PRIOR PRINTER'S NOS. 170, 931 PRINTER'S NO. 1024
No. 176 Session of 1997
INTRODUCED BY HOLL, JANUARY 21, 1997
AS AMENDED ON THIRD CONSIDERATION, APRIL 28, 1997
AN ACT
1 Providing mastectomy and breast cancer reconstructive surgery
2 coverage standards for health insurance policies.
3 TABLE OF CONTENTS <--
4 Chapter 1. Preliminary Provisions
5 Section 101. Short title.
6 Section 102. Scope.
7 Chapter 3. Mastectomy Coverage
8 Section 301. Definitions.
9 Section 302. Mastectomy coverage standards.
10 Chapter 5. Breast Cancer Reconstructive Surgery Coverage
11 Section 501. Declaration of policy.
12 Section 502. Definitions.
13 Section 503. Mandated coverage for reconstructive surgery
14 incident to mastectomy.
15 Section 504. Applicability.
16 Chapter 51. Miscellaneous Provisions
17 Section 5101. Effective date.
1 TABLE OF CONTENTS
2 SECTION 1. SHORT TITLE. <--
3 SECTION 2. DECLARATION OF POLICY.
4 SECTION 3. SCOPE.
5 SECTION 4. DEFINITIONS.
6 SECTION 5. MASTECTOMY COVERAGE STANDARDS.
7 SECTION 6. BREAST CANCER RECONSTRUCTIVE SURGERY COVERAGE.
8 SECTION 7. APPLICABILITY.
9 SECTION 8. EFFECTIVE DATE.
10 The General Assembly of the Commonwealth of Pennsylvania
11 hereby enacts as follows:
12 CHAPTER 1 <--
13 PRELIMINARY PROVISIONS
14 Section 101. Short title.
15 This act shall be known and may be cited as the Mastectomy
16 and Breast Cancer Reconstructive Surgery Coverage Standards Act.
17 Section 102. Scope.
18 This act shall not apply to the following types of policies:
19 (1) Accident only.
20 (2) Limited benefit.
21 (3) Credit.
22 (4) Dental.
23 (5) Vision.
24 (6) Specified disease.
25 (7) Medicare supplement.
26 (8) Civilian Health and Medical Program of the Uniformed
27 Services (CHAMPUS) supplement.
28 (9) Long-term care or disability income.
29 (10) Workers' compensation.
30 (11) Automobile medical payment.
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1 CHAPTER 3
2 MASTECTOMY COVERAGE
3 Section 301. Definitions.
4 The following words and phrases when used in this chapter
5 shall have the meanings given to them in this section unless the
6 context clearly indicates otherwise:
7 "Health insurance policy." Any individual or group health
8 insurance policy, contract or plan which provides medical or
9 health care coverage by any health care facility or licensed
10 health care provider on an expense-incurred service or prepaid
11 basis and which is offered by or is governed under any of the
12 following:
13 Act of May 17, 1921 (P.L.682, No.284), known as The
14 Insurance Company Law of 1921.
15 Subarticle (f) of Article IV of the act of June 13, 1967
16 (P.L.31, No.21), known as the Public Welfare Code.
17 Act of December 29, 1972 (P.L.1701, No.364), known as the
18 Health Maintenance Organization Act.
19 Act of May 18, 1976 (P.L.123, No.54), known as the
20 Individual Accident and Sickness Insurance Minimum Standards
21 Act.
22 Act of December 14, 1992 (P.L.835, No.134), known as the
23 Fraternal Benefit Societies Code.
24 A nonprofit corporation subject to 40 Pa.C.S. Chs. 61
25 (relating to hospital plan corporations) and 63 (relating to
26 professional health services plan corporations).
27 "Insurer." Any entity that issues an individual or group
28 health insurance policy, contract or plan described under the
29 definition of "health insurance policy" in this section.
30 Section 302. Mastectomy coverage standards.
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1 (a) Outpatient care.--No health insurance policy delivered,
2 issued, executed or renewed in this Commonwealth on or after the
3 effective date of this chapter shall require outpatient care
4 following a mastectomy performed in a health care facility.
5 (b) Inpatient care.--Policies described in subsection (a)
6 shall provide coverage for inpatient care following a mastectomy
7 for the length of stay that the treating physician determines is
8 necessary to meet generally accepted criteria for safe
9 discharge.
10 (c) Limitations.--Coverage under this chapter shall,
11 however, remain subject to any copayment, coinsurance or
12 deductible amounts set forth in the policy.
