(a)(1) No health insurance policy delivered, issued, executed or renewed in this Commonwealth on or after the effective date of this section shall require outpatient care following a mastectomy performed in a health care facility.
(2) Policies described in clause (1) of this subsection shall provide coverage for inpatient care following a mastectomy for the length of stay that the treating physician determines is necessary to meet generally accepted criteria for safe discharge.
(3) Such policies shall also provide coverage for a home health care visit that the treating physician determines is necessary within forty-eight hours after discharge when the discharge occurs within forty-eight hours following admission for the mastectomy.
(4) Coverage under this section shall, however, remain subject to any copayment, coinsurance or deductible amounts set forth in the policy.
(b)(1) Every health care policy which is delivered, issued for delivery, renewed, extended or modified in this Commonwealth by a health care insurer which provides coverage for the surgical procedure known as mastectomy shall also include coverage for:
(i) prosthetic devices;
(ii) physical complications including lymphedemas; and
(iii) reconstructive surgery incident to any mastectomy in a manner determined in consultation with the attending physician and the patient. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.
(2) Coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits.
(3) An insurer may not deny to a patient eligibility or continued eligibility to enroll or to renew coverage under the terms of the health insurance policy solely for the purpose of avoiding the requirements of this act.
(c) This section shall not apply to the following types of policies:
(1) Accident only.
(2) Limited benefit.
(3) Credit.
(4) Dental.
(5) Vision.
(6) Specified disease.
(7) Medicare supplement.
(8) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.
(9) Long-term care or disability income.
(10) Workers' compensation.
(11) Automobile medical payment.
(d)(1) The term “health insurance policy” when used in this section means any individual or group health insurance policy, subscriber contract, certificate or plan which provides medical or health care coverage by any health care facility or licensed health care provider which is offered by or is governed under this act or any of the following:
(i) Subarticle (f) of Article IV of the act of June 13, 1967 (P.L. 31, No. 21),1 known as the “Public Welfare Code.”
(ii) The act of December 29, 1972 (P.L. 1701, No. 364),2 known as the “Health Maintenance Organization Act.”
(iii) The act of May 18, 1976 (P.L. 123, No. 54),3 known as the “Individual Accident and Sickness Insurance Minimum Standards Act.”
(iv) The act of December 14, 1992 (P.L. 835, No. 134),4 known as the “Fraternal Benefit Societies Code.”
(v) A nonprofit corporation subject to 40 Pa.C.S. Chs. 61 (relating to hospital plan corporations) and 63 (relating to professional health services plan corporations).
(2) The term “insurer” when used in this section means any entity that issues an individual or group health insurance policy, contract or plan described under clause (1) of this subsection.
(3) The term “mastectomy” when used in this section means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician.
(4) The term “prosthetic devices” when used in this section means the use of initial and subsequent artificial devices, including custom artificial devices, to replace the removed breast or portions thereof pursuant to an order of the patient's physician.
(5) The term “reconstructive surgery” when used in this section means a surgical procedure performed on one breast or both breasts following a mastectomy, as determined by the treating physician, to reestablish symmetry between the two breasts or alleviate functional impairment caused by the mastectomy. The term “reconstructive surgery” shall include, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.
(6) The term “symmetry between breasts” when used in this section means approximate equality in size and shape of the nondiseased breast with the diseased breast after definitive reconstructive surgery on the diseased or nondiseased breast has been performed.
Credits
1921, May 17, P.L. 682, No. 284, § 633, added 1997, Nov. 4, P.L. 492, No. 51, § 3, effective in 90 days. Amended 2002, June 28, P.L. 480, No. 81, § 1, imd. effective; 2020, July 1, P.L. 535, No. 44, § 1, effective in 60 days [Aug. 31, 2020].
