HF 727 (LSB 2587YH (5) 89)

HOUSE FILE 727

BY  BROWN-POWERS and A. MEYER

A BILL FOR

An Act relating to health insurance coverage for certain post-mastectomy related issues, and including applicability provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.36  Mastectomies.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense obligation imposed on a covered person by a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses.
   b.  “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.
   c.  “Health care professional” means the same as defined in section 514J.102.
   d.  “Mastectomy” means the removal of all or part of a breast for a medically necessary reason as determined by a covered person’s health care professional.
   2.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses, and that provides coverage for mastectomies, shall provide coverage for all of the following:
   a.  Physical complications caused by a mastectomy, including lymphedema.
   b.  Prosthetic devices.
   c.  A custom fabricated breast prothesis for each breast on which a mastectomy has been performed.
   d.  One additional breast prothesis for each breast affected by a mastectomy.
   e.  Reconstructive surgery incident to a mastectomy, in the manner determined by the covered person and the covered person’s health care professional to be appropriate, including all of the following:
   (1)  All stages of reconstruction of the breast on which the mastectomy has been performed.
   (2)  Surgery and reconstruction of the breast on which the mastectomy was not performed to produce symmetry with the breast on which the mastectomy was performed.
   3.  Coverage shall not be subject to cost sharing that is greater than the cost sharing that a policy, contract, or plan imposes for a mastectomy under the policy, contract, or plan.
   4.  a.  This section shall apply to the following classes of third-party payment provider contracts, policies, or plans:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   5.  The commissioner of insurance shall adopt rules pursuant to chapter 17A to administer this section.
    Sec. 2.  APPLICABILITY.  This Act applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2022.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to health insurance coverage for certain post-mastectomy related issues.
   The bill defines “mastectomy” as the removal of all or part of a breast for a medically necessary reason as determined by a covered person’s health care professional.
   The bill requires a health carrier that offers individual, group, or small group contracts, policies, or plans (plans) in this state that provide for third-party payment or prepayment of health or medical expenses, and that provide coverage for mastectomies, to provide coverage for physical complications caused by a mastectomy, including lymphedema; prosthetic devices; a custom fabricated breast prothesis for each breast on which a mastectomy has been performed; one additional breast prothesis for each breast affected by a mastectomy; all stages of reconstruction of the breast on which the mastectomy has been performed; and surgery and reconstruction of the breast on which the mastectomy was not performed to produce symmetry with the other breast.
   The coverage cannot be subject to cost sharing that is greater than the cost sharing that a plan imposes for a mastectomy under the plan.
   The bill applies to the third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance which are not subject to the coverage requirements of the bill.
   The commissioner of insurance must adopt rules to administer the requirements of the bill.
   The bill applies to third-party payment provider plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2022.