Sec. 16.5. (a) As used in this section, “covered individual” means an individual who is entitled to coverage under a state employee health plan.

     (b) As used in this section, “mastectomy” means the removal of all or part of a breast for reasons that are determined by a licensed physician to be medically necessary.

     (c) A state employee health plan that provides coverage for a mastectomy must provide coverage as required under 29 U.S.C. § 1185b, including coverage for:

(1) prosthetic devices; and

(2) reconstructive surgery incident to a mastectomy including:

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

(B) surgery and reconstruction of the other breast to produce symmetry; and

(C) chest wall reconstruction and aesthetic flat closure (as defined by the National Cancer Institute);

in the manner determined by the attending physician and the covered individual to be appropriate.

     (d) In addition to the coverage required by 29 U.S.C. § 1185b, a state employee health plan that provides coverage for a mastectomy must provide coverage for:

(1) custom fabricated breast prostheses; and

(2) one (1) additional breast prosthesis per breast affected by the mastectomy.

     (e) Coverage required under this section is subject to:

(1) the deductible and coinsurance provisions applicable to a mastectomy; and

(2) all other terms and conditions applicable to other benefits.

     (f) A state employee health plan must provide to a covered individual, when the individual’s coverage under the state employee health plan begins and annually thereafter, written notice of the coverage required under this section. Notice that is sent by the state employee health plan that meets the requirements set forth in 29 U.S.C. § 1185b constitutes compliance with this subsection.

     (g) The coverage required under this section applies to a state employee health plan that provides coverage for a mastectomy, regardless of whether an individual who:

(1) underwent a mastectomy; and

(2) is covered under the state employee health plan;

was covered under the state employee health plan at the time of the mastectomy.

     (h) Except as provided in subsection (c)(2)(C) and subsection (d), this section does not require a state employee health plan to provide coverage related to postmastectomy care that exceeds the coverage required for postmastectomy care under federal law.

As added by P.L.67-2020, SEC.1. Amended by P.L.3-2024, SEC.2.