§ 27-41-43 - Mastectomy treatment. - Rhode Island Statutes

SECTION 27-41-43

   § 27-41-43  Mastectomy treatment. –(a) All individual or group health insurance coverage and health benefit plansdelivered, issued for delivery or renewed in this state on or after January 1,2005, which provides medical and surgical benefits with respect to mastectomyshall provide, in a case of any person covered in the individual market orcovered by a group health plan coverage for:

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

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

   (3) Prostheses and treatment of physical complications,including lymphademas, at all stages of mastectomy; in a manner determined inconsultation with the attending physician and the patient. Such coverage may besubject to annual deductibles and coinsurance provisions applied to themastectomy and consistent with those established for other benefits under theplan or coverage. As used in this section, "mastectomy" means the removal ofall or part of a breast. Written notice of the availability of such coverageshall be delivered to the participant upon enrollment and annually thereafter.

   (b) Notice. A group health plan, and a healthinsurance issuer providing health insurance coverage in connection with a grouphealth plan, shall provide notice to each participant and beneficiary undersuch plan regarding the coverage required by this section in accordance withregulations promulgated by the United States Secretary of Health and HumanServices. Such notice shall be in writing and prominently positioned in anyliterature or correspondence made available or distributed by the plan orissuer and shall be transmitted as part of any yearly informational packet sentto the participant or beneficiary.

   (c) As used in this section, "prosthetic devices" means andincludes the provision of initial and subsequent prosthetic devices pursuant toan order of the patient's physician or surgeon.

   (d) Nothing in this section shall be construed to require anindividual or group policy to cover the surgical procedure known as mastectomyor to prevent application of deductible or copayment provisions contained inthe policy or plan, nor shall this section be construed to require thatcoverage under an individual or group policy be extended to any otherprocedures.

   (2) Nothing in this section shall be construed to prevent agroup health plan or a health insurance carrier offering health insurancecoverage from negotiating the level and type of reimbursement with a providerfor care provided in accordance with this section.

   (3) Nothing in this section shall preclude the conducting ofmanaged care reviews and medical necessity reviews, by an insurer, hospital ormedical service corporation or health maintenance organization.

   (4) Prohibitions. A group health plan and a healthinsurance carrier offering group or individual health insurance coverage maynot:

   (i) Deny to a patient eligibility, or continued eligibility,to enroll or renew coverage under the terms of the plan, solely for the purposeof avoiding the requirements of this section; nor

   (ii) Penalize or otherwise reduce or limit the reimbursementof an attending provider, or provide incentives (monetary or otherwise) to anattending provider, to induce such provider to provide care to an individualparticipant or beneficiary in a manner inconsistent with this section.