Current Status Bill Number:3985 Ratification Number:452 Act Number:329 Type of Legislation:General Bill GB Introducing Body:House Introduced Date:19970410 Primary Sponsor:Seithel All Sponsors:Seithel, Allison, Spearman, Meacham, Altman, Mason, Fleming, Campsen, Lee, Rodgers, Neilson, Cobb-Hunter, Byrd, Cato, Hinson, Simrill, Loftis, Mullen, Miller, Moody-Lawrence, Limehouse, Gamble and Stuart Drafted Document Number:bbm\9346ac.97 Date Bill Passed both Bodies:19980603 Date of Last Amendment:19980603 Governor's Action:S Date of Governor's Action:19980608 Subject:Health Benefits and Education Act, Medical, Insurance, mastectomy, mammograms, pap smears, breast surgery, cancer
Body Date Action Description Com Leg Involved ______ ________ _______________________________________ _______ ____________ ------ 19980617 Act No. A329 ------ 19980608 Signed by Governor ------ 19980604 Ratified R452 House 19980603 Concurred in Senate amendment, enrolled for ratification Senate 19980603 Read third time, returned to House with amendment Senate 19980603 Amended Senate 19980602 Read second time, ordered to third reading with notice of general amendments Senate 19980602 Amended Senate 19980507 Recalled from Committee, 02 SBI placed on the Calendar Senate 19980421 Introduced, read first time, 02 SBI referred to Committee House 19980415 Read third time, sent to Senate House 19980414 Amended, read second time House 19980408 Committee report: Favorable with 26 HLCI amendment House 19970410 Introduced, read first time, 26 HLCI referred to CommitteeView additional legislative information at the LPITS web site.
(A329, R452, H3985)
AN ACT TO AMEND THE CODE OF LAWS OF SOUTH CAROLINA, 1976, TO ENACT THE OMNIBUS HEALTH BENEFITS AND EDUCATION ACT OF 1998 BY ADDING SECTION 38-33-325 SO AS TO REQUIRE HEALTH BENEFIT PLANS TO ALLOW FEMALE PARTICIPANTS DIRECT ACCESS, WITH LIMITATIONS BUT WITHOUT REFERRAL, TO OBSTETRICAL AND GYNECOLOGICAL HEALTH CARE SERVICES WITHIN THE PLAN BENEFITS AND TO REQUIRE THE PLAN TO INFORM FEMALE PARTICIPANTS IN WRITING OF THIS REQUIREMENT; BY ADDING SECTION 38-71-125 SO AS TO REQUIRE INDIVIDUAL AND GROUP HEALTH INSURANCE POLICIES AND HEALTH MAINTENANCE ORGANIZATIONS PROVIDING HOSPITALIZATION FOR MASTECTOMIES TO PROVIDE HOSPITALIZATION FOR AT LEAST FORTY-EIGHT HOURS; BY ADDING SECTION 38-71-130 SO AS TO REQUIRE HEALTH INSURANCE POLICIES AND HEALTH MAINTENANCE ORGANIZATIONS COVERING MASTECTOMY SURGERY TO PROVIDE COVERAGE FOR PROSTHETIC DEVICES AND RECONSTRUCTIVE BREAST SURGERY; AND BY ADDING SECTION 38-71-145 SO AS TO REQUIRE AN INSURER TO INCLUDE COVERAGE FOR
MAMMOGRAMS AND PAP SMEARS AND PROSTATE CANCER EXAMINATIONS, SCREENINGS, AND DIAGNOSTIC LABORATORY WORK.
Be it enacted by the General Assembly of the State of South Carolina:
Act citation
SECTION 1. This act may be cited as the Omnibus Health Benefits and Education Act of 1998.
Coverage for limited obstetrical and gynecological access without referral
SECTION 2. The 1976 Code is amended by adding:
"Section 38-33-325. (A) A health benefit plan shall allow a female enrollee thirteen years of age or older a minimum of two visits annually pursuant to the health benefit plan, without prior referral, to the health care services of an obstetrician-gynecologist in the health benefit plan.
