GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1997

S	1 

SENATE BILL 796

Short Title:  Areola Reconstruction Coverage.	(Public)

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Sponsors: Senators Martin of Pitt, Forrester, Cochrane; Albertson, Ballantine, Conder, Cooper, Dannelly, Foxx, Horton, Hoyle, Jenkins, Kerr, Kinnaird, Lee, Lucas, Martin of Guilford, Odom, Page, Perdue, Phillips, Rand, Weinstein, Wellons, and Winner.

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Referred to:  Pensions & Retirement and Insurance.

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April 10, 1997

A BILL TO BE ENTITLED
AN ACT TO PROVIDE FOR INSURANCE COVERAGE FOR BREAST AND AREOLA RECONSTRUCTION ARISING FROM A MASTECTOMY.
The General Assembly of North Carolina enacts:
Section 1.  G.S. 135-40.6(6) reads as rewritten:
"(6)	Limitations and Exclusions to Surgical Benefits. –
a.	No benefits are provided for dental prostheses such as crowns, or dentures; orthodontic care; operative restoration of teeth (fillings); dental extractions (whether impacted or not impacted); apicoectomies; treatment of dental caries, gingivitis, or periodontal diseases by gingivectomies or other periodontal surgery; vestibuloplasties, alveoplasties, removal of exostosis and tori preparatory to fitting of dentures; correction of malocclusion by orthognathic surgery or other procedures by repositioning of bone tissue except as permitted pursuant to G.S. 135-40.6(5)c; removal of cysts incidental to apicoectomies or extraction of teeth.
b.	Cosmetic surgery or surgery solely for beautifying purposes is not covered, except for procedures related to injury sustained while the individual is continuously covered under the Plan.  Nipple/areola reconstruction following a mastectomy is not cosmetic surgery or surgery solely for beautifying purposes and shall be reimbursed in accordance with this Article regardless of the lapse in time between the mastectomy and the reconstruction.
c.	If a covered individual is admitted for medical and surgical treatment for the same condition, by the same doctor, either medical or surgical care may be paid, whichever is greater, but not both.
d.	When a covered individual is admitted for medical treatment and during the hospital admission is subsequently referred to another doctor for surgery, medical benefits are provided for hospital days prior to the date of referral.
e.	If during the hospital admission for necessary medical treatment, surgery is provided for a wholly distinct and unrelated condition, both medical and surgical benefits are payable, however, the same doctor may not be paid both medical and surgical benefits provided on the same day.
f.	If during hospital admission for necessary medical treatment, a covered individual receives related surgical procedures such as paracentesis, biopsy, endoscopy, operative preparation for x-ray examination, or other diagnostic procedures for which benefits are applicable under the surgical benefits section of the Plan, both medical and surgical benefits are payable.
g.	No benefits are provided for concurrent co-attending medical and surgical care by two or more doctors for the same condition other than as provided above.
h.	No benefits will be payable for surgical procedure specifically listed by the American Medical Association or the North Carolina Medical Association as having no medical value.
i.	No benefits are payable for organ transplants not listed in G.S. 135-40.6(5)a, nor will benefits be payable for surgical procedures determined in the opinion of the Claims Processor to be experimental.
j.	No benefits are payable for radial keratotomy surgical procedures."
Section 2.  Chapter 58 of the General Statutes is amended by adding the following new section:
"§ 58-3-174.  Nipple/areola reconstruction.
Each health benefit plan, as defined in G.S. 58-3-170(b), that provides coverage for surgical benefits shall provide coverage for nipple/areola reconstruction following a mastectomy, regardless of the lapse of time between the mastectomy and the reconstruction."
Section 3.  This act is effective when it becomes law and applies to reconstructive areola surgery occurring on or after January 1, 1996.