376.1200. Certain policies to offer coverage for treatment of breast cancer--limitation on deductible, lifetime maximum benefit--administration of benefits--application, effect.
Certain policies to offer coverage for treatment of breastcancer--limitation on deductible, lifetime maximumbenefit--administration of benefits--application, effect.
376.1200. 1. Each entity offering individual and group health insurancepolicies providing coverage on an expense-incurred basis, individual and groupservice or indemnity type contracts issued by a health services corporation,individual and group service contracts issued by a health maintenanceorganization, all self-insured group arrangements to the extent not preemptedby federal law and all managed health care delivery entities of any type ordescription, that are delivered, issued for delivery, continued or renewed inthis state on or after January 1, 1996, shall offer coverage for the treatmentof breast cancer by dose-intensive chemotherapy/autologous bone marrowtransplants or stem cell transplants when performed pursuant to nationallyaccepted peer review protocols utilized by breast cancer treatment centersexperienced in dose-intensive chemotherapy/autologous bone marrow transplantsor stem cell transplants. The offer of benefits under this section shall bein writing and must be accepted in writing by the individual or grouppolicyholder or contract holder.
2. Such health care service shall not be subject to any greaterdeductible or co-payment than any other health care service provided by thepolicy, contract or plan, except that the policy, contract or plan may containa provision imposing a lifetime benefit maximum of not less than one hundredthousand dollars, for dose-intensive chemotherapy/autologous bone marrowtransplants or stem cell transplants for breast cancer treatment.
3. Benefits may be administered for such health care service through amanaged care program of exclusive and/or preferred contractual arrangementswith one or more providers rendering such health care service. Thesecontractual arrangements may provide that the provider shall hold the patientharmless for the cost of rendering such health care service if it issubsequently found by the entity authorized to resolve disputes that:
(1) Such care did not qualify under the protocols established for theproviding of care for such health care service;
(2) Such care was not medically appropriate; or
(3) The provider otherwise failed to comply with the utilizationmanagement or other managed care provision agreed to in any contract betweenthe entity and the provider.
4. The provisions of this section shall not apply to short-term travel,accident-only, limited or specified disease policies, or to short-termnonrenewable policies of not more than seven months duration.
5. Nothing in this section shall prohibit an entity from including allor part of such health care services as standard coverage in its policies,contracts or plans.
(L. 1995 S.B. 27)