13 CHAPTER 5
14 BREAST CANCER RECONSTRUCTIVE SURGERY COVERAGE
15 Section 501. Declaration of policy.
16 The General Assembly finds and declares as follows:
17 (1) Breast cancer is the most common cancer in American
18 women, afflicting 182,000 women per year, striking one out of
19 9 and killing 46,000 a year. Coping with this disease is a
20 medical and emotional struggle since it carries with it the
21 fear of disfigurement in a society that places great value on
22 physical appearance.
23 (2) Some insurance carriers deny coverage for breast
24 reconstruction, considering the procedure not medically
25 necessary. Most insurance companies will not cover procedures
26 on the opposite breast to provide symmetry for the
27 reconstruction, but do cover reconstruction of other body
28 parts, which is discriminatory.
29 Section 502. Definitions.
30 The following words and phrases when used in this chapter
19970S0176B1024 - 4 -
1 shall have the meanings given to them in this section unless the
2 context clearly indicates otherwise:
3 "Health insurance policy." Any individual or group health,
4 sickness or accident policy or subscriber contract or
5 certificate issued by an entity subject to any one of the
6 following:
7 Act of May 17, 1921 (P.L.682, No.284), known as The
8 Insurance Company Law of 1921.
9 Act of December 29, 1972 (P.L.1701, No.364), known as the
10 Health Maintenance Organization Act.
11 Act of May 18, 1976 (P.L.123, No.54), known as the
12 Individual Accident and Sickness Insurance Minimum Standards
13 Act.
14 Act of December 14, 1992 (P.L.835, No.134), known as the
15 Fraternal Benefit Societies Code.
16 40 Pa.C.S. Ch. 61 (relating to hospital plan
17 corporations) or 63 (relating to professional health services
18 plan corporations).
19 Medical assistance.
20 "Mastectomy." The removal of all or part of the breast for
21 medically necessary reasons, as determined by a licensed
22 physician.
23 "Prosthetic devices." The use of initial and subsequent
24 artificial devices to replace the removed breast or portions
25 thereof, pursuant to an order of the patient's physician.
26 "Reconstructive surgery." A surgical procedure performed
27 following a mastectomy on one breast or both breasts, as
28 determined by a licensed physician, to restore and achieve
29 symmetry between the two breasts. This term shall include, but
30 is not limited to, augmentation mammoplasty, reduction
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1 mammoplasty and mastopexy.
2 "Symmetry between breasts." Equality in size of the
3 nondiseased breast with the diseased breast after definitive
4 reconstructive surgery on the diseased breast has been
5 performed.
6 Section 503. Mandated coverage for reconstructive surgery
7 incident to mastectomy.
8 (a) Included coverage.--Every health care policy which is
9 delivered, issued for delivery, renewed, extended or modified in
10 this Commonwealth by a health care insurer which provides
11 coverage for the surgical procedure known as mastectomy shall
12 also include coverage for prosthetic devices and reconstructive
13 surgery incident to the mastectomy, which shall include
14 reconstructive surgery to restore and achieve symmetry of the
15 opposite breast after mastectomy.
16 (b) Deductible and coinsurance.--Coverage for prosthetic
17 devices and reconstructive surgery shall be subject to the
18 deductible and coinsurance conditions applied to the mastectomy
19 and all other terms and conditions applicable to other benefits.
20 (c) Limitations.--In the event that a mastectomy is
21 performed and there is no evidence of malignancy, the coverage
22 for prosthetic devices inserted during reconstructive surgery
23 and reconstructive surgery in this section may be limited to
24 such surgical procedures performed within two years of the date
25 of the mastectomy.
26 Section 504. Applicability.
27 This chapter shall apply to all insurance policies,
28 subscriber contracts and group insurance certificates issued
29 under any group master policy delivered or issued for delivery
30 on or after the effective date of this chapter. This chapter
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1 shall also apply to all renewals of contracts on any renewal
2 date which is on or after the effective date of this chapter.
3 CHAPTER 51
4 MISCELLANEOUS PROVISIONS
5 Section 5101. Effective date.
6 This act shall take effect as follows:
7 (1) Chapter 3 shall take effect in 90 days.
8 (2) This section shall take effect immediately.
9 (3) The remainder of this act shall take effect in 60
10 days.
