Federal law requires group health plans that provide medical and surgical benefits for mastectomies to provide coverage in connection with the mastectomy (in the manner determined by the attending physician and the patient) for:
- reconstruction of the breast on which the mastectomy was performed,
- surgery and reconstruction of the other breast to produce a symmetrical appearance,
- prostheses, and
- treatment of physical complications at all stages of mastectomy, including lymphedema.
Group health plans and health insurers may not deny eligibility to enroll, renew, or continue group health plan coverage to avoid providing coverage for breast reconstruction or mastectomy complications. In addition, the law prohibits penalizing or otherwise reducing or limiting the reimbursement of an attending provider for the required care, or providing any incentive (monetary or otherwise) to induce the attending provider to provide care that would be inconsistent with the law.
The above-described coverage required by applicable law may only be subject to the annual deductibles, copayments, and coinsurance provisions that apply to similar benefits.
If you have any questions about this coverage, please contact your Plan Administrator (SU Human Resources at 315-443-4042) or the health plan administrator (POMCO at 1-877-461-7844).
Date: January 2011