Read the full stored bill text
HB453 INTRODUCED
Page 0
HB453
NRX4B8J-1
By Representatives Fidler, Givens, Drummond, Hollis, Tillman,
Chestnut, McClammy, Clarke, Collins, DuBose, Boyd, Shaver,
Moore (M), Hulsey, Myrex, Paschal, Wilcox, Lamb, Morris,
Givan, Nelson, Treadaway, Pettus, Gray, Sellers, Easterbrook,
Gidley, Harrison, Travis, Fincher, Ensler, Jackson, Rigsby,
Lomax, Datcher, Robertson, Hurst, Brown, Bracy, Lawrence,
Brinyark, Estes, Oliver, Smith, Standridge, Ingram, Wood (R),
Bolton, Mooney, Warren, Yarbrough, Starnes, Reynolds
RFD: Insurance
First Read: 12-Feb-26
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NRX4B8J-1 02/04/2026 JC (L)lg 2025-2724
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First Read: 12-Feb-26
SYNOPSIS:
This bill would require that breast
reconstruction be provided under all health insurance
plans in the State of Alabama, including those covering
public employees and the Medicaid program.
This bill would permit an insured individual to
choose the type of breast reconstruction desired and a
particular surgeon to perform the reconstruction, who
may be outside of the health insurance benefit plan
network.
For private health insurance, this bill would
also set terms for cost-sharing obligations for
enrollees and insurer payments to out-of-network
providers.
This bill would provide that an insured
individual or a health care professional may bring a
civil action if the insurer fails to comply with this
act, with enforcement powers given to the Attorney
General and the Commissioner of the Department of
Insurance.
A BILL
TO BE ENTITLED
AN ACT
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AN ACT
Relating to health insurance; to add Chapter 50A,
commencing with Section 27-50A-1, to Title 27, Code of Alabama
1975, to require health benefit plans to cover breast
reconstruction; to define the scope of breast reconstruction
benefits and provide requirements for payments to health care
providers; to amend Section 10A-20-6.16, Code of Alabama 1975,
to make conforming changes; to amend Section 27-21A-23, Code
of Alabama 1975, to make conforming changes; to amend Section
16-25A-6, Code of Alabama 1975, to make conforming changes; to
add Section 16-25A-6.1 to the Code of Alabama 1975, to require
the Public Education Employees' Health Insurance Plan to cover
breast reconstruction; to add Section 22-6-11.1 to the Code of
Alabama 1975, to require Medicaid coverage for breast
reconstruction; to add Section 36-29-4.1 to the Code of
Alabama 1975, to require the State Employees' Health Insurance
Plan to cover breast reconstruction; and to amend Section
36-29-5, Code of Alabama 1975, to make conforming changes.
BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
Section 1. Chapter 50A, commencing with Section
27-50A-1, is added to Title 27 of the Code of Alabama 1975, to
read as follows:
§27-50A-1
The Legislature finds:
(1) Breast cancer affects thousands of Alabama women
annually and access to comprehensive reconstruction surgery is
essential to physical and psychological recovery.
(2) No woman residing in the State of Alabama should be
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(2) No woman residing in the State of Alabama should be
denied access to appropriate breast reconstruction surgery due
to network limitations or excessive administrative
requirements.
(3) The State of Alabama has a compelling public health
interest in fostering as broad an access as possible to breast
reconstruction services and by this act seeks to ensure
flexibility and patient choice in accessing breast
reconstruction care that is both appropriate for the
individual and comprehensive.
§27-50A-2
For the purposes of this chapter, the following terms
have the following meanings:
(1) BREAST RECONSTRUCTION. The medical repair of
physical defects caused by the removal or treatment of breast
tissue as a result of trauma, disease, lumpectomy, mastectomy,
or prophylaxis against future disease, which has as its
purpose the reconstruction of a new breast mound or a flat
chest wall and the establishment of symmetry between two
breasts, and which includes:
a. Augmentation or reduction;
b. All stages of preparatory, primary, and revision
surgery to reconstruct a breast mound or to create a new
breast mound;
c. All necessary procedures for a non-diseased,
contralateral breast to create symmetry between two breasts;
d. Chest wall reconstruction, including, but not
limited to, a flat closure that uses adjacent tissue transfer
or complex repair to eliminate all redundancies of skin and
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or complex repair to eliminate all redundancies of skin and
soft tissue;
e. Custom-fabricated breast prostheses, including, but
not limited to, replacement of the breast prostheses;
f. Hybrid procedures that involve both autologous
breast reconstruction and biologic or synthetic products or
devices; and
g. Mechanical, medical, or surgical prophylaxis to
prevent the physical complications of a mastectomy, breast
conserving surgery, chest wall reconstruction, radiation, or
lymph node surgery.
h. Mechanical, medical, and surgical treatment of
physical complications of a mastectomy, breast conserving
surgery, chest wall reconstruction, radiation, or lymph node
surgery.
(2) COMMISSIONER. The Commissioner of the Department of
Insurance of the State of Alabama.
