HOUSE AMENDED PRIOR PRINTER'S NOS. 170, 931, 1024 PRINTER'S NO. 1306
No. 176 Session of 1997
INTRODUCED BY HOLL, JANUARY 21, 1997
AS RE-REPORTED FROM COMMITTEE ON APPROPRIATIONS, HOUSE OF REPRESENTATIVES, AS AMENDED, SEPTEMBER 23, 1997
AN ACT 1 Providing mastectomy and breast cancer reconstructive surgery <-- 2 coverage standards for health insurance policies. 3 AMENDING THE ACT OF MAY 17, 1921 (P.L.682, NO.284), ENTITLED "AN <-- 4 ACT RELATING TO INSURANCE; AMENDING, REVISING, AND 5 CONSOLIDATING THE LAW PROVIDING FOR THE INCORPORATION OF 6 INSURANCE COMPANIES, AND THE REGULATION, SUPERVISION, AND 7 PROTECTION OF HOME AND FOREIGN INSURANCE COMPANIES, LLOYDS 8 ASSOCIATIONS, RECIPROCAL AND INTER-INSURANCE EXCHANGES, AND 9 FIRE INSURANCE RATING BUREAUS, AND THE REGULATION AND 10 SUPERVISION OF INSURANCE CARRIED BY SUCH COMPANIES, 11 ASSOCIATIONS, AND EXCHANGES, INCLUDING INSURANCE CARRIED BY 12 THE STATE WORKMEN'S INSURANCE FUND; PROVIDING PENALTIES; AND 13 REPEALING EXISTING LAWS," PROVIDING MASTECTOMY AND BREAST 14 CANCER RECONSTRUCTIVE SURGERY COVERAGE STANDARDS FOR HEALTH 15 INSURANCE POLICIES. 16 TABLE OF CONTENTS <-- 17 Section 1. Short title. 18 Section 2. Declaration of policy. 19 Section 3. Scope. 20 Section 4. Definitions. 21 Section 5. Mastectomy coverage standards. 22 Section 6. Breast cancer reconstructive surgery coverage. 23 Section 7. Applicability.
1 Section 8. Effective date. 2 The General Assembly of the Commonwealth of Pennsylvania 3 hereby enacts as follows: 4 Section 1. Short title. <-- 5 This act shall be known and may be cited as the Mastectomy 6 and Breast Cancer Reconstructive Surgery Coverage Standards Act. 7 Section 2. Declaration of policy. 8 The General Assembly finds and declares as follows: 9 (1) Breast cancer is the most common cancer in American 10 women, afflicting 182,000 women per year, striking one out of 11 9 and killing 46,000 a year. Coping with this disease is a 12 medical and emotional struggle since it carries with it the 13 fear of disfigurement in a society that places great value on 14 physical appearance. 15 (2) Some insurance carriers deny coverage for breast 16 reconstruction, considering the procedure not medically 17 necessary. Most insurance companies will not cover procedures 18 on the opposite breast to provide symmetry for the 19 reconstruction, but do cover reconstruction of other body 20 parts, which is discriminatory. 21 Section 3. Scope. 22 This act shall not apply to the following types of policies: 23 (1) Accident only. 24 (2) Limited benefit. 25 (3) Credit. 26 (4) Dental. 27 (5) Vision. 28 (6) Specified disease. 29 (7) Medicare supplement. 30 (8) Civilian Health and Medical Program of the Uniformed 19970S0176B1306 - 2 -
