This section adds a new section to an existing chapter 48.43. Here is the modified chapter for context.
Health plans issued or renewed on or after January 1, 2023, shall provide benefits or coverage for contralateral prophylactic mastectomies to covered individuals who:
Are determined by their physician to be at a high risk of developing breast cancer in the contralateral breast, including those who:
Have a lifetime risk of breast cancer of at least 20 percent based on assessment tools assessing family history;
Have a first degree relative with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves;
Had radiation therapy to the chest when they were between the ages of 10 and 30;
Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first degree relatives with one of these syndromes; or
Have a genetic defect, based on genetic testing, that predisposes them to breast cancer, including having a known BRCA1 or BRCA2 gene mutation;
Have a desire to eliminate the anxiety of developing breast cancer in the contralateral breast in the future; or
Have a desire for symmetry and reconstruction of both breasts following removal of a breast due to breast cancer.
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A health carrier is not required under this section to provide for a referral to a nonparticipating health care provider, unless the carrier does not have an appropriate health care provider that is available and accessible to administer the procedure and that is a participating health care provider with respect to such procedure.
If a health carrier refers an individual to a nonparticipating health care provider pursuant to this section, screening services or a resulting procedure, if any, must be provided at no additional cost to the individual beyond what the individual would otherwise pay for services provided by a participating health care provider.