PRINTER'S NO. 841
No. 714 Session of 2003
INTRODUCED BY TRAVAGLIO, BEBKO-JONES, BELARDI, BELFANTI, CAWLEY,
COSTA, CURRY, GEORGE, GRUCELA, HALUSKA, HARHAI, HORSEY,
JAMES, LAUGHLIN, LEDERER, MARKOSEK, McGILL, PALLONE,
READSHAW, SEMMEL, SHANER, SOLOBAY, TANGRETTI, E. Z. TAYLOR,
THOMAS, WALKO, WASHINGTON AND YOUNGBLOOD, MARCH 6, 2003
REFERRED TO COMMITTEE ON INSURANCE, MARCH 6, 2003
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) and amended June 28, 2002
18 (P.L.480, No.81), is amended to read:
19 Section 633. Lumpectomy, Mastectomy and Breast Cancer
20 Reconstruction.--(a) (1) No health insurance policy delivered,
21 issued, executed or renewed in this Commonwealth on or after the
1 effective date of this section shall require outpatient care
2 following a lumpectomy or mastectomy performed in a health care
3 facility.
4 (2) Policies described in clause (1) of this subsection
5 shall provide coverage for inpatient care following a lumpectomy
6 or mastectomy for the length of stay that the treating physician
7 determines is necessary to meet generally accepted criteria for
8 safe 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 lumpectomy or mastectomy.
14 (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 lumpectomy or mastectomy shall also
21 include coverage for:
22 (i) prosthetic devices;
23 (ii) physical complications including lymphedemas; and
24 (iii) reconstructive surgery incident to any lumpectomy or
25 mastectomy in a manner determined in consultation with the
26 attending physician and the patient. Written notice of the
27 availability of such coverage shall be delivered to the
28 participant upon enrollment and annually thereafter.
29 (2) Coverage for prosthetic devices and reconstructive
30 surgery shall be subject to the deductible and coinsurance
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1 conditions applied to the mastectomy and all other terms and
2 conditions applicable to other benefits.
3 (3) An insurer may not deny to a patient eligibility or
4 continued eligibility to enroll or to renew coverage under the
5 terms of the health insurance policy solely for the purpose of
6 avoiding the requirements of this act.
7 (c) This section shall not apply to the following types of
8 policies:
9 (1) Accident only.
10 (2) Limited benefit.
11 (3) Credit.
12 (4) Dental.
13 (5) Vision.
14 (6) Specified disease.
15 (7) Medicare supplement.
16 (8) Civilian Health and Medical Program of the Uniformed
17 Services (CHAMPUS) supplement.
18 (9) Long-term care or disability income.
19 (10) Workers' compensation.
20 (11) Automobile medical payment.
21 (d) (1) The term "health insurance policy" when used in
22 this section means any individual or group health insurance
23 policy, subscriber contract, certificate or plan which provides
24 medical or health care coverage by any health care facility or
25 licensed health care provider which is offered by or is governed
26 under this act or any of the following:
27 (i) Subarticle (f) of Article IV of the act of June 13, 1967
28 (P.L.31, No.21), known as the "Public Welfare Code."
29 (ii) The act of December 29, 1972 (P.L.1701, No.364), known
30 as the "Health Maintenance Organization Act."
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1 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the
2 "Individual Accident and Sickness Insurance Minimum Standards
3 Act."
4 (iv) The act of December 14, 1992 (P.L.835, No.134), known
5 as the "Fraternal Benefit Societies Code."
6 (v) A nonprofit corporation subject to 40 Pa.C.S. Chs. 61
7 (relating to hospital plan corporations) and 63 (relating to
8 professional health services plan corporations).
9 (2) The term "insurer" when used in this section means any
10 entity that issues an individual or group health insurance
11 policy, contract or plan described under clause (1) of this
12 subsection.
13 (2.1) The term "lumpectomy" when used in this section means
14 the removal of part of the breast for medically necessary
15 reasons as determined by a licensed physician.
16 (3) The term "mastectomy" when used in this section means
17 the removal of all or part of the breast for medically necessary
18 reasons as determined by a licensed physician.
19 (4) The term "prosthetic devices" when used in this section
20 means the use of initial and subsequent artificial devices to
21 replace the removed breast or portions thereof pursuant to an
22 order of the patient's physician.
23 (5) The term "reconstructive surgery" when used in this
24 section means a surgical procedure performed on one breast or
25 both breasts following a lumpectomy or mastectomy, as determined
26 by the treating physician, to reestablish symmetry between the
27 two breasts or alleviate functional impairment caused by the
28 lumpectomy or mastectomy. The term "reconstructive surgery"
29 shall include, but is not limited to, augmentation mammoplasty,
30 reduction mammoplasty and mastopexy.
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1 (6) The term "symmetry between breasts" when used in this
2 section means approximate equality in size and shape of the
3 nondiseased breast with the diseased breast after definitive
4 reconstructive surgery on the diseased or nondiseased breast has
5 been performed.
6 Section 2. This act shall take effect immediately.
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