§ 38a-504 — (Formerly Sec. 38-262i). Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Orally administered anticancer medications.

Connecticut § 38a-504

• Jurisdiction: Connecticut
• Title 38a: Insurance
• Ch. 700c: Health Insurance

Text

(a) Each insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state individual health insurance policies providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469, shall provide coverage under such policies for the surgical removal of tumors and treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost of any nondental prosthesis including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, outpatient chemotherapy following surgical procedure in connection with the treatment of tumors, and a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies. (b) Except as provided in subsection (c) of this section, the coverage required by subsection (a) of this section shall provide at least a yearly benefit of five hundred dollars for the surgical removal of tumors, five hundred dollars for reconstructive surgery, five hundred dollars for outpatient chemotherapy, three hundred fifty dollars for a wig and three hundred dollars for a nondental prosthesis, except that for purposes of the surgical removal of breasts due to tumors the yearly benefit for such prosthesis shall be at least three hundred dollars for each breast removed. (c) The coverage required by subsection (a) of this section shall provide benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a nondiseased breast to produce a symmetrical appearance. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies. For the purposes of this subsection, reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy. (d) (1) Each policy of the type specified in subsection (a) of this section that provides coverage for intravenously administered and orally administered anticancer medications used to kill or slow the growth of cancerous cells that are prescribed by a prescribing practitioner, as defined in section 20-571 , shall provide coverage for orally administered anticancer medications on a basis that is no less favorable than intravenously administered anticancer medications. (2) No insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state a policy of the type specified in subsection (a) of this section shall reclassify such anticancer medications or increase the coinsurance, copayment, deductible or other out-of-pocket expense imposed under such policy for such medications to achieve compliance with this subsection. See Ch. 700d re fraternal benefit societies. See Secs. 38a-199 to 38a-209, inclusive, re hospital service corporations. See Secs. 38a-214 to 38a-225, inclusive, re medical service corporations. See Sec. 38a-542 for similar provisions re group policies. See Sec. 38a-800 re fraternal agents.

Legislative History

(P.A. 79-327, S. 2; P.A. 86-54; P.A. 87-40; 87-275, S. 2; P.A. 90-243, S. 94; P.A. 97-198, S. 3, 5; P.A. 98-27, S. 17; P.A. 04-34, S. 1; P.A. 10-5, S. 24; 10-63, S. 1; P.A. 11-19, S. 10.) History: P.A. 86-54 clarified the section by limiting its applicability to individual and group medical expense insurance policies and contract plans, rather than to all individual and group health insurance policies and contract plans; P.A. 87-40 amended Subsec. (c) to increase the minimum coverage requirement for prosthesis from $200 to $300; P.A. 87-275 amended Subsec. (c) to provide that the yearly benefit for prosthesis shall be at least $300 for each breast surgically removed due to tumors; P.A. 90-243 deleted former Subsec. (a) re group coverages, relettered the remaining Subsecs., added references to health care centers, substituted references to health insurance policies for references to medical expense policies or contracts; Sec. 38-262i transferred to Sec. 38a-504 in 1991; P.A. 97-198 added exception in Subsec. (b) and added new Subsec. (c) re breast reconstruction after mastectomy, effective July 1, 1997; P.A. 98-27 amended Subsec. (a) to delete reference to Sec. 38a-469(6); P.A. 04-34 amended Subsec. (a) to substitute “Each” for “Any” and require coverage for a wig if prescribed for a patient who suffers hair loss as a result of chemotherapy and amended Subsec. (b) to require a yearly benefit of $350 for a wig; P.A. 10-5 made technical changes in Subsecs. (a) and (b), effective January 1, 2011; P.A. 10-63 made technical changes in Subsecs. (a) and (b), and added Subsec. (d) re orally administered anticancer medications, effective January 1, 2011; P.A. 11-19 made technical changes in Subsec. (d).