§ 58‑65‑96. Coverage for reconstructive breast surgery following mastectomy.
(a) Every insurancecertificate or subscriber contract under any hospital service plan or medicalservice plan governed by this Article and Article 66 of this Chapter, and everypreferred provider benefit plan under G.S. 58‑50‑56 that providescoverage for mastectomy shall provide coverage for reconstructive breastsurgery following a mastectomy. The coverage shall include coverage for allstages and revisions of reconstructive breast surgery performed on anondiseased breast to establish symmetry if reconstructive surgery on adiseased breast is performed, as well as coverage for prostheses and physicalcomplications in all stages of mastectomy, including lymphademas. The same deductibles,coinsurance, and other limitations as apply to similar services covered underthe policy, contract, or plan shall apply to coverage for reconstructive breastsurgery. Reconstruction of the nipple/areolar complex following a mastectomy iscovered without regard to the lapse of time between the mastectomy and thereconstruction, subject to the approval of the treating physician.
(b) As used in thissection, the following terms have the meanings indicated:
(1) "Mastectomy"means the surgical removal of all or part of a breast as a result of breastcancer or breast disease.
(2) "Reconstructivebreast surgery" means surgery performed as a result of a mastectomy toreestablish symmetry between the two breasts, and includes reconstruction ofthe mastectomy site, creation of a new breast mound, and creation of a newnipple/areolar complex. "Reconstructive breast surgery" also includesaugmentation mammoplasty, reduction mammoplasty, and mastopexy of thenondiseased breast.
(c) A policy, contract,or plan subject to this section shall not:
(1) Deny coveragedescribed in subsection (a) of this section on the basis that the coverage isfor cosmetic surgery;
(2) Deny to a womaneligibility or continued eligibility to enroll or to renew coverage under theterms of the contract, policy, or plan, solely for the purpose of avoiding therequirements of this section;
(3) Provide monetarypayments or rebates to a woman to encourage her to accept less than the minimumprotections available under this section;
(4) Penalize orotherwise reduce or limit the reimbursement of an attending provider becausethe provider provided care to an individual participant or beneficiary inaccordance with this section; or
(5) Provide incentives,monetary or otherwise, to an attending provider to induce the provider toprovide care to an individual participant or beneficiary in a mannerinconsistent with this section.
(d) Written notice ofthe availability of the coverage provided by this section shall be delivered toevery subscriber under an individual certificate, contract, or plan and toevery certificate holder under a group policy, contract, or plan upon initialcoverage under the certificate, contract, or plan and annually thereafter. Thenotice required by this subsection may be included as a part of any yearlyinformational packet sent to the subscriber or certificate holder. (1997‑312, s. 2; 1997‑519,s. 3.10; 1999‑351, s. 3.2; 2001‑334, s. 13.2.)
§ 58‑65‑96. Coverage for reconstructive breast surgery following mastectomy.
(a) Every insurancecertificate or subscriber contract under any hospital service plan or medicalservice plan governed by this Article and Article 66 of this Chapter, and everypreferred provider benefit plan under G.S. 58‑50‑56 that providescoverage for mastectomy shall provide coverage for reconstructive breastsurgery following a mastectomy. The coverage shall include coverage for allstages and revisions of reconstructive breast surgery performed on anondiseased breast to establish symmetry if reconstructive surgery on adiseased breast is performed, as well as coverage for prostheses and physicalcomplications in all stages of mastectomy, including lymphademas. The same deductibles,coinsurance, and other limitations as apply to similar services covered underthe policy, contract, or plan shall apply to coverage for reconstructive breastsurgery. Reconstruction of the nipple/areolar complex following a mastectomy iscovered without regard to the lapse of time between the mastectomy and thereconstruction, subject to the approval of the treating physician.
(b) As used in thissection, the following terms have the meanings indicated:
(1) "Mastectomy"means the surgical removal of all or part of a breast as a result of breastcancer or breast disease.
(2) "Reconstructivebreast surgery" means surgery performed as a result of a mastectomy toreestablish symmetry between the two breasts, and includes reconstruction ofthe mastectomy site, creation of a new breast mound, and creation of a newnipple/areolar complex. "Reconstructive breast surgery" also includesaugmentation mammoplasty, reduction mammoplasty, and mastopexy of thenondiseased breast.
