Sec. 38a-504. (Formerly Sec. 38-262i). Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis and chemotherapy. Mandatory coverage for breast reconstruction after mastectomy. (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) 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.

(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.)

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 two hundred to three hundred dollars; P.A. 87-275 amended Subsec. (c) to provide that the yearly benefit for prosthesis shall be at least three hundred dollars 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 Subdiv. (6) of Sec. 38a-469.

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 Secs. 38a-595 to 38a-626, inclusive, 38a-631 to 38a-640, inclusive, and 38a-800 re fraternal benefit societies.

          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

Copyright 2000-2007 Alex Keller, MD, FACS. pc.  All rights reserved.