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