1 Services (CHAMPUS) supplement. 2 (9) Long-term care or disability income. 3 (10) Workers' compensation. 4 (11) Automobile medical payment. 5 Section 4. Definitions. 6 The following words and phrases when used in this act shall 7 have the meanings given to them in this section unless the 8 context clearly indicates otherwise: 9 "Health insurance policy." Any individual or group health 10 insurance policy, subscriber contract, certificate or plan which 11 provides medical or health care coverage by any health care 12 facility or licensed health care provider which is offered by or 13 is governed under any of the following: 14 Act of May 17, 1921 (P.L.682, No.284), known as The 15 Insurance Company Law of 1921. 16 Subarticle (f) of Article IV of the act of June 13, 1967 17 (P.L.31, No.21), known as the Public Welfare Code. 18 Act of December 29, 1972 (P.L.1701, No.364), known as the 19 Health Maintenance Organization Act. 20 Act of May 18, 1976 (P.L.123, No.54), known as the 21 Individual Accident and Sickness Insurance Minimum Standards 22 Act. 23 Act of December 14, 1992 (P.L.835, No.134), known as the 24 Fraternal Benefit Societies Code. 25 A nonprofit corporation subject to 40 Pa.C.S. Chs. 61 26 (relating to hospital plan corporations) and 63 (relating to 27 professional health services plan corporations). 28 "Insurer." Any entity that issues an individual or group 29 health insurance policy, contract or plan described under the 30 definition of "health insurance policy" in this section. 19970S0176B1306 - 3 -
1 "Mastectomy." The removal of all or part of the breast for 2 medically necessary reasons, as determined by a licensed 3 physician. 4 "Prosthetic devices." The use of initial and subsequent 5 artificial devices to replace the removed breast or portions 6 thereof, pursuant to an order of the patient's physician. 7 "Reconstructive surgery." A surgical procedure performed 8 following a mastectomy on one breast or both breasts, as 9 determined by the treating physician, to reestablish symmetry 10 between the two breasts or alleviate functional impairment 11 caused by the mastectomy. This term shall include, but is not 12 limited to, augmentation mammoplasty, reduction mammoplasty and 13 mastopexy. 14 "Symmetry between breasts." Approximate equality in size and 15 shape of the nondiseased breast with the diseased breast after 16 definitive reconstructive surgery on the diseased breast has 17 been performed. 18 Section 5. Mastectomy coverage standards. 19 (a) Outpatient care.--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 mastectomy performed in a health care facility. 23 (b) Inpatient care.--Policies described in subsection (a) 24 shall provide coverage for inpatient care following a mastectomy 25 for the length of stay that the treating physician determines is 26 necessary to meet generally accepted criteria for safe 27 discharge. 28 (c) Limitations.--Coverage under this section shall, 29 however, remain subject to any copayment, coinsurance or 30 deductible amounts set forth in the policy. 19970S0176B1306 - 4 -