(3) CORE-BASED STATISTICAL AREA. A metropolitan or
micropolitan statistical area as defined by the U.S. Office of
Management and Budget.
(4) COST-SHARING. An enrollee's payment obligation for
a covered health care service, including a deductible,
copayment, or coinsurance.
(5) ENROLLEE. A patient who is covered under a health
benefit plan.
(6) HEALTH BENEFIT PLAN. Any individual or group plan,
employee welfare benefit plan, policy, or contract for health
care services issued, delivered, issued for delivery, or
renewed in this state by a health care insurer, health
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renewed in this state by a health care insurer, health
maintenance organization, accident and sickness insurer,
fraternal benefit society, nonprofit hospital service
corporation, nonprofit medical service corporation, health
care service plan, or any other person, firm, corporation,
joint venture, or other similar business entity that pays for
insureds or beneficiaries in this state. The term includes,
but is not limited to, entities created pursuant to Article 6
of Chapter 20 of Title 10A. A health benefit plan located or
domiciled outside of the State of Alabama is deemed to be
subject to this chapter if it receives, processes,
adjudicates, pays, or denies claims for health care services
submitted by or on behalf of patients, insureds, or
beneficiaries who reside in Alabama. The term shall not
include accident-only, specified disease, hospital indemnity,
Medicare supplement, long-term care, disability income, or
other limited benefit health insurance policies.
(7) HEALTH CARE PROFESSIONAL. A physician, physician
assistant, or certified registered nurse practitioner licensed
pursuant to Title 34, including, but not limited to, a
physician who performs plastic and reconstructive surgery or
who is a referring or consulting physician providing oncology
treatment or breast surgery, or an employee acting under the
direction of the same.
(8) HEALTH CARE SERVICES. The term includes, but is not
limited to, all of the following:
a. Health care professional services, including, but
not limited to, consultation, diagnosis, treatment,
anesthesia, surgery, and therapy.
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anesthesia, surgery, and therapy.
b. Prescription drugs.
c. Facilities, including a hospital or ambulatory
surgical treatment center.
d. Prostheses and devices for breast reconstruction,
including tissue expanders, customized implants, and nerve
graft products, mesh, or repair products.
(9) INSURER. The term includes all of the following:
a. Any entity that issues, delivers, or renews a health
benefit plan.
b. Any department or office of the entity described in
paragraph a., or any individual employed by the entity, which
performs utilization review or makes determinations of prior
authorization or coverage.
c. Any separate entity or individual that is a
contractor or agent of the entity described in paragraph a.
which performs utilization review or makes determinations of
prior authorization or coverage.
(10) MODALITY, TYPE, AND TECHNIQUE. A method of breast
reconstruction surgery that employs a modality such as an
implant, natural tissue, or fat, or some combination of the
foregoing, and includes any of the following types and
techniques:
a. Immediate implant-based, tissue-based, or combined
reconstruction.
b. Delayed implant-based, tissue-based, or combined
reconstruction.
c. Myocutaneous flap tissue-based reconstruction.
d. Microvascular free flap tissue-based reconstruction.
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d. Microvascular free flap tissue-based reconstruction.
e. Structural fat grafting tissue-based breast
reconstruction.
f. Combined implant-based and tissue-based breast
reconstruction.
g. Any type of breast reconstruction that is developed
subsequent to the effective date of this act that is
recognized within Level I or Level II of the Healthcare Common
Procedure Coding System (HCPCS) codes.
h. All techniques and procedural variations,
iterations, or approaches associated with a type of breast
reconstruction, as noted within the short descriptor or
description for the Level I Healthcare Common Procedure Coding
System code covering the type of breast reconstruction.
(11) NETWORK PROVIDER. A health care professional or
facility that participates in the provider network of a
health benefit plan to receive a contractually-established
amount as payment in full for providing health care services.
(12) OUT-OF-NETWORK PROVIDER. A health care
professional or facility located anywhere in the United States
which does not receive a contractually-established amount from
an insurer or health benefit plan as payment in full for
providing health care services.
(13) PREVAILING MEDICAL STANDARD. The standards of care
for breast reconstruction established by national specialty
organizations, including the American Society of Plastic
Surgeons, the American Society for Reconstructive
Microsurgery, the American Society of Breast Surgeons, the
National Comprehensive Cancer Network, and other
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National Comprehensive Cancer Network, and other
nationally-recognized medical specialty organizations, the
members of which routinely perform breast reconstruction
surgery.
§27-50A-3
(a) On and after January 1, 2027, a health benefit plan
shall pay or reimburse for breast reconstruction, including
all component health care services, subject to the
requirements of this chapter.
(b) Coverage for breast reconstruction shall include
any modality, type, and technique chosen by an enrollee in
consultation with her health care professional based on
personal factors such as the enrollee's anatomy, health
status, preference, lifestyle, and reconstruction goals.
(c) Coverage shall include health care services for the
breast reconstruction which are rendered by either a network
or out-of-network provider as selected by an enrollee,
provided that any surgeon shall be board certified or eligible
for board certification in plastic and reconstructive surgery.
