2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 38 - Health Maintenance Organizations 38.38-1934 Coverage for medical and surgical benefits with respect to mastectomy, diagnosis and treatment of endometrioses and endometritis, and bone density testing -- Duties of health maintenance organization.
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304.38-1934 Coverage for medical and surgical benefits with respect to
mastectomy, diagnosis and treatment of endometrioses and
endometritis, and bone density testing -- Duties of health maintenance
organization.
(1)
(2)
(3)
(4)
Health maintenance organizations issuing contracts in this Commonwealth that
provide hospital, medical, or surgical expense benefits shall make available
and offer to the purchaser coverage for:
(a) The following, if a health maintenance organization provides medical and
surgical benefits with respect to a mastectomy, in a manner determined in
consultation with the attending physician and the covered person, and
subject to annual deductibles and coinsurance provisions as may be
deemed appropriate and as are consistent with those established for
other benefits under the coverage:
1.
All stages of breast reconstruction surgery of the breast on which
the mastectomy has been performed;
2.
Surgery and reconstruction of the other breast to produce a
symmetrical appearance; and
3.
Prostheses and physical complications of all stages of mastectomy,
including lymphedemas;
(b) Diagnosis and treatment of endometriosis if the health maintenance
organization also covers hysterectomies; and
(c) Bone density testing for women age thirty-five (35) years and older, as
indicated by the health-care provider, in accordance with standard
medical practice, to obtain baseline data for the purpose of early detection
of osteoporosis.
No health maintenance organization under this section shall offer medical and
surgical benefits with respect to mastectomy that requires the procedure be
performed on an outpatient basis.
A health maintenance organization shall provide written notice to a covered
person of the availability of medical and surgical benefits with respect to a
mastectomy upon enrollment and annually thereafter.
A health maintenance organization shall not:
(a) Deny eligibility, or continued eligibility, to an individual to enroll or to
renew coverage under the terms of the plan, solely for the purpose of
avoiding the requirements of 42 U.S.C. secs. 300gg-6 and 300gg-52; and
(b) Penalize or otherwise reduce or limit the reimbursement of an attending
provider or provide incentives to an attending provider, to induce the
provider to provide care to an individual in a manner inconsistent with 42
U.S.C. secs. 300gg-6 and 300gg-52.
Effective:July 15, 2002
History: Amended 2002 Ky. Acts ch. 181, sec. 21, effective July 15, 2002. -Created 1998 Ky. Acts ch. 427, sec. 5, effective July 15, 1998.
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