Section 4521.132  Required Coverage for Reconstructive Surgery Following Mastectomies

a)         As required by the Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) (42 USC 300gg-6, 300gg-52, incorporating 29 USC 1185(b)), every individual and group contract or evidence of coverage issued by a health maintenance organization that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of an enrollee who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with a mastectomy, coverage in a manner determined in consultation with the attending physician and the patient for:

1)         Reconstruction for the breast on which the mastectomy has been performed;

2)         Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3)         Prostheses and physical complications for all stages of mastectomy, including lymphedemas.

b)         This coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan coverage.  Written notice of the availability of coverage under this Part shall be delivered to the enrollee upon enrollment and annually thereafter.

c)         A health maintenance organization operating a health care plan shall provide notice to each enrollee under the plan regarding the coverage required by this Part.  The notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the health maintenance organization and shall be transmitted the earlier of:

1)         In the next mailing made by the health maintenance organization to the enrollee;

2)         As part of any yearly informational packet sent to the enrollee.

d)         A health maintenance organization offering individual or group health insurance may not:

1)         Deny to an enrollee 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 Part; or

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

e)         Nothing in this Section shall be construed to prevent a health maintenance organization from negotiating the level and type of reimbursement with a provider for care provided in accordance with this Part.

(Source:  Amended at 30 Ill. Reg. 4732, effective March 2, 2006)