION 2. Section 27-19-34 of the General Laws in Chapter 27-19 entitled "Nonprofit

Hospital Service Corporations" is hereby amended to read as follows:

     27-19-34. Mastectomy treatment.

     (a) All individual or group health insurance coverage and health benefit plans delivered,

issued for delivery or renewed in this state on or after January 1, 2005, which provides medical

and surgical benefits with respect to mastectomy shall provide, in a case of any person covered in

LC003302/SUB A - Page 2 of 7

the individual market or covered by a group health plan coverage for:

     (1) Reconstruction of the breast on which the mastectomy has been performed;

     (2) Surgery and reconstruction of the other breast to produce a symmetrical appearance;

and

     (3) Prostheses and treatment of physical complications, including lymphademas, at all

stages of mastectomy; in a manner determined in consultation with the attending physician,

physician assistant as defined in § 5-54-2, or an advance practice registered nurse as defined in §

5-34-3, and the patient. Such coverage may be subject to annual deductibles and coinsurance

provisions applied to the mastectomy and consistent with those established for other benefits

under the plan or coverage. As used in this section, "mastectomy" means the removal of all or

part of a breast. Written notice of the availability of such coverage shall be delivered to the

participant upon enrollment and annually thereafter.

     (b) Notice. A group health plan, and a health insurance issuer providing health insurance

coverage in connection with a group health plan, shall provide notice to each participant and

beneficiary under such plan regarding the coverage required by this section in accordance with

regulations promulgated by the United States Secretary of Health and Human Services. Such

notice shall be in writing and prominently positioned in any literature or correspondence made

available or distributed by the plan or issuer and shall be transmitted as part of any yearly

informational packet sent to the participant or beneficiary.

     (c) As used in this section, "prosthetic devices" means and includes the provisions of

initial and subsequent prosthetic devices pursuant to an order of the patient's physician, physician

assistant, advance practice registered nurse, or surgeon.

     (d) Nothing in this section shall be construed to require an individual or group policy to

cover the surgical procedure known as mastectomy or to prevent the application of deductible or

copayment provisions contained in the policy or plan, nor shall this section be construed to

require that coverage under an individual or group policy be extended to any other procedures.

     (e) Nothing in this section shall be construed to prevent a group health plan or a health

insurance carrier offering health insurance coverage from negotiating the level and type of

reimbursement with a provider for care provided in accordance with this section.

     (f) Nothing in this section shall preclude the conducting of managed care reviews and

medical necessity reviews by an insurer, hospital or medical service corporation or health

maintenance organization.

     (g) Prohibitions. A group health plan and a health insurance carrier offering group or

individual health insurance coverage may not:

LC003302/SUB A - Page 3 of 7

     (1) Deny to a patient eligibility, or continued eligibility, to enroll or renew coverage

under the terms of the plan, solely for the purpose of avoiding the requirements of this section;

nor

     (2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or

provide incentives (monetary or otherwise) to an attending provider, to induce such provider to

provide care to an individual participant or beneficiary in a manner inconsistent with this section.

     SECTION 3. Section 27-20-29 of the General Laws in Chapter 27-20 entitled "Nonprofit

Medical Service Corporations" is hereby amended to read as follows:

     27-20-29. Mastectomy treatment.

     (a) All individual or group health insurance coverage and health benefit plans delivered,

issued for delivery or renewed in this state on or after January 1, 2005, which provides medical

and surgical benefits with respect to mastectomy shall provide, in a case of any person covered in

the individual market or covered by a group health plan coverage for:

     (1) Reconstruction of the breast on which the mastectomy has been performed;

     (2) Surgery and reconstruction of the other breast to produce a symmetrical appearance;

and

     (3) Prostheses and treatment of physical complications, including lymphademas, at all

stages of mastectomy; in a manner determined in consultation with the attending physician,

physician assistant as defined in § 5-54-2, or an advance practice registered nurse as defined in §

5-34-3, and the patient. Such coverage may be subject to annual deductibles and coinsurance

provisions applied to the mastectomy and consistent with those established for other benefits

under the plan or coverage. As used in this section, "mastectomy" means the removal of all or

part of a breast. Written notice of the availability of such coverage shall be delivered to the

participant upon enrollment and annually thereafter.

     (b) Notice. A group health plan, and a health insurance issuer providing health insurance

coverage in connection with a group health plan, shall provide notice to each participant and

beneficiary under such plan regarding the coverage required by this section in accordance with

regulations promulgated by the United States Secretary of Health and Human Services. Such

notice shall be in writing and prominently positioned in any literature or correspondence made

available or distributed by the plan or issuer and shall be transmitted as part of any yearly

informational packet sent to the participant or beneficiary.

