New York Law on Breast Reconstruction

BREAST RECONSTRUCTION SURGERY- INSURANCE COVERAGE

CHAPTER 21

S. 761-A, A. 1458-A

Approved March 18, 1997
Effective Jan. 1, 1998

AN ACT to amend the insurance law, in relation to coverage for breast reconstruction surgery after a mastectomy

The People of the State of New York, represented in Senate and Assembly, do enact as follows:

1. Subsection (i) of section 3216 of the insurance law is amended by adding a new paragraph 20 to read as follows:

(20) (A) Every policy which provides medical, major medical, or similar comprehensive type coverage shall provide the following coverage for breast reconstruction surgery after a mastectomy:

(i) all stages of reconstruction of the breast on which the mastectomy has been performed: and

(ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; in the manner determined by the attending physician and the patient to be appropriate. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. Written notice of the availability of such coverage shall be delivered to the policyholder prior to inception of such policy and annually thereafter.

B. An insurer providing coverage under this paragraph and any participating entity through which the insurer offers health services shall not:

(i) deny to a covered person eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy or vary the terms of the policy for the purpose or with the effect of avoiding compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered person to accept less than the minimum protections available under this paragraph;

(iii) penalize in any way or reduce or limit the compensation of a health care practitioner for recommending or providing care to a covered person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care practitioner relating to the services provided pursuant to this paragraph intended to induce or have the effect of inducing such practitioner to provide care to a covered person in a manner inconsistent with this paragraph; or

(v) restrict coverage for any portion of a period within a hospital length of stay required under this paragraph in a manner which is inconsistent with the coverage provided for any preceding portion of such stay.

(C) The prohibitions in this paragraph shall be in addition to the provisions of sections three thousand two hundred thirty-one and three thousand tow hundred thirty-two of this article and nothing in this paragraph shall be construed to suspend, supercede, amend or otherwise modify such sections.

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