(1) Any group, blanket, or franchise accident or health insurance policy that is issued, amended, delivered, or renewed in this state which provides coverage for breast cancer treatment may not limit inpatient hospital coverage for mastectomies to any period that is less than that determined by the treating physician to be medically necessary in accordance with prevailing medical standards and after consultation with the insured patient.
(2) Any group, blanket, or franchise accident or health insurance policy that provides coverage for mastectomies under subsection (1) must also provide coverage for outpatient postsurgical followup care in keeping with prevailing medical standards by a licensed health care professional qualified to provide postsurgical mastectomy care. The treating physician, after consultation with the insured patient, may choose that the outpatient care be provided at the most medically appropriate setting, which may include the hospital, treating physician’s office, outpatient center, or home of the insured patient.
(3) An insurer subject to subsection (1) may not:(a) Deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section;
(b) Provide monetary payments or rebates to an insured patient to accept less than the minimum protections available under this section;
(c) Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an insured patient under this section;
(d) Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an insured patient in a manner inconsistent with this section; or
(e) Subject to the other provisions of this section, restrict benefits for any portion of a period within a hospital length of stay or outpatient care as required by this section in a manner that is less than favorable than the benefits provided for any preceding portion of such stay.
(4)(a) This section does not require an insured patient to have the mastectomy in the hospital or stay in the hospital for a fixed period of time following the mastectomy.
(b) This section does not prevent a policy from imposing deductibles, coinsurance, or other cost sharing in relation to benefits under this section, except that such cost sharing may not exceed cost sharing with other benefits.
(5) Except as provided in subsection (3), this section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers and does not prohibit appropriate utilization review or case management by the insurer.
(6) This section does not apply to disability income, specified diseases other than cancer, or hospital indemnity policies.
(7) As used in this section, the term “mastectomy” means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician.
