29 USC 1185b - Required coverage for reconstructive surgery following mastectomies

U.S Code last checked for updates: Nov 22, 2024

§ 1185b.

Required coverage for reconstructive surgery following mastectomies

(a)

In general

A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for—

(1)

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

(2)

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

(3)

prostheses and physical complications of mastectomy, including lymphedemas;

in a manner determined in consultation with the attending physician and the patient. 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 or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.

(b)

Notice

A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan shall provide notice to each participant and beneficiary under such plan regarding the coverage required by this section in accordance with regulations promulgated by the Secretary. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan or issuer and shall be transmitted—

(1)

in the next mailing made by the plan or issuer to the participant or beneficiary;

(2)

as part of any yearly informational packet sent to the participant or beneficiary; or

(3)

not later than January 1, 1999;

whichever is earlier.

(c)

Prohibitions

A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not—

(1)

deny to a patient 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 section; and

(2)

penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.

(d)

Rule of construction

(e)

Preemption, relation to State laws

(1)

In general

(2)

ERISA

(Pub. L. 93–406, title I, § 713, as added Pub. L. 105–277, div. A, § 101(f) [title IX, § 902(a)], Oct. 21, 1998, 112 Stat. 2681–337, 2681–436.)

cite as: 29 USC 1185b