(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, which provides medical and surgical benefits with respect to mastectomy excluding supplemental policies which 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:
Terms Used In Rhode Island General Laws 27-18-39. Mastectomy treatment
- Group health plan: means an employee welfare benefit plan, as defined in 29 USC § 1002(1), to the extent that the plan provides health benefits to employees or their dependents directly or through insurance, reimbursement, or otherwise. See Rhode Island General Laws 27-18-1.1
- Health insurance carrier: means a person, firm, corporation or other entity subject to the jurisdiction of the commissioner under this chapter. See Rhode Island General Laws 27-18-1.1
- in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
- person: extends to and includes co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
- provider: means a health care professional or a health care facility. See Rhode Island General Laws 27-18-1.1
- United States: include the several states and the territories of the United States. See Rhode Island General Laws 43-3-8
(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 and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions applied to the mastectomy and consistent with those established for other benefits under the plan or coverage. As used in this section, “mastectomy” means the removal of all or part of a breast. Written notice of the availability of such 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 or surgeon.
(c) Nothing in this section shall be construed to require an individual or group policy to cover the surgical procedure known as mastectomy or to prevent application of deductible or co-payment provisions contained in the policy or plan, nor shall this section be construed to require that coverage under an individual or group policy be extended to any other procedures.
(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 such plan regarding the coverage required by this section in accordance with regulations promulgated by the United States Secretary of Health and Human Services. Such 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 such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
(P.L. 1996, ch. 66, § 1; P.L. 2002, ch. 292, § 33; P.L. 2004, ch. 41, § 1; P.L. 2004, ch. 45, § 1.)