PRINTER'S NO. 768
No. 721 Session of 1999
INTRODUCED BY TRAVAGLIO, BELARDI, M. COHEN, EVANS, THOMAS,
MARKOSEK, STURLA, LEDERER, TRELLO, E. Z. TAYLOR, SEYFERT AND
HARHAI, MARCH 8, 1999
REFERRED TO COMMITTEE ON INSURANCE, MARCH 8, 1999
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," providing for lumpectomy
12 reconstruction.
13 The General Assembly of the Commonwealth of Pennsylvania
14 hereby enacts as follows:
15 Section 1. Section 633 of the act of May 17, 1921 (P.L.682,
16 No.284), known as The Insurance Company Law of 1921, added
17 November 4, 1997 (P.L.492, No.51), is amended to read:
18 Section 633. Lumpectomy, Mastectomy and Breast Cancer
19 Reconstruction.--(a) (1) No health insurance policy delivered,
20 issued, executed or renewed in this Commonwealth on or after the
21 effective date of this section shall require outpatient care
22 following a lumpectomy or mastectomy performed in a health care
1 facility.
2 (2) Policies described in clause (1) of this subsection
3 shall provide coverage for inpatient care following a lumpectomy
4 or mastectomy for the length of stay that the treating physician
5 determines is necessary to meet generally accepted criteria for
6 safe discharge.
7 (3) Such policies shall also provide coverage for a home
8 health care visit that the treating physician determines is
9 necessary within forty-eight hours after discharge when the
10 discharge occurs within forty-eight hours following admission
11 for the lumpectomy or mastectomy.
12 (4) Coverage under this section shall, however, remain
13 subject to any copayment, coinsurance or deductible amounts set
14 forth in the policy.
15 (b) (1) Every health care policy which is delivered, issued
16 for delivery, renewed, extended or modified in this Commonwealth
17 by a health care insurer which provides coverage for the
18 surgical procedure known as lumpectomy or mastectomy shall also
19 include coverage for prosthetic devices and reconstructive
20 surgery incident to any lumpectomy or mastectomy.
21 (2) Coverage for prosthetic devices and reconstructive
22 surgery shall be subject to the deductible and coinsurance
23 conditions applied to the lumpectomy or mastectomy and all other
24 terms and conditions applicable to other benefits.
25 (3) The coverage for prosthetic devices inserted during
26 reconstructive surgery and reconstructive surgery pursuant to
27 this section may be limited to such surgical procedures
28 performed within six years of the date of the lumpectomy or
29 mastectomy.
30 (c) This section shall not apply to the following types of
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1 policies:
2 (1) Accident only.
3 (2) Limited benefit.
4 (3) Credit.
5 (4) Dental.
6 (5) Vision.
7 (6) Specified disease.
8 (7) Medicare supplement.
9 (8) Civilian Health and Medical Program of the Uniformed
10 Services (CHAMPUS) supplement.
11 (9) Long-term care or disability income.
12 (10) Workers' compensation.
13 (11) Automobile medical payment.
14 (d) (1) The term "health insurance policy" when used in
15 this section means any individual or group health insurance
16 policy, subscriber contract, certificate or plan which provides
17 medical or health care coverage by any health care facility or
18 licensed health care provider which is offered by or is governed
19 under this act or any of the following:
20 (i) Subarticle (f) of Article IV of the act of June 13, 1967
21 (P.L.31, No.21), known as the "Public Welfare Code."
22 (ii) The act of December 29, 1972 (P.L.1701, No.364), known
23 as the "Health Maintenance Organization Act."
24 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the
25 "Individual Accident and Sickness Insurance Minimum Standards
26 Act."
27 (iv) The act of December 14, 1992 (P.L.835, No.134), known
28 as the "Fraternal Benefit Societies Code."
29 (v) A nonprofit corporation subject to 40 Pa.C.S. Chs. 61
30 (relating to hospital plan corporations) and 63 (relating to
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1 professional health services plan corporations).
2 (2) The term "insurer" when used in this section means any
3 entity that issues an individual or group health insurance
4 policy, contract or plan described under clause (1) of this
5 subsection.
6 (2.1) The term "lumpectomy" when used in this section means
7 the removal of part of the breast for medically necessary
8 reasons as determined by a licensed physician.
9 (3) The term "mastectomy" when used in this section means
10 the removal of all or part of the breast for medically necessary
11 reasons as determined by a licensed physician.
12 (4) The term "prosthetic devices" when used in this section
13 means the use of initial and subsequent artificial devices to
14 replace the removed breast or portions thereof pursuant to an
15 order of the patient's physician.
16 (5) The term "reconstructive surgery" when used in this
17 section means a surgical procedure performed on one breast or
18 both breasts following a lumpectomy or mastectomy, as determined
19 by the treating physician, to reestablish symmetry between the
20 two breasts or alleviate functional impairment caused by the
21 lumpectomy or mastectomy. The term "reconstructive surgery"
22 shall include, but is not limited to, augmentation mammoplasty,
23 reduction mammoplasty and mastopexy.
24 (6) The term "symmetry between breasts" when used in this
25 section means approximate equality in size and shape of the
26 nondiseased breast with the diseased breast after definitive
27 reconstructive surgery on the diseased or nondiseased breast has
28 been performed.
29 Section 2. This act shall take effect immediately.
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