2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-542. - Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Orally administered anticancer medications.

(a) Each insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state group health insurance policies providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall provide coverage under such policies for treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost of any nondental prosthesis, including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, outpatient chemotherapy following surgical procedures in connection with the treatment of tumors, a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy, and costs of removal of any breast implant which was implanted on or before July 1, 1994, without regard to the purpose of such implantation, which removal is determined to be medically necessary. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.
(b) Except as provided in subsection (c) of this section, the coverage required by subsection (a) of this section shall provide at least a yearly benefit of one thousand dollars for the costs of removal of any breast implant, five hundred dollars for the surgical removal of tumors, five hundred dollars for reconstructive surgery, five hundred dollars for outpatient chemotherapy, three hundred fifty dollars for a wig and three hundred dollars for a nondental prosthesis, except that for purposes of the surgical removal of breasts due to tumors the yearly benefit for such prosthesis shall be at least three hundred dollars for each breast removed.
(c) The coverage required by subsection (a) of this section shall provide benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a nondiseased breast to produce a symmetrical appearance. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies. For the purposes of this subsection, reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.
(d) (1) Each policy of the type specified in subsection (a) of this section that provides coverage for intravenously administered and orally administered anticancer medications used to kill or slow the growth of cancerous cells that are prescribed by a prescribing practitioner, as defined in section 20-571, shall provide coverage for orally administered anticancer medications on a basis that is no less favorable than intravenously administered anticancer medications.
(2) No insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state a policy of the type specified in subsection (a) of this section shall reclassify such anticancer medications or increase the coinsurance, copayment, deductible or other out-of-pocket expense imposed under such policy for such medications to achieve compliance with this subsection.
(P.A. 90-243, S. 123; P.A. 94-71, S. 12; P.A. 97-198, S. 4, 5; P.A. 04-34, S. 2; P.A. 10-5, S. 31; 10-63, S. 2; P.A. 11-19, S. 11.)
History: P.A. 94-71 amended Subsec. (a) by adding a provision to cover the cost of removal of any breast implant which was implanted on or before July 1, 1994, without regard to the purpose of the implantation, provided the removal is determined to be medically necessary and added a provision in Subsec. (b) for a benefit of $1,000 for the costs of removal of the breast implant; P.A. 97-198 deleted provision from Subsec. (a) re coverage for the surgical removal of tumors, added exception to Subsec. (b) and added Subsec. (c) re reconstructive surgery after mastectomy, effective July 1, 1997; P.A. 04-34 amended Subsec. (a) to substitute “Each” for “Any” and require coverage for a wig if prescribed for a patient who suffers hair loss as a result of chemotherapy and amended Subsec. (b) to require a yearly benefit of $350 for a wig; P.A. 10-5 made technical changes in Subsecs. (a) and (b), effective January 1, 2011; P.A. 10-63 made technical changes in Subsecs. (a) and (b) and added Subsec. (d) re orally administered anticancer medications, effective January 1, 2011; P.A. 11-19 made technical changes in Subsec. (d).
See Sec. 38a-504 for similar provisions re individual policies.