20:06:40:17. Group health plans to offer breast reconstruction options after covered mastectomy. A group health plan, as defined by SDCL 58-18-42, and a health insurance issuer providing health insurance coverage in connection with a group health plan that provides medical and surgical benefits with respect to a mastectomy, shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for:
(1) Reconstruction 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 at all stages of a mastectomy, including lymphedemas.
Coverage shall be provided in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.
Source: 27 SDR 15, effective September 6, 2000.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:40:17.01. Written notification regarding coverage of reconstructive surgery after a mastectomy required. A group health plan, and a health insurance issuer providing insurance coverage in connection with a group health plan, shall provide notice to each participant and beneficiary under such plan regarding the coverage required by § 20:06:40:17. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan or issuer and shall be transmitted:
(1) In the first mailing made by the plan or issuer to the participant or beneficiary after September 6, 2000; and
(2) As a part of any yearly informational packet sent to the participant or beneficiary.
If a plan or issuer has made a mailing prior to September 6, 2000, that complies with subdivision (1), the requirement of subdivision (1) is met.
Source: 27 SDR 15, effective September 6, 2000.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:40:17.02. Prohibited practices. A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not:
(1) Deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of § 20:06:40:17; or
(2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with § 20:06:40:17.
Source: 27 SDR 15, effective September 6, 2000.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:40:17.03. Not a termination of collective bargaining agreement. In the case of a group health plan maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers, any plan amendment which amends the plan solely to conform to any requirement added by §§ 20:06:40:17 to 20:06:40:17.02, inclusive, may not be treated as a termination of such collective bargaining agreement.
Source: 27 SDR 15, effective September 6, 2000.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
