Section 1367.6 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.6
. (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, delivered, or renewed on or after January 1, 2000, shall
provide coverage for screening for, diagnosis of, and treatment for,
breast cancer.
(b) No health care service plan contract shall deny enrollment or
coverage to an individual solely due to a family history of breast
cancer, or who has had one or more diagnostic procedures for breast
disease but has not developed or been diagnosed with breast cancer.
(c) Every health care service plan contract shall cover screening
and diagnosis of breast cancer, consistent with generally accepted
medical practice and scientific evidence, upon the referral of the
enrollee's participating physician.
(d) Treatment for breast cancer under this section shall include
coverage for prosthetic devices or reconstructive surgery to restore
and achieve symmetry for the patient incident to a mastectomy.
Coverage for prosthetic devices and reconstructive surgery shall be
subject to the copayment, or deductible and coinsurance conditions,
that are applicable to the mastectomy and all other terms and
conditions applicable to other benefits.
(e) As used in this section, "mastectomy" means the removal of all
or part of the breast for medically necessary reasons, as determined
by a licensed physician and surgeon. Partial removal of a breast
includes, but is not limited to, lumpectomy, which includes surgical
removal of the tumor with clear margins.
(f) As used in this section, "prosthetic devices" means the
provision of initial and subsequent devices pursuant to an order of
the patient's physician and surgeon.