(c) A policy, contract,or plan subject to this section shall not:
(1) Deny coveragedescribed in subsection (a) of this section on the basis that the coverage isfor cosmetic surgery;
(2) Deny to a womaneligibility or continued eligibility to enroll or to renew coverage under theterms of the contract, policy, or plan, solely for the purpose of avoiding therequirements of this section;
(3) Provide monetarypayments or rebates to a woman to encourage her to accept less than the minimumprotections available under this section;
(4) Penalize orotherwise reduce or limit the reimbursement of an attending provider becausethe provider provided care to an individual participant or beneficiary inaccordance with this section; or
(5) Provide incentives,monetary or otherwise, to an attending provider to induce the provider toprovide care to an individual participant or beneficiary in a mannerinconsistent with this section.
(d) Written notice ofthe availability of the coverage provided by this section shall be delivered toevery subscriber under an individual certificate, contract, or plan and toevery certificate holder under a group policy, contract, or plan upon initialcoverage under the certificate, contract, or plan and annually thereafter. Thenotice required by this subsection may be included as a part of any yearlyinformational packet sent to the subscriber or certificate holder. (1997‑312, s. 2; 1997‑519,s. 3.10; 1999‑351, s. 3.2; 2001‑334, s. 13.2.)
§ 58‑65‑96. Coverage for reconstructive breast surgery following mastectomy.
(a) Every insurancecertificate or subscriber contract under any hospital service plan or medicalservice plan governed by this Article and Article 66 of this Chapter, and everypreferred provider benefit plan under G.S. 58‑50‑56 that providescoverage for mastectomy shall provide coverage for reconstructive breastsurgery following a mastectomy. The coverage shall include coverage for allstages and revisions of reconstructive breast surgery performed on anondiseased breast to establish symmetry if reconstructive surgery on adiseased breast is performed, as well as coverage for prostheses and physicalcomplications in all stages of mastectomy, including lymphademas. The same deductibles,coinsurance, and other limitations as apply to similar services covered underthe policy, contract, or plan shall apply to coverage for reconstructive breastsurgery. Reconstruction of the nipple/areolar complex following a mastectomy iscovered without regard to the lapse of time between the mastectomy and thereconstruction, subject to the approval of the treating physician.
(b) As used in thissection, the following terms have the meanings indicated:
(1) "Mastectomy"means the surgical removal of all or part of a breast as a result of breastcancer or breast disease.
(2) "Reconstructivebreast surgery" means surgery performed as a result of a mastectomy toreestablish symmetry between the two breasts, and includes reconstruction ofthe mastectomy site, creation of a new breast mound, and creation of a newnipple/areolar complex. "Reconstructive breast surgery" also includesaugmentation mammoplasty, reduction mammoplasty, and mastopexy of thenondiseased breast.
(c) A policy, contract,or plan subject to this section shall not:
(1) Deny coveragedescribed in subsection (a) of this section on the basis that the coverage isfor cosmetic surgery;
(2) Deny to a womaneligibility or continued eligibility to enroll or to renew coverage under theterms of the contract, policy, or plan, solely for the purpose of avoiding therequirements of this section;
(3) Provide monetarypayments or rebates to a woman to encourage her to accept less than the minimumprotections available under this section;
(4) Penalize orotherwise reduce or limit the reimbursement of an attending provider becausethe provider provided care to an individual participant or beneficiary inaccordance with this section; or
(5) Provide incentives,monetary or otherwise, to an attending provider to induce the provider toprovide care to an individual participant or beneficiary in a mannerinconsistent with this section.
(d) Written notice ofthe availability of the coverage provided by this section shall be delivered toevery subscriber under an individual certificate, contract, or plan and toevery certificate holder under a group policy, contract, or plan upon initialcoverage under the certificate, contract, or plan and annually thereafter. Thenotice required by this subsection may be included as a part of any yearlyinformational packet sent to the subscriber or certificate holder. (1997‑312, s. 2; 1997‑519,s. 3.10; 1999‑351, s. 3.2; 2001‑334, s. 13.2.)
