Chapter 04-041

2004 -- H 8167 SUBSTITUTE A

Enacted 06/09/04

A N A C T

RELATING TO INSURANCE

Introduced By: Representative Susan A. Story

Date Introduced: February 25, 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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LC02471/SUB A

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