11 SECTION 1. SHORT TITLE. <--
12 THIS ACT SHALL BE KNOWN AND MAY BE CITED AS THE MASTECTOMY
13 AND BREAST CANCER RECONSTRUCTIVE SURGERY COVERAGE STANDARDS ACT.
14 SECTION 2. DECLARATION OF POLICY.
15 THE GENERAL ASSEMBLY FINDS AND DECLARES AS FOLLOWS:
16 (1) BREAST CANCER IS THE MOST COMMON CANCER IN AMERICAN
17 WOMEN, AFFLICTING 182,000 WOMEN PER YEAR, STRIKING ONE OUT OF
18 9 AND KILLING 46,000 A YEAR. COPING WITH THIS DISEASE IS A
19 MEDICAL AND EMOTIONAL STRUGGLE SINCE IT CARRIES WITH IT THE
20 FEAR OF DISFIGUREMENT IN A SOCIETY THAT PLACES GREAT VALUE ON
21 PHYSICAL APPEARANCE.
22 (2) SOME INSURANCE CARRIERS DENY COVERAGE FOR BREAST
23 RECONSTRUCTION, CONSIDERING THE PROCEDURE NOT MEDICALLY
24 NECESSARY. MOST INSURANCE COMPANIES WILL NOT COVER PROCEDURES
25 ON THE OPPOSITE BREAST TO PROVIDE SYMMETRY FOR THE
26 RECONSTRUCTION, BUT DO COVER RECONSTRUCTION OF OTHER BODY
27 PARTS, WHICH IS DISCRIMINATORY.
28 SECTION 3. SCOPE.
29 THIS ACT SHALL NOT APPLY TO THE FOLLOWING TYPES OF POLICIES:
30 (1) ACCIDENT ONLY.
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1 (2) LIMITED BENEFIT.
2 (3) CREDIT.
3 (4) DENTAL.
4 (5) VISION.
5 (6) SPECIFIED DISEASE.
6 (7) MEDICARE SUPPLEMENT.
7 (8) CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED
8 SERVICES (CHAMPUS) SUPPLEMENT.
9 (9) LONG-TERM CARE OR DISABILITY INCOME.
10 (10) WORKERS' COMPENSATION.
11 (11) AUTOMOBILE MEDICAL PAYMENT.
12 SECTION 4. DEFINITIONS.
13 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ACT SHALL
14 HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
15 CONTEXT CLEARLY INDICATES OTHERWISE:
16 "HEALTH INSURANCE POLICY." ANY INDIVIDUAL OR GROUP HEALTH
17 INSURANCE POLICY, SUBSCRIBER CONTRACT, CERTIFICATE OR PLAN WHICH
18 PROVIDES MEDICAL OR HEALTH CARE COVERAGE BY ANY HEALTH CARE
19 FACILITY OR LICENSED HEALTH CARE PROVIDER WHICH IS OFFERED BY OR
20 IS GOVERNED UNDER ANY OF THE FOLLOWING:
21 ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN AS THE
22 INSURANCE COMPANY LAW OF 1921.
23 SUBARTICLE (F) OF ARTICLE IV OF THE ACT OF JUNE 13, 1967
24 (P.L.31, NO.21), KNOWN AS THE PUBLIC WELFARE CODE.
25 ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN AS THE
26 HEALTH MAINTENANCE ORGANIZATION ACT.
27 ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS THE
28 INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS
29 ACT.
30 ACT OF DECEMBER 14, 1992 (P.L.835, NO.134), KNOWN AS THE
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1 FRATERNAL BENEFIT SOCIETIES CODE.
