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2002 SESSION
025480828Be it enacted by the General Assembly of Virginia:
1. That § 38.2-3418.4 of the Code of Virginia is amended and reenacted as follows:
§ 38.2-3418.4. Coverage for reconstructive breast surgery.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing to
issue individual or group accident and sickness insurance policies providing
hospital, medical and surgical, or major medical coverage on an expense-incurred
basis; each corporation providing individual or group accident and sickness
subscription contracts; and each health maintenance organization providing a
health care plan for health care services shall provide coverage for
reconstructive breast surgery under such policy, contract or plan delivered,
issued for delivery or renewed in this Commonwealth on or after July 1, 1998.
B. The reimbursement for reconstructive breast surgery shall be determined according to the same formula by which charges are developed for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles and coinsurance factors that are no less favorable than for physical illness generally. Coverage shall be provided in a manner determined in consultation with the attending physician and the patient.
C. For purposes of this section, "mastectomy" means the surgical removal of all
or part of the breast as a result of breast cancer and "reconstructive breast
surgery" means surgery performed on or after July 1, 1998, (i) coincident with
or following a mastectomy performed for breast cancer or (ii) following a
mastectomy performed on or after July 1, 1998, for breast cancer to reestablish
symmetry between the two breasts, provided that such reconstructive breast
surgery is performed while the patient is or was a covered person under the policy,
contract or plan. Reconstructive breast surgery shall also include coverage
for prostheses, determined as necessary in consultation with the attending physician and
patient, and physical complications of mastectomy, including medically necessary treatment
of lymphedemas.
D. Written notice of the availability of this coverage shall be provided to the enrollee upon enrollment in the policy and annually thereafter. Such notice shall be prominently positioned in any literature or correspondence provided to the enrollee.
E. Eligibility for coverage shall not be denied solely for the purpose of
avoiding the requirements of this section, nor shall an attending provider be
penalized or have the reimbursement reduced or incentives, monetary [ of or ]
otherwise, provided to induce such provider to provide care in a manner
inconsistent with this section.
D F. The provisions of this section shall not apply to short-term travel,
accident only, limited or specified disease policies (except policies issued
for cancer), policies or contracts designed for issuance to persons eligible
for coverage under Title XVIII of the Social Security Act, known as Medicare,
or any other similar coverage under state or federal governmental plans or to
short-term nonrenewable policies of not more than six months' duration.