§ 38.2-3418.4. Coverage for reconstructive breast surgery; notice;eligibility.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shallprovide coverage for reconstructive breast surgery under such policy,contract or plan delivered, issued for delivery or renewed in thisCommonwealth.
B. The reimbursement for reconstructive breast surgery shall be determinedaccording to the same formula by which charges are developed for othermedical and surgical procedures. Such coverage shall have durational limits,dollar limits, deductibles and coinsurance factors that are no less favorablethan for physical illness generally. Coverage shall be provided in a mannerdetermined in consultation with the attending physician and the patient.
C. For purposes of this section, "mastectomy" means the surgical removal ofall or part of the breast and "reconstructive breast surgery" means surgeryperformed (i) coincident with or following a mastectomy or (ii) following amastectomy to reestablish symmetry between the two breasts, forreconstructive breast surgery performed on or after October 21, 1998, andwhile the patient is or was a covered person under the policy, contract orplan. Reconstructive breast surgery shall also include coverage forprostheses, determined as necessary in consultation with the attendingphysician and patient, and physical complications of mastectomy, includingmedically necessary treatment of lymphedemas.
D. Written notice of the availability of this coverage shall be provided tothe subscribers upon enrollment in the policy and annually thereafter. Suchnotice shall be prominently positioned in any literature or correspondenceprovided to the subscribers.
E. Eligibility for coverage shall not be denied solely for the purpose ofavoiding the requirements of this section, nor shall an attending provider bepenalized or have the reimbursement reduced or incentives, monetary orotherwise, provided to induce such provider to provide care in a mannerinconsistent with this section.
F. The provisions of this section shall not apply to short-term travel,accident only, limited or specified disease policies (except policies issuedfor cancer), policies or contracts designed for issuance to persons eligiblefor coverage under Title XVIII of the Social Security Act, known as Medicare,or any other similar coverage under state or federal governmental plans or toshort-term nonrenewable policies of not more than six months' duration.
§ 38.2-3418.4. Coverage for reconstructive breast surgery; notice;eligibility.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shallprovide coverage for reconstructive breast surgery under such policy,contract or plan delivered, issued for delivery or renewed in thisCommonwealth.
B. The reimbursement for reconstructive breast surgery shall be determinedaccording to the same formula by which charges are developed for othermedical and surgical procedures. Such coverage shall have durational limits,dollar limits, deductibles and coinsurance factors that are no less favorablethan for physical illness generally. Coverage shall be provided in a mannerdetermined in consultation with the attending physician and the patient.
C. For purposes of this section, "mastectomy" means the surgical removal ofall or part of the breast and "reconstructive breast surgery" means surgeryperformed (i) coincident with or following a mastectomy or (ii) following amastectomy to reestablish symmetry between the two breasts, forreconstructive breast surgery performed on or after October 21, 1998, andwhile the patient is or was a covered person under the policy, contract orplan. Reconstructive breast surgery shall also include coverage forprostheses, determined as necessary in consultation with the attendingphysician and patient, and physical complications of mastectomy, includingmedically necessary treatment of lymphedemas.
D. Written notice of the availability of this coverage shall be provided tothe subscribers upon enrollment in the policy and annually thereafter. Suchnotice shall be prominently positioned in any literature or correspondenceprovided to the subscribers.
E. Eligibility for coverage shall not be denied solely for the purpose ofavoiding the requirements of this section, nor shall an attending provider bepenalized or have the reimbursement reduced or incentives, monetary orotherwise, provided to induce such provider to provide care in a mannerinconsistent with this section.
F. The provisions of this section shall not apply to short-term travel,accident only, limited or specified disease policies (except policies issuedfor cancer), policies or contracts designed for issuance to persons eligiblefor coverage under Title XVIII of the Social Security Act, known as Medicare,or any other similar coverage under state or federal governmental plans or toshort-term nonrenewable policies of not more than six months' duration.
§ 38.2-3418.4. Coverage for reconstructive breast surgery; notice;eligibility.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shallprovide coverage for reconstructive breast surgery under such policy,contract or plan delivered, issued for delivery or renewed in thisCommonwealth.
B. The reimbursement for reconstructive breast surgery shall be determinedaccording to the same formula by which charges are developed for othermedical and surgical procedures. Such coverage shall have durational limits,dollar limits, deductibles and coinsurance factors that are no less favorablethan for physical illness generally. Coverage shall be provided in a mannerdetermined in consultation with the attending physician and the patient.
C. For purposes of this section, "mastectomy" means the surgical removal ofall or part of the breast and "reconstructive breast surgery" means surgeryperformed (i) coincident with or following a mastectomy or (ii) following amastectomy to reestablish symmetry between the two breasts, forreconstructive breast surgery performed on or after October 21, 1998, andwhile the patient is or was a covered person under the policy, contract orplan. Reconstructive breast surgery shall also include coverage forprostheses, determined as necessary in consultation with the attendingphysician and patient, and physical complications of mastectomy, includingmedically necessary treatment of lymphedemas.
D. Written notice of the availability of this coverage shall be provided tothe subscribers upon enrollment in the policy and annually thereafter. Suchnotice shall be prominently positioned in any literature or correspondenceprovided to the subscribers.
E. Eligibility for coverage shall not be denied solely for the purpose ofavoiding the requirements of this section, nor shall an attending provider bepenalized or have the reimbursement reduced or incentives, monetary orotherwise, provided to induce such provider to provide care in a mannerinconsistent with this section.
F. The provisions of this section shall not apply to short-term travel,accident only, limited or specified disease policies (except policies issuedfor cancer), policies or contracts designed for issuance to persons eligiblefor coverage under Title XVIII of the Social Security Act, known as Medicare,or any other similar coverage under state or federal governmental plans or toshort-term nonrenewable policies of not more than six months' duration.
