                                 CODE OF VIRGINIA

COVERAGE FOR RECONSTRUCTIVE BREAST SURGERY; NOTICE; ELIGIBILITY (§ 38.2-3418.4)

A. Notwithstanding the provisions of &#xA7; 38.2-3419, each insurer proposing to
issue individual or group accident and sickness insurance policies providing
hospital, medical and surgical, or major medical coverage on an expense-incurred
basis; each corporation providing individual or group accident and sickness
subscription contracts; and each health maintenance organization providing a
health care plan for health care services shall provide coverage for
reconstructive breast surgery under such policy, contract or plan delivered,
issued for delivery or renewed in this Commonwealth.

B. The reimbursement for reconstructive breast surgery shall be determined
according to the same formula by which charges are developed for other medical
and surgical procedures. Such coverage shall have durational limits, dollar
limits, deductibles and coinsurance factors that are no less favorable than for
physical illness generally. Coverage shall be provided in a manner determined in
consultation with the attending physician and the patient.

C. For purposes of this section, &#8220;mastectomy&#8221; means the surgical
removal of all or part of the breast and &#8220;reconstructive breast
surgery&#8221; means surgery performed (i) coincident with or following a
mastectomy or (ii) following a mastectomy to reestablish symmetry between the
two breasts, for reconstructive breast surgery performed on or after October 21,
1998, and while the patient is or was a covered person under the policy,
contract or plan. Reconstructive breast surgery shall also include coverage for
prostheses, determined as necessary in consultation with the attending physician
and patient, and physical complications of mastectomy, including medically
necessary treatment of lymphedemas.

D. Written notice of the availability of this coverage shall be provided to the
subscribers upon enrollment in the policy and annually thereafter. Such notice
shall be prominently positioned in any literature or correspondence provided to
the subscribers.

E. Eligibility for coverage shall not be denied solely for the purpose of
avoiding the requirements of this section, nor shall an attending provider be
penalized or have the reimbursement reduced or incentives, monetary or
otherwise, provided to induce such provider to provide care in a manner
inconsistent with this section.

F. The provisions of this section shall not apply to short-term travel, accident
only, limited or specified disease policies (except policies issued for cancer),
policies or contracts designed for issuance to persons eligible for coverage
under Title XVIII of the Social Security Act, known as Medicare, or any other
similar coverage under state or federal governmental plans or to short-term
nonrenewable policies of not more than six months&#8217; duration.

HISTORY: 1998, c. 56; 2002, c. 415; 2003, c. 250.