TITLE 27
Insurance

CHAPTER 27-19
Nonprofit Hospital Service Corporations

SECTION 27-19-34


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

History of Section.
(P.L. 1996, ch. 66, § 2; P.L. 2002, ch. 292, § 37; P.L. 2004, ch. 41, § 2; P.L. 2004, ch. 45, § 2.)