Senate Bill No. 324

Introduced By estrada, sands, baer, harp, halligan, franklin, foster, cocchiarella, kottel, krenzler, mccarthy, nelson, emerson, jenkins, depratu, mohl, cole, mcnutt, grosfield, mesaros, hargrove, doherty, mahlum, keating

A Bill for an Act entitled: "An Act providing for coverage of postmastectomy care as determined by a AN ATTENDING physician and patient OR, FOR AN HMO, BY A PRIMARY CARE PHYSICIAN, ATTENDING PHYSICIAN, AND PATIENT; providing for coverage of reconstructive surgery following a mastectomy; requiring written informed consent for patients receiving treatment for breast cancer; clarifying that the small employer health insurance availability act must offer coverage for mammography examinations; and amending sections 33-22-101, 33-22-1827, and 33-31-111, MCA; AND PROVIDING AN APPLICABILITY DATE."

Be it enacted by the Legislature of the State of Montana:

NEW SECTION. Section 1.  Postmastectomy care. Each group and individual disability policy, certificate of insurance, or membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for hospital inpatient care for a period of time as is determined by the attending physician AND, IN THE CASE OF A HEALTH MAINTENANCE ORGANIZATION, ALSO THE PRIMARY CARE PHYSICIAN, in consultation with the patient, to be medically appropriate NECESSARY following a mastectomy, a lumpectomy, or a lymph node dissection for the treatment of breast cancer. THIS SECTION ALSO APPLIES TO THE STATE EMPLOYEE GROUP INSURANCE PROGRAM, THE UNIVERSITY SYSTEM EMPLOYEE GROUP INSURANCE PROGRAM, ANY EMPLOYEE GROUP INSURANCE PROGRAM OF A CITY, TOWN, COUNTY, SCHOOL DISTRICT, OR OTHER POLITICAL SUBDIVISION OF THE STATE, AND ANY SELF-FUNDED MULTIPLE EMPLOYER WELFARE ASSOCIATION THAT IS NOT REGULATED BY THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

NEW SECTION. Section 2.  Coverage for reconstructive breast surgery after mastectomy. (1) Each group and individual disability policy, certificate of insurance, or membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for reconstructive breast surgery resulting from a mastectomy that resulted from breast cancer.

(2) Each group and individual disability policy, certificate of insurance, or membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for all stages of one reconstructive breast surgery on the nondiseased breast to establish symmetry with the diseased breast after definitive reconstructive breast surgery on the diseased breast has been performed.

(3) For the purposes of this section:

(a) "mastectomy" means the surgical removal of all or part of a breast as a result of breast cancer;

(b) "reconstructive breast surgery" means surgery performed as a result of a mastectomy to reestablish symmetry between the breasts. The term includes augmentation mammoplasty, reduction mammoplasty, and mastopexy.

(4) Benefits for reconstructive breast surgery include but are not limited to the costs of prostheses and, under any contract providing outpatient x-ray or radiation therapy, benefits for outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer that must be included as a part of the outpatient x-ray or radiation therapy benefit.

NEW SECTION. Section 3.  Written informed consent for breast cancer treatment. (1) For the purpose of this section, "written informed consent" means an agreement in writing that is freely executed by the patient that certifies that full disclosure has been made to the patient about:

(a) the full range of efficacious medical treatment alternatives that may be viable, including surgical procedures relating to the removal of breast tissue, radiological or chemotherapeutic treatments or any other generally accepted medical treatment, or combinations of procedures and treatments;

(b) the advantages, disadvantages, risks, and descriptions of the procedures and treatments listed in subsection (1)(a); and

(c) aspects of recovery, including the options that are available for reconstructive surgery.

(2) Failure of a physician or surgeon to provide written informed consent as provided in subsection (1) constitutes unprofessional conduct.

Section 4.  Section 33-22-101, MCA, is amended to read:

"33-22-101.   Exceptions to scope. Parts 1 through 4 of this chapter, except 33-22-107, 33-22-110, 33-22-111, 33-22-114, 33-22-125, 33-22-130 through 33-22-132, [sections 1 and 2], 33-22-243, and 33-22-304, do not apply to or affect:

(1)  any policy of liability or workers' compensation insurance with or without supplementary expense coverage;

(2)  any group or blanket policy;

(3)  life insurance, endowment, or annuity contracts or supplemental contracts that contain only those provisions relating to disability insurance as:

(a)  provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or

(b)  operate to safeguard contracts against lapse or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract;

(4)  reinsurance."

Section 5.  Section 33-22-1827, MCA, is amended to read:

"33-22-1827.   Benefits required in basic health benefit plan. (1) The basic health benefit plan must provide at least the following benefits:

(a)  coverage for the services and articles required by 33-22-1521(2);

(b)  coverage for mental health and chemical dependency required by Title 33, chapter 22, part 7; and

(c)  coverage for conversion of benefits required by 33-22-508 and 33-22-510 or by 33-30-1007; and

(d) coverage for mammography examinations required by 33-22-132.

(2)  The small employer carrier may determine varying levels of deductibles, copayments, maximum annual out-of-pocket expenses, maximum lifetime benefits, and other financial cost-sharing arrangements with the insured that give the basic health benefit plan a lower benefit value than the standard health benefit plan.

(3)  A basic health benefit plan provided by a health maintenance organization or a basic health benefit plan with a restricted network provision must provide a comparable level of benefits to those required by subsections (1) and (2), as determined by the benefit equivalency and benefit value."

Section 6.  Section 33-31-111, MCA, is amended to read:

"33-31-111.   Statutory construction and relationship to other laws. (1) Except as otherwise provided in this chapter, the insurance or health service corporation laws do not apply to any health maintenance organization authorized to transact business under this chapter. This provision does not apply to an insurer or health service corporation licensed and regulated pursuant to the insurance or health service corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.

(2)  Solicitation of enrollees by a health maintenance organization granted a certificate of authority or its representatives may not be construed as a violation of any law relating to solicitation or advertising by health professionals.

(3)  A health maintenance organization authorized under this chapter may not be considered to be practicing medicine and is exempt from Title 37, chapter 3, relating to the practice of medicine.

(4)  The provisions of this chapter do not exempt a health maintenance organization from the applicable certificate of need requirements under Title 50, chapter 5, parts 1 and 3.

(5)  The provisions of this section do not exempt a health maintenance organization from material transaction disclosure requirements under 33-3-701 through 33-3-704. A health maintenance organization must be considered an insurer for the purposes of 33-3-701 through 33-3-704.

(6) The provisions of this section do not exempt a health maintenance organization from the requirements of [sections 1 and 2]."

NEW SECTION. Section 7. Codification instruction. (1) [Sections 1 and 2] are intended to be codified as an integral part of Title 33, chapter 22, part 1, and the provisions of Title 33, chapter 22, part 1, apply to [sections 1 and 2].

(2) [Section 3] is intended to be codified in Title 37, chapter 3, and the provisions of Title 37, chapter 3, apply to [section 3].

NEW SECTION. SECTION 8. APPLICABILITY.  [THIS ACT] IS APPLICABLE TO ALL CONTRACTS ISSUED OR RENEWED ON OR AFTER JANUARY 1, 1998.

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