§ 27-18-39. 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, that provide
medical and surgical benefits with respect to mastectomy, excluding supplemental policies
that only provide coverage for specified diseases or other supplemental policies,
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,
physician assistant as defined in § 5-54-2, or an advance practice registered nurse as defined in § 5-34-3, and the patient. As used in this section, "mastectomyâ€� means the removal of all
or part of a breast. Written notice of the availability of this 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,
physician assistant, advance practice registered nurse, or surgeon.
(c) [Deleted by P.L. 2018, ch. 114, § 1 and P.L. 2018, ch. 204, § 1].
(d) 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.
(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 the plan regarding the coverage required by this section in accordance
with regulations promulgated by the United States Secretary of Health and Human Services.
The 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
the provider to provide care to an individual participant or beneficiary in a manner
inconsistent with this section.