IndianaState employee plans and certain private plans would cover breast reconstruction
State employee plans, certain private health policies, and HMO contracts started, changed, or renewed after 2026 would cover breast reconstruction and offer surgeon networks.
What it does
Plans started, changed, or renewed after 2026 would cover breast reconstruction that a clinician finds best with the patient. Coverage would include surgical methods and access to surgeons.
If a plan lacks enough surgeons, a patient forced to go outside its network would still pay the in-network rate for reconstruction. This applies to plans started, changed, or renewed after 2026.
For breast reconstruction performed as approved, claim reviewers could deny payment only after formally showing strong evidence of provider fraud. The advance approval must have been requested from January 1, 2027.
Argument forPatients forced to use a surgeon outside an inadequate network could avoid higher bills because their share would stay at the in-network rate.
Argument againstClaim reviewers might have less room to address billing errors when surgery is approved in advance and performed as approved, because denial would require strong evidence of provider fraud.
More detail
These plans would cover breast reconstruction and provide access to reconstruction surgeons. The rules cover state employee health plans, certain private health policies, and HMO contracts. A health care professional must find the surgery best under medical standards after consulting the patient. The rules would apply to plans started, changed, or renewed after December 31, 2026.
The plan would keep the patient's share at its in-network rate. This covers patients in the affected state employee plans, private health policies, and HMO contracts. The patient must use a surgeon outside the plan's network because the network is inadequate. The rule would apply to plans started, changed, or renewed after December 31, 2026.
A claim reviewer would need a formal statement of strong evidence of provider fraud to deny the claim. This covers claims for breast reconstruction surgery approved in advance and performed as approved. The evidence must concern fraud by the health care provider during the approval request or claim filing. The advance approval must have been requested on or after January 1, 2027.
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Where it stands
- Introduced
- Passed House
- Passed Senate
- To Governor
- Became Law
Looking ahead
No hearings or votes scheduled.
History
- 2026
- Jan 8First reading: referred to Committee on InsuranceLatest
- Jan 8Authored by Representative King
- Jan 8Coauthored by Representative BarrettIntroduced
HealthcareConsumer Protection