Chapter 114
2018 -- H 7002 SUBSTITUTE A
Enacted 07/02/2018

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

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 that provides
provide medical and surgical benefits with respect to mastectomy, excluding supplemental
policies which that 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 this 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 the plan regarding the coverage required by this section in accordance
with regulations promulgated by the United States Secretary of Health and Human Services. Such
The 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 the 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 that
provide 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 this 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 the plan regarding the coverage required by this section in accordance
with regulations promulgated by the United States Secretary of Health and Human Services. Such
The 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
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) 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 the 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 that
provide 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 the plan regarding the coverage required by this section in accordance
with regulations promulgated by the United States Secretary of Health and Human Services. Such
The 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) 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 the 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 that
provide 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 the plan regarding the coverage required by this section in accordance
with regulations promulgated by the United States Secretary of Health and Human Services. Such
The 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 the 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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