PRIA, Government Policy, Made Personal

§1185b Required Coverage for Reconstructive Surgery Following Mastectomies

Title 29 › CHAPTER 18 — EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM › SUBCHAPTER I — PROTECTION OF EMPLOYEE BENEFIT RIGHTS › Subtitle B — Regulatory Provisions › part 7 — group health plan requirements › Subpart B — Other Requirements › § 1185b

Last updated Sep 22, 2026|Official source

Summary

Group health plans and their insurers must pay for breast reconstruction when someone has a mastectomy and chooses reconstruction. They must cover all stages of rebuilding the removed breast, surgery on the other breast to make them match, and prosthetic devices and treatment for physical problems from the mastectomy (for example, lymphedema). Doctors and patients decide the details together. Plans can apply the same yearly deductibles and coinsurance they use for other benefits. People must be told in writing that this coverage is available when they enroll and at least once a year. Plans must give a clear written notice about this coverage following rules set by the Secretary. The notice must be in plan mailings or yearly packets, or sent by January 1, 1999, whichever comes first. Plans may not deny or refuse renewal just to avoid these rules, nor punish or pay providers to steer care away from what the patient and doctor want. Plans can still negotiate payment amounts with providers. State laws already in effect on October 21, 1998 that require equal or greater coverage remain in force, and this does not change the ERISA rules in section 1144.

Title 29, §1185b

Labor, Source: USLM XML via OLRC

(a)In general

A group health plan, 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)

(2)surgery and reconstruction of the other breast to produce a symmetrical appearance; and

(3)prostheses and physical complications of mastectomy, including lymphedemas;

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.

(b)Notice

A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan shall provide notice to each participant and beneficiary under such plan regarding the coverage required by this section in accordance with regulations promulgated by the Secretary. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan or issuer and shall be transmitted—

(1)in the next mailing made by the plan or issuer to the participant or beneficiary;

(2)as part of any yearly informational packet sent to the participant or beneficiary; or

(3)not later than January 1, 1999;

whichever is earlier.

(c)Prohibitions

A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not—

(1)deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; and

(2)penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.

(d)Rule of construction

Nothing in this section shall be construed to prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section.

(e)Preemption, relation to State laws

(1)In general

Nothing in this section shall be construed to preempt any State law in effect on October 21, 1998, with respect to health insurance coverage that requires coverage of at least the coverage of reconstructive breast surgery otherwise required under this section.

(2)ERISA

Nothing in this section shall be construed to affect or modify the provisions of section 1144 of this title with respect to group health plans.

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Pub. L. 105–277, div. A, § 101(f) [title IX, § 902(c)], Oct. 21, 1998, 112 Stat. 2681–337, 2681–438, provided that: “(1) In general.—The

Amendments

made by this section [enacting this section] shall apply with respect to plan years beginning on or after the date of enactment of this Act [Oct. 21, 1998]. “(2) Special rule for collective bargaining agreements.—In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this section shall not be treated as a termination of such collective bargaining agreement.”