Required provision in policy covering mastectomies concerning coverage relating to mastectomy; prohibited acts

1. A policy of group health insurance which provides coverage for the surgical procedure known as a mastectomy must also provide commensurate coverage for: (a) Reconstruction of the breast on which the mastectomy has been performed; (b) Surgery and reconstruction of the other breast to produce a symmetrical structure; and (c) Prostheses and physical complications for all stages of mastectomy, including lymphedemas. 2. The provision of services must be determined by the attending physician and the patient. 3. The plan or issuer may require deductibles and coinsurance payments if they are consistent with those established for other benefits. 4. Written notice of the availability of the coverage must be given upon enrollment and annually thereafter. The notice must be sent to all participants: (a) In the next mailing made by the plan or issuer to the participant or beneficiary; or (b) As part of any annual information packet sent to the participant or beneficiary, Ê whichever is earlier. 5. A plan or issuer may not: (a) Deny eligibility, or continued eligibility, to enroll or renew coverage, in order to avoid the requirements of subsections 1 to 4, inclusive; or (b) Penalize, or limit reimbursement to, a provider of care, or provide incentives to a provider of care, in order to induce the provider not to provide the care listed in subsections 1 to 4, inclusive. 6. A plan or issuer may negotiate rates of reimbursement with providers of care. 7. If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal those amounts provided for in the policy at the time of the mastectomy. If the surgery is begun more than 3 years after the mastectomy, the benefits provided are subject to all of the terms, conditions and exclusions contained in the policy at the time of the reconstructive surgery. 8. A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after October 1, 2001, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void. 9. For the purposes of this section, “reconstructive surgery” means a surgical procedure performed following a mastectomy on one breast or both breasts to re-establish symmetry between the two breasts. The term includes augmentation mammoplasty, reduction mammoplasty and mastopexy.