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
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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.
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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.
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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
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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.
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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
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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.
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