1 Section 6. Breast cancer reconstructive surgery coverage. 2 (a) Included coverage.--Every health care policy which is 3 delivered, issued for delivery, renewed, extended or modified in 4 this Commonwealth by a health care insurer which provides 5 coverage for the surgical procedure known as mastectomy shall 6 also include coverage for prosthetic devices and reconstructive 7 surgery incident to the mastectomy. 8 (b) Deductible and coinsurance.--Coverage for prosthetic 9 devices and reconstructive surgery shall be subject to the 10 deductible and coinsurance conditions applied to the mastectomy 11 and all other terms and conditions applicable to other benefits. 12 (c) Limitations.--The coverage for prosthetic devices 13 inserted during reconstructive surgery and reconstructive 14 surgery pursuant to this act may be limited to such surgical 15 procedures performed within three years of the date of the 16 mastectomy. 17 Section 7. Applicability. 18 This act shall apply to all insurance policies, subscriber 19 contracts and group insurance certificates issued under any 20 group master policy delivered or issued for delivery on or after 21 the effective date of this act. This act shall also apply to all 22 renewals of contracts on any renewal date which is on or after 23 the effective date of this act. 24 Section 8. Effective date. 25 This act shall take effect in 90 days. 26 SECTION 1. THE ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN <-- 27 AS THE INSURANCE COMPANY LAW OF 1921, IS AMENDED BY ADDING A 28 SECTION TO READ: 29 SECTION 633. MASTECTOMY AND BREAST CANCER RECONSTRUCTION.-- 30 (A) (1) NO HEALTH INSURANCE POLICY DELIVERED, ISSUED, EXECUTED 19970S0176B1306 - 5 -
1 OR RENEWED IN THIS COMMONWEALTH ON OR AFTER THE EFFECTIVE DATE 2 OF THIS SECTION SHALL REQUIRE OUTPATIENT CARE FOLLOWING A 3 MASTECTOMY PERFORMED IN A HEALTH CARE FACILITY. 4 (2) POLICIES DESCRIBED IN CLAUSE (1) OF THIS SUBSECTION 5 SHALL PROVIDE COVERAGE FOR INPATIENT CARE FOLLOWING A MASTECTOMY 6 FOR THE LENGTH OF STAY THAT THE TREATING PHYSICIAN DETERMINES IS 7 NECESSARY TO MEET GENERALLY ACCEPTED CRITERIA FOR SAFE 8 DISCHARGE. 9 (3) COVERAGE UNDER THIS SECTION SHALL, HOWEVER, REMAIN 10 SUBJECT TO ANY COPAYMENT, COINSURANCE OR DEDUCTIBLE AMOUNTS SET 11 FORTH IN THE POLICY. 12 (B) (1) EVERY HEALTH CARE POLICY WHICH IS DELIVERED, ISSUED 13 FOR DELIVERY, RENEWED, EXTENDED OR MODIFIED IN THIS COMMONWEALTH 14 BY A HEALTH CARE INSURER WHICH PROVIDES COVERAGE FOR THE 15 SURGICAL PROCEDURE KNOWN AS MASTECTOMY SHALL ALSO INCLUDE 16 COVERAGE FOR PROSTHETIC DEVICES AND RECONSTRUCTIVE SURGERY 17 INCIDENT TO THE MASTECTOMY. 18 (2) COVERAGE FOR PROSTHETIC DEVICES AND RECONSTRUCTIVE 19 SURGERY SHALL BE SUBJECT TO THE DEDUCTIBLE AND COINSURANCE 20 CONDITIONS APPLIED TO THE MASTECTOMY AND ALL OTHER TERMS AND 21 CONDITIONS APPLICABLE TO OTHER BENEFITS. 22 (3) THE COVERAGE FOR PROSTHETIC DEVICES INSERTED DURING 23 RECONSTRUCTIVE SURGERY AND RECONSTRUCTIVE SURGERY PURSUANT TO 24 THIS SECTION MAY BE LIMITED TO SUCH SURGICAL PROCEDURES 25 PERFORMED WITHIN THREE YEARS OF THE DATE OF THE MASTECTOMY. 26 (C) THIS SECTION SHALL NOT APPLY TO THE FOLLOWING TYPES OF 27 POLICIES: 28 (1) ACCIDENT ONLY. 29 (2) LIMITED BENEFIT. 30 (3) CREDIT. 19970S0176B1306 - 6 -
