Substitute Senate Bill No. 334
Substitute Senate Bill No. 334
PUBLIC ACT NO. 97-198
AN ACT CONCERNING INSURANCE COVERAGE FOR
MASTECTOMY AND BREAST RECONSTRUCTION AFTER
MASTECTOMY.
Be it enacted by the Senate and House of
Representatives in General Assembly convened:
Section 1. (NEW) (a) Each individual health
insurance policy providing coverage of the type
specified in subdivisions (1), (2), (4), (10),
(11) and (12) of section 38a-469 of the general
statutes delivered, issued for delivery, amended,
renewed or continued in this state on or after
July 1, 1997, shall provide coverage for at least
forty-eight hours of inpatient care following a
mastectomy or lymph node dissection, and shall
provide coverage for a longer period of inpatient
care if such care is recommended by the patient's
treating physician after conferring with the
patient. No such insurance policy may require
mastectomy surgery or lymph node dissection to be
performed on an outpatient basis. Outpatient
surgery or shorter inpatient care is allowable
under this section if the patient's treating
physician recommends such outpatient surgery or
shorter inpatient care after conferring with the
patient.
(b) No individual health insurance carrier may
terminate the services of, require additional
documentation from, require additional utilization
review, reduce payments or otherwise penalize or
provide financial disincentives to any attending
health care provider on the basis that the
provider orders care consistent with the
provisions of this section.
Sec. 2. (NEW) (a) Each group health insurance
policy providing coverage of the type specified in
subdivisions (1), (2), (4), (10), (11) and (12) of
section 38a-469 of the general statutes delivered,
issued for delivery, amended, renewed or continued
in this state on or after July 1, 1997, shall
provide coverage for at least forty-eight hours of
inpatient care following a mastectomy or lymph
node dissection, and shall provide coverage for a
longer period of inpatient care if such care is
recommended by the patient's treating physician
after conferring with the patient. No such
insurance policy may require mastectomy surgery or
lymph node dissection to be performed on an
outpatient basis. Outpatient surgery or shorter
inpatient care is allowable under this section if
the patient's treating physician recommends such
outpatient surgery or shorter inpatient care after
conferring with the patient.
(b) No group health insurance carrier may
terminate the services of, require additional
documentation from, require additional utilization
review, reduce payments or otherwise penalize or
provide financial disincentives to any attending
health care provider on the basis that the
provider orders care consistent with the
provisions of this section.
Sec. 3. Section 38a-504 of the general
statutes is repealed and the following is
substituted in lieu thereof:
(a) Any insurance company, hospital service
corporation, medical service corporation, health
care center or fraternal benefit society which
delivers or issues for delivery 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, and outpatient chemotherapy
following surgical procedure in connection with
the treatment of tumors. Such benefits shall be
subject to the same terms and conditions
applicable to all other benefits under such
policies.
(b) [The] 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 and three
hundred dollars for prosthesis, except that for
purposes of the surgical removal of breasts due to
tumors the yearly benefit for 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.
Sec. 4. Section 38a-542 of the general
statutes is repealed and the following is
substituted in lieu thereof:
(a) Any insurance company, hospital service
corporation, medical service corporation, health
care center or fraternal benefit society which
delivers or issues for delivery in this state
group health insurance policies providing coverage
of the type specified in subdivisions (1), (2),
(4), (11) and (12) of section 38a-469 [which
provide coverage for the surgical removal of
tumors] shall provide coverage under such policies
for 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 procedures in connection with the
treatment of tumors and costs of removal of any
breast implant which was implanted on or before
July 1, 1994, without regard to the purpose of
such implantation, which removal is determined to
be medically necessary. Such benefits shall be
subject to the same terms and conditions
applicable to all other benefits under such
policies.
(b) [The] 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 one thousand dollars for
the costs of removal of any breast implant, five
hundred dollars for the surgical removal of
tumors, five hundred dollars for reconstructive
surgery, five hundred dollars for outpatient
chemotherapy and three hundred dollars for
prosthesis, except that for purposes of the
surgical removal of breasts due to tumors the
yearly benefit for 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.
Sec. 5. This act shall take effect July 1,
1997.
Approved June 24, 1997