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Indiana Code Title 27. Insurance § 27-13-7-14

Current as of January 02, 2024 | Updated by Findlaw Staff

Sec. 14. (a) As used in this section, “mastectomy” means the removal of all or part of the breast for reasons that are determined by a licensed physician to be medically necessary.

(b) A contract with a health maintenance organization that provides coverage for a mastectomy must provide coverage as required under 29 U.S.C. 1185b, including coverage for:

(1) prosthetic devices;  and

(2) reconstructive surgery incident to a mastectomy including:

(A) all stages of reconstruction of the breast on which the mastectomy has been performed;

(B) surgery and reconstruction of the other breast to produce symmetry;  and

(C) chest wall reconstruction, including aesthetic flat closure (as defined by the National Cancer Institute);

in the manner determined by the attending physician and the patient to be appropriate.

(c) In addition to the coverage required by 29 U.S.C. 1185b, a health maintenance organization contract that provides coverage for a mastectomy must provide coverage for:

(1) custom fabricated breast prostheses;  and

(2) one (1) additional breast prosthesis per breast affected by the mastectomy.

(d) Coverage required under this section is subject to:

(1) the deductible and coinsurance provisions applicable to a mastectomy;  and

(2) all other terms and conditions applicable to other services under the contract.

(e) A health maintenance organization shall provide to an enrollee, at the time that an individual contract or a group contract is entered into and annually thereafter, written notice of the coverage required under this section.  Notice that is sent by the health maintenance organization that meets the requirements set forth in 29 U.S.C. 1185b constitutes compliance with this subsection.

(f) The coverage required under this section applies to a contract with a health maintenance organization that provides coverage for a mastectomy, regardless of whether an individual who:

(1) underwent a mastectomy;  and

(2) is covered under the contract;

was covered under the contract at the time of the mastectomy.

(g) Except as provided in subsection (b)(2)(C) and subsection (c), this section does not require a health maintenance organization to provide coverage related to post mastectomy care that exceeds the coverage required for post mastectomy care under federal law.

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Cite this article: FindLaw.com - Indiana Code Title 27. Insurance § 27-13-7-14 - last updated January 02, 2024 | https://codes.findlaw.com/in/title-27-insurance/in-code-sect-27-13-7-14/

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