1 (4) DENTAL. 2 (5) VISION. 3 (6) SPECIFIED DISEASE. 4 (7) MEDICARE SUPPLEMENT. 5 (8) CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED 6 SERVICES (CHAMPUS) SUPPLEMENT. 7 (9) LONG-TERM CARE OR DISABILITY INCOME. 8 (10) WORKERS' COMPENSATION. 9 (11) AUTOMOBILE MEDICAL PAYMENT. 10 (D) (1) THE TERM "HEALTH INSURANCE POLICY" WHEN USED IN 11 THIS SECTION MEANS ANY INDIVIDUAL OR GROUP HEALTH INSURANCE 12 POLICY, SUBSCRIBER CONTRACT, CERTIFICATE OR PLAN WHICH PROVIDES 13 MEDICAL OR HEALTH CARE COVERAGE BY ANY HEALTH CARE FACILITY OR 14 LICENSED HEALTH CARE PROVIDER WHICH IS OFFERED BY OR IS GOVERNED 15 UNDER THIS ACT OR ANY OF THE FOLLOWING: 16 (I) SUBARTICLE (F) OF ARTICLE IV OF THE ACT OF JUNE 13, 1967 17 (P.L.31, NO.21), KNOWN AS THE "PUBLIC WELFARE CODE." 18 (II) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN 19 AS THE "HEALTH MAINTENANCE ORGANIZATION ACT." 20 (III) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS THE 21 "INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS 22 ACT." 23 (IV) THE ACT OF DECEMBER 14, 1992 (P.L.835, NO.134), KNOWN 24 AS THE "FRATERNAL BENEFIT SOCIETIES CODE." 25 (V) A NONPROFIT CORPORATION SUBJECT TO 40 PA.C.S. CHS. 61 26 (RELATING TO HOSPITAL PLAN CORPORATIONS) AND 63 (RELATING TO 27 PROFESSIONAL HEALTH SERVICES PLAN CORPORATIONS). 28 (2) THE TERM "INSURER" WHEN USED IN THIS SECTION MEANS ANY 29 ENTITY THAT ISSUES AN INDIVIDUAL OR GROUP HEALTH INSURANCE 30 POLICY, CONTRACT OR PLAN DESCRIBED UNDER CLAUSE (1) OF THIS 19970S0176B1306 - 7 -
1 SUBSECTION. 2 (3) THE TERM "MASTECTOMY" WHEN USED IN THIS SECTION MEANS 3 THE REMOVAL OF ALL OR PART OF THE BREAST FOR MEDICALLY NECESSARY 4 REASONS, AS DETERMINED BY A LICENSED PHYSICIAN. 5 (4) THE TERM "PROSTHETIC DEVICES" WHEN USED IN THIS SECTION 6 MEANS THE USE OF INITIAL AND SUBSEQUENT ARTIFICIAL DEVICES TO 7 REPLACE THE REMOVED BREAST OR PORTIONS THEREOF, PURSUANT TO AN 8 ORDER OF THE PATIENT'S PHYSICIAN. 9 (5) THE TERM "RECONSTRUCTIVE SURGERY" WHEN USED IN THIS 10 SECTION MEANS A SURGICAL PROCEDURE PERFORMED FOLLOWING A 11 MASTECTOMY ON ONE BREAST OR BOTH BREASTS, AS DETERMINED BY THE 12 TREATING PHYSICIAN, TO REESTABLISH SYMMETRY BETWEEN THE TWO 13 BREASTS OR ALLEVIATE FUNCTIONAL IMPAIRMENT CAUSED BY THE 14 MASTECTOMY. THE TERM "RECONSTRUCTIVE SURGERY" SHALL INCLUDE, BUT 15 IS NOT LIMITED TO, AUGMENTATION MAMMOPLASTY, REDUCTION 16 MAMMOPLASTY AND MASTOPEXY. 17 (6) THE TERM "SYMMETRY BETWEEN BREASTS" WHEN USED IN THIS 18 SECTION MEANS APPROXIMATE EQUALITY IN SIZE AND SHAPE OF THE 19 NONDISEASED BREAST WITH THE DISEASED BREAST AFTER DEFINITIVE 20 RECONSTRUCTIVE SURGERY ON THE DISEASED BREAST HAS BEEN 21 PERFORMED. 22 SECTION 2. THIS ACT SHALL APPLY TO ALL INSURANCE POLICIES, 23 SUBSCRIBER CONTRACTS AND GROUP INSURANCE CERTIFICATES ISSUED 24 UNDER ANY GROUP MASTER POLICY DELIVERED OR ISSUED FOR DELIVERY 25 ON OR AFTER THE EFFECTIVE DATE OF THIS ACT. THIS ACT SHALL ALSO 26 APPLY TO ALL RENEWALS OF CONTRACTS ON ANY RENEWAL DATE WHICH IS 27 ON OR AFTER THE EFFECTIVE DATE OF THIS ACT. 28 SECTION 3. THIS ACT SHALL TAKE EFFECT IN 90 DAYS. A13L40WMB/19970S0176B1306 - 8 -