(B) For any continuing treatment resulting from obstetrical or gynecological, or both, complications diagnosed during the two visits for a calendar year, authorization must be made for medical necessity directly by the health maintenance organization. Written communication should be sent by the obstetrician-gynecologist to the patient's primary care physician regarding the condition being treated within a reasonable time after each visit.
(C) A health benefit plan must notify its members of the provisions of this subsection (A). The information must be provided in the Summary Plan Description materials and enrollment materials.
(D) For purposes of this section:
(1) 'Health benefit plan' means a health maintenance organization, a preferred provider plan, an exclusive provider plan, or other managed care arrangement plan;
(2) 'Health care services' means the full scope of medically necessary services provided by the participating obstetrician-gynecologist in the care of or related to the female reproductive system and breasts."
Hospitalization for mastectomies
SECTION 3. The 1976 Code is amended by adding:
"Section 38-71-125. All individual and group health insurance policies and health maintenance organizations providing coverage for the hospitalization for mastectomies must provide benefits for hospitalization for at least forty-eight hours following a mastectomy. Nothing in this section shall be construed to prohibit an attending physician from releasing the patient prior to the expiration of the time provided herein. In the case of an early release, coverage shall include at least one home care visit if ordered by the attending physician."
Coverage for prosthetic devices and reconstructive surgery
SECTION 4. The 1976 Code is amended by adding:
"Section 38-71-130. All individual and group health insurance policies and health maintenance organizations providing coverage for mastectomy surgery must provide coverage for prosthetic devices and reconstruction of the breast on which surgery for breast cancer has been performed and surgery and reconstruction of the non-diseased breast, if determined medically necessary by the patient's attending physician with the approval of the insurer or HMO. The provisions of this section shall not require supplemental health insurance policies to provide coverage for reconstruction of the non-diseased breast."
Coverage for mammograms, pap smears, and prostate cancer examinations, screenings, and laboratory work
SECTION 5. The 1976 Code is amended by adding:
"Section 38-71-145. (A) All individual and group health insurance and health maintenance organization policies in this State shall include coverage in the policy for:
(1) mammograms;
(2) annual pap smears;
(3) prostate cancer examinations, screenings, and laboratory work for diagnostic purposes in accordance with the most recent published guidelines of the American Cancer Society.
(B) The coverage required to be offered under subsection (A) may not contain any exclusions, reductions, or other limitations as to coverages, deductibles, or coinsurance provisions which apply to that coverage unless these provisions apply generally to other similar benefits provided and paid for under the health insurance policy.
(C) Nothing in this section prohibits a health insurance policy from providing benefits greater than those required to be offered by subsections (A) and (B) or more favorable to the enrollee than those required to be offered by subsections (A) and (B).
(D) This section applies to individual and group health insurance policies issued by a fraternal benefit society, an insurer, a health maintenance organization, or any similar entity, except as exempted by ERISA.
(E) For purposes of this section:
(1) 'Mammogram' means a radiological examination of the breast for purposes of detecting breast cancer when performed as a result of a physician referral or by a health testing service which utilizes radiological equipment approved by the Department of Health and Environmental Control, which examination may be made with the following minimum frequency:
(a) once as a base-line mammogram for a female who is at least thirty-five years of age but less than forty years of age;
(b) once every two years for a female who is at least forty years of age but less than fifty years of age;
(c) once a year for a female who is at least fifty years of age; or
(d) in accordance with the most recent published guidelines of the American Cancer Society.
(2) 'Pap smear' means an examination of the tissues of the cervix of the uterus for the purpose of detecting cancer when performed upon the recommendation of a medical doctor, which examination may be made once a year or more often if recommended by a medical doctor.
(3) 'Health insurance policy' means a health benefit plan, contract, or evidence of coverage providing health insurance coverage as defined in Section 38-71-670(6) and Section 38-71-840(14)."
Time effective
SECTION 6. This act takes effect upon approval by the Governor and applies to all individual and group health insurance and health maintenance organization policies, as the case may be, issued, delivered, issued for delivery, or renewed in this State on or after January 1, 1999.
Approved the 8th day of June, 1998.