PRINTER'S NO. 4047
No. 2916 Session of 1998
INTRODUCED BY TRAVAGLIO, BELARDI, EVANS, ITKIN, TIGUE, THOMAS,
PETRONE, ORIE, READSHAW, KENNEY, HALUSKA, BEBKO-JONES,
E. Z. TAYLOR, MAHER, SHANER, C. WILLIAMS, HARHAI, LEDERER,
CAPPABIANCA, STABACK, MANDERINO, CORPORA, TANGRETTI,
McILHATTAN AND BOSCOLA, NOVEMBER 9, 1998
REFERRED TO COMMITTEE ON INSURANCE, NOVEMBER 9, 1998
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
1 following a lumpectomy or mastectomy performed in a health care
2 facility.
3 (2) Policies described in clause (1) of this subsection
4 shall provide coverage for inpatient care following a lumpectomy
5 or mastectomy for the length of stay that the treating physician
6 determines is necessary to meet generally accepted criteria for
7 safe discharge.
8 (3) Such policies shall also provide coverage for a home
9 health care visit that the treating physician determines is
10 necessary within forty-eight hours after discharge when the
11 discharge occurs within forty-eight hours following admission
12 for the lumpectomy or mastectomy.
13 (4) Coverage under this section shall, however, remain
14 subject to any copayment, coinsurance or deductible amounts set
15 forth in the policy.
16 (b) (1) Every health care policy which is delivered, issued
17 for delivery, renewed, extended or modified in this Commonwealth
18 by a health care insurer which provides coverage for the
19 surgical procedure known as lumpectomy or mastectomy shall also
20 include coverage for prosthetic devices and reconstructive
21 surgery incident to any lumpectomy or mastectomy.
22 (2) Coverage for prosthetic devices and reconstructive
23 surgery shall be subject to the deductible and coinsurance
24 conditions applied to the lumpectomy or mastectomy and all other
25 terms and conditions applicable to other benefits.
26 (3) The coverage for prosthetic devices inserted during
27 reconstructive surgery and reconstructive surgery pursuant to
28 this section may be limited to such surgical procedures
29 performed within six years of the date of the lumpectomy or
30 mastectomy.
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1 (c) This section shall not apply to the following types of
2 policies:
3 (1) Accident only.
4 (2) Limited benefit.
5 (3) Credit.
6 (4) Dental.
7 (5) Vision.
8 (6) Specified disease.
9 (7) Medicare supplement.
10 (8) Civilian Health and Medical Program of the Uniformed
11 Services (CHAMPUS) supplement.
12 (9) Long-term care or disability income.
13 (10) Workers' compensation.
14 (11) Automobile medical payment.
15 (d) (1) The term "health insurance policy" when used in
16 this section means any individual or group health insurance
17 policy, subscriber contract, certificate or plan which provides
18 medical or health care coverage by any health care facility or
19 licensed health care provider which is offered by or is governed
20 under this act or any of the following:
21 (i) Subarticle (f) of Article IV of the act of June 13, 1967
22 (P.L.31, No.21), known as the "Public Welfare Code."
23 (ii) The act of December 29, 1972 (P.L.1701, No.364), known
24 as the "Health Maintenance Organization Act."
25 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the
26 "Individual Accident and Sickness Insurance Minimum Standards
27 Act."
28 (iv) The act of December 14, 1992 (P.L.835, No.134), known
29 as the "Fraternal Benefit Societies Code."
30 (v) A nonprofit corporation subject to 40 Pa.C.S. Chs. 61
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1 (relating to hospital plan corporations) and 63 (relating to
2 professional health services plan corporations).
3 (2) The term "insurer" when used in this section means any
4 entity that issues an individual or group health insurance
5 policy, contract or plan described under clause (1) of this
6 subsection.
7 (2.1) The term "lumpectomy" when used in this section means
8 the removal of part of the breast for medically necessary
9 reasons as determined by a licensed physician.
10 (3) The term "mastectomy" when used in this section means
11 the removal of all or part of the breast for medically necessary
12 reasons as determined by a licensed physician.
13 (4) The term "prosthetic devices" when used in this section
14 means the use of initial and subsequent artificial devices to
15 replace the removed breast or portions thereof pursuant to an
16 order of the patient's physician.
17 (5) The term "reconstructive surgery" when used in this
18 section means a surgical procedure performed on one breast or
19 both breasts following a lumpectomy or mastectomy, as determined
20 by the treating physician, to reestablish symmetry between the
21 two breasts or alleviate functional impairment caused by the
22 lumpectomy or mastectomy. The term "reconstructive surgery"
23 shall include, but is not limited to, augmentation mammoplasty,
24 reduction mammoplasty and mastopexy.
25 (6) The term "symmetry between breasts" when used in this
26 section means approximate equality in size and shape of the
27 nondiseased breast with the diseased breast after definitive
28 reconstructive surgery on the diseased or nondiseased breast has
29 been performed.
30 Section 2. This act shall take effect immediately.
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