Mastectomy; Lymph Node Dissection; Coverage for Inpatient Care and Follow-Up Visits Required by Health Insurers; Notice to Policyholders

  1. Law
  2. Georgia Code
  3. Insurance
  4. Insurance Generally
  5. Breast Cancer Patient Care
  6. Mastectomy; Lymph Node Dissection; Coverage for Inpatient Care and Follow-Up Visits Required by Health Insurers; Notice to Policyholders

Checkout our iOS App for a better way to browser and research.

  1. As used in this Code section, the term:
    1. "Attending physician" means any surgeon or other physician attending the breast cancer patient.
    2. "Health benefit policy" means any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, or renewed in this state, including, but not limited to, those contracts executed by the state on behalf of indigents and on behalf of state employees under Article 1 of Chapter 18 of Title 45, by a health care corporation, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, or other insurer or similar entity; except that such term does not include any policy of limited benefit insurance as defined in paragraph (4) of subsection (e) of Code Section 33-30-12.
    3. "Insurer" means an accident and sickness insurer, fraternal benefit society, health care corporation, health maintenance organization, managed care plan other than a dental plan, or any similar entity authorized to issue contracts under this title and also means any state program funded under Title XIX of the federal Social Security Act, 42 U.S.C.A. Section 1396, et seq., and any other publicly funded state health care program.
    4. "Lymph node dissection" means the removal of a part of the lymph node system under the arm using general anesthesia as part of a diagnostic process that is used to evaluate the spread of cancer and to determine the need for further treatment.
    5. "Mastectomy" means surgical removal of one or both breasts.
  2. Every health benefit policy that provides surgical benefits for mastectomies that is delivered, issued, executed, or renewed in this state or approved for issuance or renewal in this state by the Commissioner shall provide coverage in a licensed health care facility for inpatient care following a mastectomy or lymph node dissection until the completion of the appropriate period of stay for such inpatient care as determined by the attending physician in consultation with the patient.Coverage shall also be provided for such number of follow-up visits as determined to be appropriate by the attending physician after consultation with the patient.Such follow-up visits shall be conducted by a physician, a physician assistant, or a registered professional nurse with experience and training in postsurgical care.In consultation with the patient, such attending physician, physician assistant, or registered professional nurse shall determine whether any follow-up visit or visits will be conducted at home or at the office.
  3. Every insurer shall provide notice to policyholders regarding the coverage required by this Code section.The notice shall be in writing and prominently positioned in any of the following literature:
    1. A mailing to the policyholder;
    2. The yearly informational packets sent to the policyholder; or
    3. Other mailed literature.
  4. No insurer covered under this Code section shall deselect, terminate the services of, require additional utilization review, reduce capitation payment, or otherwise penalize an attending physician or other health care provider who orders care consistent with the provisions of this Code section. For purposes of this subsection, health care provider shall include the attending physician and hospital.

(Code 1981, §33-24-72, enacted by Ga. L. 1999, p. 319, § 1; Ga. L. 2009, p. 859, § 3/HB 509; Ga. L. 2019, p. 386, § 78/SB 133; Ga. L. 2020, p. 493, § 33/SB 429.)

The 2019 amendment, effective July 1, 2019, substituted "the state" for "the State of Georgia" near the middle of paragraph (a)(2); deleted "hospital service corporation, medical service corporation," following "fraternal benefit society," in paragraphs (a)(2) and (a)(3); in subsection (b), deleted "on or after July 1, 1999," following "Commissioner" in the middle of the first sentence, and substituted "shall also be provided" for "shall be provided also" near the beginning of the second sentence; substituted "A mailing" for "The next mailing" at the beginning of paragraph (c)(1); and substituted "mailed literature" for "literature mailed before January 1, 2000" in paragraph (c)(3).

The 2020 amendment, effective July 29, 2020, part of an Act to revise, modernize, and correct the Code, revised punctuation in paragraph (a)(3).

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 1999, "removal of" was substituted for "removal or" in paragraph (a)(4).

ARTICLE 4 UNDERWRITING AND RATE RISKING

Editor's notes.

- Ga. L. 2003, p. 386, § 2, not codified by the General Assembly, makes this article applicable to all personal insurance policies issued or renewed on or after July 1, 2003.

RESEARCH REFERENCES

Am. Jur. 2d.

- 15A Am. Jur. 2d, Collection and Credit Agencies, § 80. 43 Am. Jur. 2d, Insurance, § 58 et seq.

C.J.S.

- 44 C.J.S., Insurance, §§ 150, 151, 222.


Download our app to see the most-to-date content.