§1077. Required coverage for reconstructive surgery following mastectomies

A. The legislature hereby finds that approximately three thousand women will be diagnosed with breast cancer each year in Louisiana. Studies documenting breast cancer statistics indicate that Louisiana has the highest mastectomy rate in the nation: fifty-one percent of all women diagnosed with breast cancer will undergo a mastectomy as part of their treatment regimen. Despite laws which require insurers and physicians to inform women that breast reconstruction is an insured surgical option, seven of ten women are not provided this information. The purpose of this Section is to assure that state law mirrors the federal Women's Health and Cancer Rights Act, to extend its application to all health insurance issuers in Louisiana, to stress that decisions regarding the reconstructive procedures to be performed shall be made solely by the patient in consultation with attending physicians, and to clarify that all stages of breast reconstruction as defined pursuant to this Section are medically necessary and shall not be excluded from coverage.

B. Any health benefit plan offered by a health insurance issuer that provides medical and surgical benefits with respect to a partial or full mastectomy shall also provide medical and surgical benefits for breast reconstruction. Such coverage shall be for breast reconstruction procedures selected by the patient in consultation with attending physicians. The coverage provided in this Section may be subject to annual deductibles, coinsurance, and copayment provisions as are consistent with those established for mastectomy procedures under the health benefit plan. Written notice of the availability of coverage shall be delivered to the insured or enrollee upon enrollment and annually thereafter as approved by the commissioner of insurance.

C. Any health benefit plan offered by a health insurance issuer shall provide notice to each insured or enrollee under such plan regarding the coverage required by this Section in accordance with regulations adopted by the Department of Insurance. This 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 in one of the following ways, whichever is earlier:

(1) In the next mailing made by the plan or issuer to the insured or enrollee.

(2) As part of any annual informational packet sent to the insured or enrollee.

D. Any health benefit plan offered by a health insurance issuer shall 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.

(2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide monetary or nonmonetary incentives to an attending provider, to induce such provider to provide care to an insured or enrollee in a manner inconsistent with this Section.

(3) Require that the mastectomy procedures and reconstructive procedures be performed under the same policy or plan.

(4) Reduce or limit coverage benefits to a patient for the reconstructive procedures performed pursuant to this Section as determined in consultation with the attending physician and patient.

E. In the case of a health benefit plan maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement imposed pursuant to this Section shall not be treated as a termination of the collective bargaining agreement.

F. For purposes of this Section:

(1) "Breast reconstruction"means all stages of reconstruction of the breast on which a mastectomy has been performed and on the other breast to produce a symmetrical appearance, including but not limited to liposuction performed for transfer to a reconstructed breast or to repair a donor site deformity, tattooing the areola of the breast, surgical adjustments of the non-mastectomized breast, unforeseen medical complications which may require additional reconstruction in the future, and prostheses and physical complications, including but not limited to lymphedemas.

(2) "Health benefit plan" means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. "Health benefit plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061 and short-term policies that have a term of less than twelve months.

(3) "Health insurance issuer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization, or any similar entity, or any other entity providing a plan of health insurance or health benefits.

Acts 1999, No. 30, §1; Redesignated from R.S. 22:250.17 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2016, No. 145, §1, eff. May 19, 2016.

NOTE: Former R.S. 22:1077 redesignated as R.S. 22:835 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.