Section 2016.10  Purpose

To establish minimum benefit standards and guidelines for enforcement related to mastectomy coverage.

Section 2016.20  Applicability and Scope

This Part, incorporating requirements established by the Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) (42 USC 300gg-6, 300gg-52, incorporating 29 USC 1185(b)) shall apply to all individual and group accident and health insurance policies, contracts, or certificates of insurance.

Section 2016.30  Required Coverage for Reconstructive Surgery Following Mastectomies

Every policy, contract, or certificate of group or individual insurance that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of an insured who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage in a manner determined in consultation with the attending physician and the patient for:

a)         Reconstruction for the breast on which the mastectomy has been performed;

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

c)         Prostheses and physical complications for all stages of mastectomy, including lymphedemas.

Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan coverage. Written notice of the availability of coverage under this Part shall be delivered to the insured upon enrollment and annually thereafter.

Section 2016.40  Notice of Coverage

An insurer providing health insurance coverage shall provide notice to each insured under the plan regarding the coverage required by this Part.  Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the insurer and shall be transmitted the earlier of:

a)         In the next mailing made by the insurer to the insured;

b)         As part of any yearly informational packet sent to the insured.

Section 2016.50  Prohibitions

An insurer offering individual or group health insurance may not:

a)         Deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this Part; or

b)         Penalize or otherwise reduce or limit the reimbursement of an attending provider or provide incentives (monetary or otherwise) to an attending provider to induce the provider to provide care to an insured in a manner inconsistent with this Part.

Section 2016.60  Provider Reimbursement

Nothing in this Section shall be construed to prevent an insurer from negotiating the level and type of reimbursement with a provider for care provided in accordance with this Part.