Chapter
04-045
2004 -- S 2814 SUBSTITUTE A
Enacted 06/09/04
A N A C T
RELATING TO INSURANCE
Introduced By: Senators
Gibbs, and Parella
Date
Introduced: February 11, 2004
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) Every All individual or
group health insurance
contract, plan, or policy coverage and health benefit plans delivered,
issued for delivery or
renewed in this state on or
after January 1, 2005, which provides medical coverage that includes
coverage for physician services
in a physician's office, and every policy which provides major
medical or similar
comprehensive-type coverage and
surgical benefits with respect to mastectomy
excluding supplemental policies
which only provide coverage for specified diseases or other
supplemental policies, shall include
provide, in a case of any person covered in the individual
market or covered by a group
health plan coverage for: prosthetic
devices and or reconstructive
surgery to restore and achieve
symmetry for the patient incident to a mastectomy.
(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 and
the patient. Such Ccoverage for prosthetic devices and
reconstructive surgery shall may be
subject to the annual
deductibles and coinsurance conditions provisions applied
to the
mastectomy and consistent with
all other terms and conditions applicable to those established for
other benefits under the plan or
coverage. Any reconstructive surgery under this section must be
performed within eighteen (18)
months of the original mastectomy. As
used in this section,
"mastectomy" means the
removal of all or part of the a breast. to treat breast
cancer, tumor, or
mass. 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 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 authorize an insured or plan
member to
receive the coverage required by
this section if that coverage is furnished by a nonparticipating
provider, unless the insured or
plan member is referred to that provider by a participating
physician, nurse practitioner,
or certified nurse midwife providing care. 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) Every All individual or
group health insurance
contract, plan, or policy coverage and health benefit plans delivered,
issued for delivery or
renewed in this state on or
after January 1, 2005, which provides medical coverage that includes
coverage for physician services
in a physician's office, and every policy which provides major
medical or similar
comprehensive-type coverage, 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 include coverage for: prosthetic
devices and/or reconstructive surgery to
restore and achieve symmetry for
the patient incident to a mastectomy.
(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 and
the patient. Such Ccoverage for prosthetic devices and
reconstructive surgery shall may be
subject to the annual
deductibles and coinsurance conditions provisions applied
to the
mastectomy and consistent with
all other terms and conditions applicable to those established for
other benefits under the plan or
coverage. Any reconstructive surgery under this section must be
performed within eighteen (18)
months of the original mastectomy. As
used in this section,
"mastectomy" means the
removal of all or part of the a breast. to treat a
breast cancer, tumor, or
mass. Written notice of the availability of such
coverage shall be delivered to the participant
upon enrollment and annually
thereafter.
(b) Any
provision in any contract issued, amended, delivered or renewed in this state
which is in conflict with this
section shall be of no force or effect.
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 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 authorize an insured or plan
member to
receive the coverage required by
this section if that coverage is furnished by a nonparticipating
provider, unless the insured or
plan member is referred to that provider by a participating
physician, nurse practitioner,
or certified nurse midwife providing care. 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
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) Every All individual or
group health insurance
contract, plan or policy coverage and health benefit plans delivered,
issued for delivery or
renewed in this state on or after
January 1, 2005, which provides medical coverage that includes
coverage for physician services
in a physician's office, and every policy which provides major
medical or similar
comprehensive-type coverage, 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 include coverage for: prosthetic
devices or reconstructive surgery to restore
and achieve symmetry for the
patient incident to a mastectomy.
(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 and
the patient. Such Ccoverage for prosthetic devices and
reconstructive surgery may shall be
subject to the annual
deductibles and coinsurance conditions provisions applied
to the
mastectomy and all other terms
and conditions applicable to consistent with those established for
other benefits under the plan or
coverage. Any reconstructive surgery under this section must be
performed within eighteen (18)
months of the original mastectomy. As
used in this section,
"mastectomy" means the
removal of all or part of the a breast. to treat a
breast cancer, tumor, or
mass. Written notice of the availability of such
coverage shall be delivered to the participant
upon enrollment and annually
thereafter.
(b) Any
provision in any contract issued, amended, delivered or renewed in this state
which is in conflict with this
section shall be of no force or effect.
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 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 authorize an insured or plan
member to
receive the coverage required by
this section if that coverage is furnished by a nonparticipating
provider, unless the insured or
plan member is referred to that provider by a participating
physician, nurse practitioner,
or certified nurse midwife providing care. 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) Every All individual or group
health insurance
contract, plan, or policy 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 coverage that includes coverage for physician
services in a
physician's office, and every
policy which provides major medical or similar comprehensive-type
coverage, shall include provide, in a case of any
person covered in the individual market or
covered by a group health plan coverage for: prosthetic devices and or
reconstructive surgery to
restore and achieve symmetry for
the patient incident to a mastectomy.
(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 and
the patient. Such Ccoverage for prosthetic devices and
reconstructive surgery shall may be
subject to the annual
deductibles and coinsurance conditions provisions applied
to the
mastectomy and consistent with
all other terms and conditions applicable to those established for
other benefits under the plan or
coverage. Any reconstructive surgery under this section must be
performed within eighteen (18)
months of the original mastectomy. As
used in this section,
"mastectomy" means the
removal of all or part of the a breast. to treat a
breast cancer, tumor, or
mass. Written notice of the availability of such
coverage shall be delivered to the participant
upon enrollment and annually
thereafter.
(b) Any
provision in any contract issued, amended, delivered or renewed in this state
which is in conflict with this
section shall be of no force or effect.
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 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 authorize an insured or plan
member to
receive the coverage required by
this section if that coverage is furnished by a nonparticipating
provider, unless the insured or
plan member is referred to that provider by a participating
physician, nurse practitioner,
or certified nurse midwife providing care. 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 upon passage.
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LC02295/SUB A
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