Chapter 208
Oregon Laws 2011
AN ACT
HB 3616
Relating to
health insurance coverage of mastectomy; amending ORS 743A.110.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 743A.110 is amended to
read:
743A.110. (1) As used in this section,
“mastectomy” means the surgical removal of all or part of a breast or a breast
tumor suspected to be malignant.
[(1)]
(2) All insurers offering a health benefit plan as defined in ORS 743.730
shall provide payment, coverage or reimbursement for mastectomy and for
the following [mastectomy-related]
services related to a mastectomy as determined by the attending
physician and enrollee to be part of the enrollee’s course or plan of
treatment:
(a) All stages of reconstruction of
the breast on which a mastectomy was performed, including but not limited to
nipple reconstruction, skin grafts and stippling of the nipple and areola;
(b) Surgery and reconstruction of the
other breast to produce a symmetrical appearance;
(c) Prostheses;
(d) Treatment of physical
complications of the mastectomy, including lymph edemas; and
(e) Inpatient care related to the
mastectomy and post-mastectomy services.
[(2)]
(3) An insurer providing coverage under subsection [(1)] (2) of this section shall provide written notice describing
the coverage to the enrollee at the time of enrollment in the health benefit
plan and annually thereafter.
[(3)]
(4) A health benefit plan must provide a single determination of prior
authorization for all [mastectomy-related]
services related to a mastectomy covered under subsection [(1)] (2) of this section that are
part of the enrollee’s course or plan of treatment.
[(4)]
(5) When an enrollee requests an external review of an adverse decision by
the insurer regarding services described in subsection [(1)] (2) of this section, the insurer must expedite the
enrollee’s case pursuant to ORS 743.857 (4).
[(5)]
(6) The coverage required under subsection [(1)] (2) of this section is subject to the same terms and
conditions in the plan that apply to other benefits under the plan.
[(6)]
(7) This section is exempt from ORS 743A.001.
Approved by
the Governor June 1, 2011
Filed in the
office of Secretary of State June 2, 2011
Effective date
January 1, 2012
__________