33-22-135. Coverage for reconstructive breast surgery after mastectomy -- benefits and conditions. (1) Each group and individual disability policy, certificate of insurance, or membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for:

(a) all stages of reconstruction of the breast on which a mastectomy has been performed;

(b) surgery and reconstruction of the other breast to produce a symmetrical appearance; and

(c) prostheses and physical complications of a mastectomy, including lymphedemas.

(2) The treatment covered under subsection (1) must be determined in consultation with the attending physician and the patient.

(3) The coverage required under this section may be subject to annual deductibles and coinsurance provisions consistent with those established for other benefits under an insurance policy, a membership contract, or a certificate of insurance.

(4) For the purposes of this section:

(a) "mastectomy" means the surgical removal of all or part of a breast;

(b) "reconstructive breast surgery" means surgery performed as a result of a mastectomy to reestablish symmetry between the breasts. The term includes but is not limited to augmentation mammoplasty, reduction mammoplasty, and mastopexy.

(5) Benefits for reconstructive breast surgery under any contract providing outpatient x-ray or radiation therapy include benefits for outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer that must be included as a part of the outpatient x-ray or radiation therapy benefit.

(6) An insurer shall provide written notice in compliance with the model language of the Women's Health and Cancer Rights Act of 1998 to a covered person of the availability of benefits with respect to the Women's Health and Cancer Rights Act of 1998 upon enrollment and subsequently on an annual basis.

(7) (a) An insurer may not deny to an individual eligibility or continued eligibility to enroll or to renew coverage under the terms of a plan solely for the purpose of avoiding the requirements of this section.

(b) An insurer may not penalize or otherwise reduce or limit the reimbursement of an attending health care provider or provide incentives to an attending health care provider to induce the health care provider to provide care for a covered person in a manner that is inconsistent with this section.

History: En. Sec. 2, Ch. 410, L. 1997; amd. Sec. 1, Ch. 67, L. 2009.