     (c) As used in this section, "prosthetic devices" means and includes the provision of

initial and subsequent prosthetic devices pursuant to an order of the patient's physician, physician

assistant, advance practice registered nurse, or surgeon.

LC003302/SUB A - Page 4 of 7

     (d) Nothing in this section shall be construed to require an individual or group policy to

cover the surgical procedure known as mastectomy or to prevent the application of deductible or

copayment provisions contained in the policy or plan, nor shall this section be construed to

require that coverage under an individual or group policy be extended to any other procedures.

     (e) Nothing in this section shall be construed to prevent a group health plan or a health

insurance carrier offering health insurance coverage from negotiating the level and type of

reimbursement with a provider for care provided in accordance with this section.

     (f) Nothing in this section shall preclude the conducting of managed care reviews and

medical necessity reviews by an insurer, hospital or medical service corporation or health

maintenance organization.

     (g) Prohibitions. A group health plan and a health insurance carrier offering group or

individual health insurance coverage may not:

     (1) Deny to a patient eligibility, or continued eligibility, to enroll or renew coverage

under the terms of the plan, solely for the purpose of avoiding the requirements of this section;

nor

     (2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or

provide incentives (monetary or otherwise) to an attending provider, to induce such provider to

provide care to an individual participant or beneficiary in a manner inconsistent with this section.

     SECTION 4. Section 27-41-43 of the General Laws in Chapter 27-41 entitled "Health

Maintenance Organizations" is hereby amended to read as follows:

     27-41-43. Mastectomy treatment.

     (a) All individual or group health insurance coverage and health benefit plans delivered,

issued for delivery or renewed in this state on or after January 1, 2005, which provides medical

and surgical benefits with respect to mastectomy shall provide, in a case of any person covered in

the individual market or covered by a group health plan coverage for:

     (1) Reconstruction of the breast on which the mastectomy has been performed;

     (2) Surgery and reconstruction of the other breast to produce a symmetrical appearance;

and

     (3) Prostheses and treatment of physical complications, including lymphademas, at all

stages of mastectomy; in a manner determined in consultation with the attending physician,

physician assistant as defined in § 5-54-2, or an advance practice registered nurse as defined in §

5-34-3, and the patient. Such coverage may be subject to annual deductibles and coinsurance

provisions applied to the mastectomy and consistent with those established for other benefits

under the plan or coverage. As used in this section, "mastectomy" means the removal of all or

LC003302/SUB A - Page 5 of 7

part of a breast. Written notice of the availability of such coverage shall be delivered to the

participant upon enrollment and annually thereafter.

     (b) Notice. A group health plan, and a health insurance issuer providing health insurance

coverage in connection with a group health plan, shall provide notice to each participant and

beneficiary under such plan regarding the coverage required by this section in accordance with

regulations promulgated by the United States Secretary of Health and Human Services. Such

notice shall be in writing and prominently positioned in any literature or correspondence made

available or distributed by the plan or issuer and shall be transmitted as part of any yearly

informational packet sent to the participant or beneficiary.

     (c) As used in this section, "prosthetic devices" means and includes the provision of

initial and subsequent prosthetic devices pursuant to an order of the patient's physician, physician

assistant, advance practice registered nurse, or surgeon.

     (d) (1) Nothing in this section shall be construed to require an individual or group policy

to cover the surgical procedure known as mastectomy or to prevent application of deductible or

copayment provisions contained in the policy or plan, nor shall this section be construed to

require that coverage under an individual or group policy be extended to any other procedures.

     (2) Nothing in this section shall be construed to prevent a group health plan or a health

insurance carrier offering health insurance coverage from negotiating the level and type of

reimbursement with a provider for care provided in accordance with this section.

     (3) Nothing in this section shall preclude the conducting of managed care reviews and

medical necessity reviews, by an insurer, hospital or medical service corporation or health

maintenance organization.

     (4) Prohibitions. A group health plan and a health insurance carrier offering group or

individual health insurance coverage may not:

     (i) Deny to a patient eligibility, or continued eligibility, to enroll or renew coverage under

the terms of the plan, solely for the purpose of avoiding the requirements of this section; nor

     (ii) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or

provide incentives (monetary or otherwise) to an attending provider, to induce such provider to

provide care to an individual participant or beneficiary in a manner inconsistent with this section.

     SECTION 5. This act shall take effect on January 1, 2019.

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LC003302/SUB A

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LC003302/SUB A - Page 6 of 7

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would require individual or group policy insurance to cover mastectomies.

     This act would take effect on January 1, 2019.

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LC003302/SUB A

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LC003302/SUB A - Page 7 of 7