Figures for Mandatory Benefit Notices: 28 TAC §21.2106
Figure: 28 TAC §21.2106(b)(1)
NOTICE OF CERTAIN MANDATORY BENEFITS
This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].
Mastectomy or Lymph Node Dissection
Minimum Inpatient Stay: If due to treatment of breast cancer, any person covered by this plan has either a mastectomy or a lymph node dissection, this plan will provide coverage for inpatient care for a minimum of:
(b) 24 hours following a lymph node dissection.
The minimum number of inpatient hours is not required if the covered person receiving the treatment and the attending physician determine that a shorter period of inpatient care is appropriate.
Prohibitions: We may not (a) deny any covered person eligibility or continued eligibility or fail to renew this plan solely to avoid providing the minimum inpatient hours; (b) provide money payments or rebates to encourage any covered person to accept less than the minimum inpatient hours; (c) reduce or limit the amount paid to the attending physician, or otherwise penalize the physician, because the physician required a covered person to receive the minimum inpatient hours; or (d) provide financial or other incentives to the attending physician to encourage the physician to provide care that is less than the minimum hours.
If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier’s customer service or related department address].
Form Number 349 Mastectomy
Figure: 28 TAC §21.2106(b)(2)
NOTICE OF CERTAIN MANDATORY BENEFITS
This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].
Coverage and/or Benefits for Reconstructive Surgery After Mastectomy-Enrollment
Coverage and/or benefits are provided to each covered person for reconstructive surgery after mastectomy, including:
(a) all stages of the reconstruction of the breast on which mastectomy has been performed;
(b) surgery and reconstruction of the other breast to achieve a symmetrical appearance; and
(c) prostheses and treatment of physical complications, including lymphedemas, at all stages of mastectomy.
The coverage and/or benefits must be provided in a manner determined to be appropriate in consultation with the covered person and the attending physician.
[Include any specific deductibles, copayments, and/or coinsurance applicable to the coverage and/or benefits, which may not be greater than the deductibles, copayments and/or coinsurance applicable to other coverage and/or benefits under the health benefit plan.]
Prohibitions: We may not (a) offer the covered person a financial incentive to forego breast reconstruction or waive the coverage and/or benefits shown above; (b) condition, limit, or deny any covered person’s eligibility or continued eligibility to enroll in the plan or fail to renew this plan solely to avoid providing the coverage and/or benefits shown above; or (c) reduce or limit the amount paid to the physician or provider, nor otherwise penalize, or provide a financial incentive to induce the physician or provider to provide care to a covered person in a manner inconsistent with the coverage and/or benefits shown above.
If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier’s customer service or related department address].
Form Number 1764 Reconstructive Surgery After Mastectomy-Enrollment
Figure: 28 TAC §21.2106(b)(3)
NOTICE OF CERTAIN MANDATORY BENEFITS
This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].
Coverage and/or Benefits for Reconstructive Surgery After Mastectomy-Annual
Your contract, as required by the federal Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema).
If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier’s customer service or related department address].
Form Number 1764 Reconstructive Surgery After Mastectomy-Annual
Figure: 28 TAC §21.2106(b)(4)
NOTICE OF CERTAIN MANDATORY BENEFITS
This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].
Examinations for Detection of Prostate Cancer
Benefits are provided for each covered male for an annual medically recognized diagnostic examination for the detection of prostate cancer. Benefits include:
(a) a physical examination for the detection of prostate cancer; and
(b) a prostate-specific antigen test for each covered male who is
(1) at least 50 years of age; or
(2) at least 40 years of age with a family history of prostate cancer or other prostate cancer risk factor.
If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier’s customer service or related department address].
Form Number 258 Prostate
Figure: 28 TAC §21.2106(b)(5)
NOTICE OF CERTAIN MANDATORY BENEFITS
This notice is to advise you of certain coverage and/or benefits provided by your contract with [name of carrier].
Inpatient Stay following Birth of a Child
For each person covered for maternity/childbirth benefits, we will provide inpatient care for the mother and her newborn child in a health care facility for a minimum of:
(a) 48 hours following an uncomplicated vaginal delivery, and
(b) 96 hours following an uncomplicated delivery by cesarean section.
This benefit does not require a covered female who is eligible for maternity/childbirth benefits to (a) give birth in a hospital or other health care facility or (b) remain in a hospital or other health care facility for the minimum number of hours following birth of the child.
If a covered mother or her newborn child is discharged before the 48 or 96 hours has expired, we will provide coverage for postdelivery care. Postdelivery care includes parent education, assistance and training in breast-feeding and bottle-feeding and the performance of any necessary and appropriate clinical tests. Care will be provided by a physician, registered nurse or other appropriate licensed health care provider, and the mother will have the option of receiving the care at her home, the health care provider’s office or a health care facility.
[In-home postdelivery care language, if applicable, is to be inserted here.]
Prohibitions. We may not (a) modify the terms of this coverage based on any covered person requesting less than the minimum coverage required; (b) offer the mother financial incentives or other compensation for waiver of the minimum number of hours required; (c) refuse to accept a physician’s recommendation for a specified period of inpatient care made in consultation with the mother if the period recommended by the physician does not exceed guidelines for prenatal care developed by nationally recognized professional associations of obstetricians and gynecologists or pediatricians; (d) reduce payments or reimbursements below the usual and customary rate; or (f) penalize a physician for recommending inpatient care for the mother and/or the newborn child.
If any person covered by this plan has questions concerning the above, please call [name of carrier] at [customer service or related department phone number], or write us at [carrier’s customer service or related department address].
Form Number 102 Maternity
For more information contact:
Last updated: 06/14/2007
