State Codes and Statutes

Statutes > North-carolina > Chapter_58 > GS_58-51-62

§ 58‑51‑62. Coverage for reconstructive breast surgery following mastectomy.

(a)        Every policy orcontract of accident and health insurance, and every preferred provider benefitplan under G.S. 58‑50‑56 that provides coverage for mastectomyshall provide coverage for reconstructive breast surgery following amastectomy. The coverage shall include coverage for all stages and revisions ofreconstructive breast surgery performed on a nondiseased breast to establishsymmetry if reconstructive surgery on a diseased breast is performed, as wellas coverage for prostheses and physical complications in all stages ofmastectomy, including lymphademas. The same deductibles, coinsurance, and otherlimitations as apply to similar services covered under the policy, contract, orplan shall apply to coverage for reconstructive breast surgery. Reconstructionof the nipple/areolar complex following a mastectomy is covered without regardto the lapse of time between the mastectomy and the reconstruction, subject tothe 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 manner inconsistentwith this section.

(d)        Written notice ofthe availability of the coverage provided by this section shall be delivered toevery policyholder under an individual policy, contract, or plan and to everycertificate holder under a group policy, contract, or plan upon initialcoverage under the policy, contract, or plan and annually thereafter. Thenotice required by this subsection may be included as a part of any yearlyinformational packet sent to the policyholder or certificate holder. (1997‑312, s. 1; 1997‑456,s. 40(a); 1997‑519, s. 3.9; 1999‑351, s. 3.1; 2001‑334, s.13.1.)

State Codes and Statutes

Statutes > North-carolina > Chapter_58 > GS_58-51-62

§ 58‑51‑62. Coverage for reconstructive breast surgery following mastectomy.

(a)        Every policy orcontract of accident and health insurance, and every preferred provider benefitplan under G.S. 58‑50‑56 that provides coverage for mastectomyshall provide coverage for reconstructive breast surgery following amastectomy. The coverage shall include coverage for all stages and revisions ofreconstructive breast surgery performed on a nondiseased breast to establishsymmetry if reconstructive surgery on a diseased breast is performed, as wellas coverage for prostheses and physical complications in all stages ofmastectomy, including lymphademas. The same deductibles, coinsurance, and otherlimitations as apply to similar services covered under the policy, contract, orplan shall apply to coverage for reconstructive breast surgery. Reconstructionof the nipple/areolar complex following a mastectomy is covered without regardto the lapse of time between the mastectomy and the reconstruction, subject tothe 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 manner inconsistentwith this section.

(d)        Written notice ofthe availability of the coverage provided by this section shall be delivered toevery policyholder under an individual policy, contract, or plan and to everycertificate holder under a group policy, contract, or plan upon initialcoverage under the policy, contract, or plan and annually thereafter. Thenotice required by this subsection may be included as a part of any yearlyinformational packet sent to the policyholder or certificate holder. (1997‑312, s. 1; 1997‑456,s. 40(a); 1997‑519, s. 3.9; 1999‑351, s. 3.1; 2001‑334, s.13.1.)


State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_58 > GS_58-51-62

§ 58‑51‑62. Coverage for reconstructive breast surgery following mastectomy.

(a)        Every policy orcontract of accident and health insurance, and every preferred provider benefitplan under G.S. 58‑50‑56 that provides coverage for mastectomyshall provide coverage for reconstructive breast surgery following amastectomy. The coverage shall include coverage for all stages and revisions ofreconstructive breast surgery performed on a nondiseased breast to establishsymmetry if reconstructive surgery on a diseased breast is performed, as wellas coverage for prostheses and physical complications in all stages ofmastectomy, including lymphademas. The same deductibles, coinsurance, and otherlimitations as apply to similar services covered under the policy, contract, orplan shall apply to coverage for reconstructive breast surgery. Reconstructionof the nipple/areolar complex following a mastectomy is covered without regardto the lapse of time between the mastectomy and the reconstruction, subject tothe 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 manner inconsistentwith this section.

(d)        Written notice ofthe availability of the coverage provided by this section shall be delivered toevery policyholder under an individual policy, contract, or plan and to everycertificate holder under a group policy, contract, or plan upon initialcoverage under the policy, contract, or plan and annually thereafter. Thenotice required by this subsection may be included as a part of any yearlyinformational packet sent to the policyholder or certificate holder. (1997‑312, s. 1; 1997‑456,s. 40(a); 1997‑519, s. 3.9; 1999‑351, s. 3.1; 2001‑334, s.13.1.)