HOUSE AMENDED PRIOR PRINTER'S NOS. 170, 931, 1024, 1306 PRINTER'S NO. 1339
No. 176 Session of 1997
INTRODUCED BY HOLL, JANUARY 21, 1997
AS AMENDED ON THIRD CONSIDERATION, HOUSE OF REPRESENTATIVES, SEPTEMBER 29, 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 19970S0176B1339 - 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. 19970S0176B1339 - 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. 19970S0176B1339 - 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 19970S0176B1339 - 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) SUCH POLICIES SHALL ALSO PROVIDE COVERAGE FOR A HOME <-- 10 HEALTH CARE VISIT THAT THE TREATING PHYSICIAN DETERMINES IS 11 NECESSARY WITHIN FORTY-EIGHT HOURS AFTER DISCHARGE, WHEN THE 12 DISCHARGE OCCURS WITHIN FORTY-EIGHT HOURS FOLLOWING ADMISSION 13 FOR THE MASTECTOMY. 14 (3) (4) COVERAGE UNDER THIS SECTION SHALL, HOWEVER, REMAIN <-- 15 SUBJECT TO ANY COPAYMENT, COINSURANCE OR DEDUCTIBLE AMOUNTS SET 16 FORTH IN THE POLICY. 17 (B) (1) EVERY HEALTH CARE POLICY WHICH IS DELIVERED, ISSUED 18 FOR DELIVERY, RENEWED, EXTENDED OR MODIFIED IN THIS COMMONWEALTH 19 BY A HEALTH CARE INSURER WHICH PROVIDES COVERAGE FOR THE 20 SURGICAL PROCEDURE KNOWN AS MASTECTOMY SHALL ALSO INCLUDE 21 COVERAGE FOR PROSTHETIC DEVICES AND RECONSTRUCTIVE SURGERY 22 INCIDENT TO THE ANY MASTECTOMY. <-- 23 (2) COVERAGE FOR PROSTHETIC DEVICES AND RECONSTRUCTIVE 24 SURGERY SHALL BE SUBJECT TO THE DEDUCTIBLE AND COINSURANCE 25 CONDITIONS APPLIED TO THE MASTECTOMY AND ALL OTHER TERMS AND 26 CONDITIONS APPLICABLE TO OTHER BENEFITS. 27 (3) THE COVERAGE FOR PROSTHETIC DEVICES INSERTED DURING 28 RECONSTRUCTIVE SURGERY AND RECONSTRUCTIVE SURGERY PURSUANT TO 29 THIS SECTION MAY BE LIMITED TO SUCH SURGICAL PROCEDURES 30 PERFORMED WITHIN THREE SIX YEARS OF THE DATE OF THE MASTECTOMY. <-- 19970S0176B1339 - 6 -
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 19970S0176B1339 - 7 -
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 (3) THE TERM "MASTECTOMY" WHEN USED IN THIS SECTION MEANS 8 THE REMOVAL OF ALL OR PART OF THE BREAST FOR MEDICALLY NECESSARY 9 REASONS, AS DETERMINED BY A LICENSED PHYSICIAN. 10 (4) THE TERM "PROSTHETIC DEVICES" WHEN USED IN THIS SECTION 11 MEANS THE USE OF INITIAL AND SUBSEQUENT ARTIFICIAL DEVICES TO 12 REPLACE THE REMOVED BREAST OR PORTIONS THEREOF, PURSUANT TO AN 13 ORDER OF THE PATIENT'S PHYSICIAN. 14 (5) THE TERM "RECONSTRUCTIVE SURGERY" WHEN USED IN THIS 15 SECTION MEANS A SURGICAL PROCEDURE PERFORMED ON ONE BREAST OR <-- 16 BOTH BREASTS FOLLOWING A MASTECTOMY ON ONE BREAST OR BOTH <-- 17 BREASTS, AS DETERMINED BY THE TREATING PHYSICIAN, TO REESTABLISH 18 SYMMETRY BETWEEN THE TWO BREASTS OR ALLEVIATE FUNCTIONAL 19 IMPAIRMENT CAUSED BY THE MASTECTOMY. THE TERM "RECONSTRUCTIVE 20 SURGERY" SHALL INCLUDE, BUT IS NOT LIMITED TO, AUGMENTATION 21 MAMMOPLASTY, REDUCTION MAMMOPLASTY AND MASTOPEXY. 22 (6) THE TERM "SYMMETRY BETWEEN BREASTS" WHEN USED IN THIS 23 SECTION MEANS APPROXIMATE EQUALITY IN SIZE AND SHAPE OF THE 24 NONDISEASED BREAST WITH THE DISEASED BREAST AFTER DEFINITIVE 25 RECONSTRUCTIVE SURGERY ON THE DISEASED OR NONDISEASED BREAST HAS <-- 26 BEEN PERFORMED. 27 SECTION 2. THIS ACT 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 ACT. THIS ACT SHALL ALSO 19970S0176B1339 - 8 -
1 APPLY TO ALL RENEWALS OF CONTRACTS ON ANY RENEWAL DATE WHICH IS 2 ON OR AFTER THE EFFECTIVE DATE OF THIS ACT. 3 SECTION 3. THIS ACT SHALL TAKE EFFECT IN 90 DAYS. A13L40WMB/19970S0176B1339 - 9 -