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Rule 20:06:40:17 Group health plans to offer breast reconstruction options after covered mastectomy.

          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.


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