Rhode Island General Laws 27-41-43. Mastectomy treatment
(a) All individual or group health insurance coverage and health benefit plans delivered, issued for delivery, or renewed in this state on or after January 1, 2005, that provide medical and surgical benefits with respect to mastectomy shall provide, in a case of any person covered in the individual market or covered by a group health plan, coverage for:
(1) 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 treatment of physical complications, including lymphademas, at all stages of mastectomy; in a manner determined in consultation with the attending physician, physician assistant as defined in § 5-54-2, or an advance practice registered nurse as defined in § 5-34-3, and the patient. As used in this section, “mastectomy” means the removal of all or part of a breast. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.
Terms Used In Rhode Island General Laws 27-41-43
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Group health insurance coverage: means , in connection with a group health plan, health insurance coverage offered in connection with that plan. See Rhode Island General Laws 27-41-2
- Group health plan: means an employee welfare benefit plan as defined in Rhode Island General Laws 27-41-2
- Health insurance carrier: means a person, firm, corporation, or other entity subject to the jurisdiction of the commissioner under this chapter, and includes a health maintenance organization. See Rhode Island General Laws 27-41-2
- Health maintenance organization: means a single public or private organization that:
(i) Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;
(ii) Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis;
(iii)(A) Provides physicians' services primarily:
(I) Directly through physicians who are either employees or partners of the organization; or
(II) Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;
(B) "Health maintenance organization" does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations; and
(iv) Provides the services of licensed midwives primarily:
(A) Directly through licensed midwives who are either employees or partners of the organization; or
(B) Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2
- in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
- person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
- Physician: includes a podiatrist as defined in chapter 29 of Title 5. See Rhode Island General Laws 27-41-2
- provider: means a healthcare professional or a healthcare facility. See Rhode Island General Laws 27-41-2
- United States: include the several states and the territories of the United States. See Rhode Island General Laws 43-3-8
(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 the plan regarding the coverage required by this section in accordance with regulations promulgated by the United States Secretary of Health and Human Services. The 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 as part of any yearly informational packet sent to the participant or beneficiary.
(c) As used in this section, “prosthetic devices” means and includes the provision of initial and subsequent prosthetic devices pursuant to an order of the patient’s physician, physician assistant, advance practice registered nurse, or surgeon.
(d)(1) [Deleted by P.L. 2018, ch. 114, § 4 and P.L. 2018, ch. 204, § 4.]
(2) Nothing in this section shall be construed to prevent a group health plan or a health insurance carrier offering health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section.
(3) Nothing in this section shall preclude the conducting of managed care reviews and medical necessity reviews, by an insurer, hospital or medical service corporation or health maintenance organization.
(4) Prohibitions. A group health plan and a health insurance carrier offering group or individual health insurance coverage may not:
(i) Deny to a patient eligibility, or continued eligibility, to enroll or renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; nor
(ii) 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 individual participant or beneficiary in a manner inconsistent with this section.
History of Section.
P.L. 1996, ch. 66, § 4; P.L. 2002, ch. 292, § 85; P.L. 2004, ch. 41, § 4; P.L. 2004, ch. 45, § 4; P.L. 2018, ch. 114, § 4; P.L. 2018, ch. 204, § 4.