2 A NONPROFIT CORPORATION SUBJECT TO 40 PA.C.S. CHS. 61
3 (RELATING TO HOSPITAL PLAN CORPORATIONS) AND 63 (RELATING TO
4 PROFESSIONAL HEALTH SERVICES PLAN CORPORATIONS).
5 "INSURER." ANY ENTITY THAT ISSUES AN INDIVIDUAL OR GROUP
6 HEALTH INSURANCE POLICY, CONTRACT OR PLAN DESCRIBED UNDER THE
7 DEFINITION OF "HEALTH INSURANCE POLICY" IN THIS SECTION.
8 "MASTECTOMY." THE REMOVAL OF ALL OR PART OF THE BREAST FOR
9 MEDICALLY NECESSARY REASONS, AS DETERMINED BY A LICENSED
10 PHYSICIAN.
11 "PROSTHETIC DEVICES." THE USE OF INITIAL AND SUBSEQUENT
12 ARTIFICIAL DEVICES TO REPLACE THE REMOVED BREAST OR PORTIONS
13 THEREOF, PURSUANT TO AN ORDER OF THE PATIENT'S PHYSICIAN.
14 "RECONSTRUCTIVE SURGERY." A SURGICAL PROCEDURE PERFORMED
15 FOLLOWING A MASTECTOMY ON ONE BREAST OR BOTH BREASTS, AS
16 DETERMINED BY THE TREATING PHYSICIAN, TO REESTABLISH SYMMETRY
17 BETWEEN THE TWO BREASTS OR ALLEVIATE FUNCTIONAL IMPAIRMENT
18 CAUSED BY THE MASTECTOMY. THIS TERM SHALL INCLUDE, BUT IS NOT
19 LIMITED TO, AUGMENTATION MAMMOPLASTY, REDUCTION MAMMOPLASTY AND
20 MASTOPEXY.
21 "SYMMETRY BETWEEN BREASTS." APPROXIMATE EQUALITY IN SIZE AND
22 SHAPE OF THE NONDISEASED BREAST WITH THE DISEASED BREAST AFTER
23 DEFINITIVE RECONSTRUCTIVE SURGERY ON THE DISEASED BREAST HAS
24 BEEN PERFORMED.
25 SECTION 5. MASTECTOMY COVERAGE STANDARDS.
26 (A) OUTPATIENT CARE.--NO HEALTH INSURANCE POLICY DELIVERED,
27 ISSUED, EXECUTED OR RENEWED IN THIS COMMONWEALTH ON OR AFTER THE
28 EFFECTIVE DATE OF THIS SECTION SHALL REQUIRE OUTPATIENT CARE
29 FOLLOWING A MASTECTOMY PERFORMED IN A HEALTH CARE FACILITY.
30 (B) INPATIENT CARE.--POLICIES DESCRIBED IN SUBSECTION (A)
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1 SHALL PROVIDE COVERAGE FOR INPATIENT CARE FOLLOWING A MASTECTOMY
2 FOR THE LENGTH OF STAY THAT THE TREATING PHYSICIAN DETERMINES IS
3 NECESSARY TO MEET GENERALLY ACCEPTED CRITERIA FOR SAFE
4 DISCHARGE.
5 (C) LIMITATIONS.--COVERAGE UNDER THIS SECTION SHALL,
6 HOWEVER, REMAIN SUBJECT TO ANY COPAYMENT, COINSURANCE OR
7 DEDUCTIBLE AMOUNTS SET FORTH IN THE POLICY.
8 SECTION 6. BREAST CANCER RECONSTRUCTIVE SURGERY COVERAGE.
9 (A) INCLUDED COVERAGE.--EVERY HEALTH CARE POLICY WHICH IS
10 DELIVERED, ISSUED FOR DELIVERY, RENEWED, EXTENDED OR MODIFIED IN
11 THIS COMMONWEALTH BY A HEALTH CARE INSURER WHICH PROVIDES
12 COVERAGE FOR THE SURGICAL PROCEDURE KNOWN AS MASTECTOMY SHALL
13 ALSO INCLUDE COVERAGE FOR PROSTHETIC DEVICES AND RECONSTRUCTIVE
14 SURGERY INCIDENT TO THE MASTECTOMY.
15 (B) DEDUCTIBLE AND COINSURANCE.--COVERAGE FOR PROSTHETIC
16 DEVICES AND RECONSTRUCTIVE SURGERY SHALL BE SUBJECT TO THE
17 DEDUCTIBLE AND COINSURANCE CONDITIONS APPLIED TO THE MASTECTOMY
18 AND ALL OTHER TERMS AND CONDITIONS APPLICABLE TO OTHER BENEFITS.
19 (C) LIMITATIONS.--THE COVERAGE FOR PROSTHETIC DEVICES
20 INSERTED DURING RECONSTRUCTIVE SURGERY AND RECONSTRUCTIVE
21 SURGERY PURSUANT TO THIS ACT MAY BE LIMITED TO SUCH SURGICAL
22 PROCEDURES PERFORMED WITHIN THREE YEARS OF THE DATE OF THE
23 MASTECTOMY.
24 SECTION 7. APPLICABILITY.
25 THIS ACT SHALL APPLY TO ALL INSURANCE POLICIES, SUBSCRIBER
26 CONTRACTS AND GROUP INSURANCE CERTIFICATES ISSUED UNDER ANY
27 GROUP MASTER POLICY DELIVERED OR ISSUED FOR DELIVERY ON OR AFTER
28 THE EFFECTIVE DATE OF THIS ACT. THIS ACT SHALL ALSO APPLY TO ALL
29 RENEWALS OF CONTRACTS ON ANY RENEWAL DATE WHICH IS ON OR AFTER
30 THE EFFECTIVE DATE OF THIS ACT.
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1 SECTION 8. EFFECTIVE DATE.
2 THIS ACT SHALL TAKE EFFECT IN 90 DAYS.
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