(d) The modality, type, and technique of breast
reconstruction chosen by an enrollee in consultation with her
surgeon who meets the requirement of subsection (c) shall be
presumed by the insurer to meet both: (i) prevailing medical
standards; and (ii) the requirement of medical necessity for
purposes of a request for prior authorization.
(e) Coverage for breast reconstruction shall extend to
all health care services that are necessary to achieve the
breast reconstruction outcome determined appropriate by the
the enrollee and her health care professional, including the
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the enrollee and her health care professional, including the
initial and all subsequent surgeries required by the modality,
type, and technique and not limited with respect to any
revision surgery, symmetry procedure, nipple reconstruction,
lymphovenous bypass, tattooing, nerve grafting, scar revision,
fat grafting, or treatment for a complication.
§27-50A-4
(a) An insurer shall respond to a request for prior
authorization for breast reconstruction no later than three
business days after the date and time of the submission of the
request.
(b)(1) An insurer may deny a request for prior
authorization of a specific modality, type, and technique of
breast reconstruction chosen by an enrollee in consultation
with her health care professional if the conditions in this
subsection are met.
(2) Any determination of denial shall be made upon
review of the request and all relevant clinical information by
a health care professional who: (i) is board certified or
eligible for board certification in plastic surgery and
reconstructive surgery; and (ii) has specific training in the
modality, type, and technique at issue.
(3) The reviewing health care professional shall rebut
the presumption of medical necessity recognized under Section
27-50A-3(d) by providing to the enrollee and her health care
professional articulable reasons in writing that support a
conclusion that: (i) the modality, type, and technique
proposed fails to comport with prevailing medical standards;
or (ii) clinical considerations unique to the enrollee make
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or (ii) clinical considerations unique to the enrollee make
the enrollee a poor candidate for the modality, type, and
technique requested.
(4) An enrollee or health care professional whose
request for prior authorization is denied may appeal the
denial in the internal appeal process afforded by the insurer,
provided the appeal is determined by a health care
professional who did not perform the initial review but who
otherwise meets the requirements of subdivision (2).
(5) A health care professional acting on behalf of an
insurer, who meets the requirements of subdivision (2), while
a denial of prior authorization is under consideration, or
pursuant to an appeal of a denial of prior authorization under
subdivision (4), shall provide a direct telephone number to
the enrollee's health care professional, and may request or
shall consider additional clinical information concerning the
enrollee for purposes of review.
(c) An insurer may not deny a request for prior
authorization of the modality, type, and technique of breast
reconstruction chosen by the enrollee in consultation with her
health care professional on any of the following grounds:
(1) A different modality, type, and technique of breast
reconstruction is also appropriate for the enrollee, in
absence of articulable reasons required under subdivision
(b)(3).
(2) The health care services required in providing
coverage, including the plastic surgeon or facility, are
out-of-network, unless the individual or facility proposed to
render the health care service is outside of the United States
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render the health care service is outside of the United States
or does not hold the necessary professional or other license
under the law of the state where the individual or facility is
located.
(3) The modality, type, and technique of breast
reconstruction requested by the enrollee or her health care
professional is more expensive than the modality, type, and
technique or the related health care services proposed by the
insurer.
§27-50A-5
(a) An enrollee's cost-sharing obligations for breast
reconstruction shall not exceed the health benefit plan's
rates that apply to network providers for comparable coverages
under the plan, and an enrollee who receives health care
services for breast reconstruction from health care
professionals, facilities, or other services that are
out-of-network shall pay in-network cost-sharing rates.
(b) Other coverages provided under the health benefit
plan may not be limited or reduced as a result of including in
the plan the coverage described in this chapter.
(c) If an enrollee receives coverage for breast
reconstruction, the enrollee's contractual right to other
coverages or benefits available under the health benefit plan
may not in any way be reduced or limited, nor may receiving
coverage for breast reconstruction render an enrollee
ineligible to renew coverage under the plan.
(d) The requirements of this chapter apply regardless
of whether the health benefit plan otherwise provides coverage
for out-of-network services or contains any provision that
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for out-of-network services or contains any provision that
purports to limit or exclude out-of-network coverage.
§27-50A-6
(a)(1) A health benefit plan may not impose a
requirement that an enrollee receive breast reconstruction
health care services from a network provider as a condition
for coverage.
(2) An insurer shall approve the choice of an enrollee
to receive health care services from a health care
professional who is an out-of-network provider, unless the
individual proposed to render the service does not hold the
necessary professional license under the law of the state
where the entity or individual is located.
(3) The requirement of subdivision (2) applies to an
out-of-network hospital or facility in which surgery is to be
performed if the hospital or facility complies with the
applicable licensure or certification requirements under
federal law and the law of the state where the hospital or
facility is located.
(b) With respect to a surgeon who is an out-of-network
provider chosen by an enrollee, an insurer may not do any of
the following:
(1) Undertake any communication or action, or impose
any provision, that has the effect of discouraging the
enrollee from choosing the surgeon, including any incentive,
disincentive, or penalty related to the enrollee's health
benefit plan coverage.
(2) Require the enrollee to first consult with or
consider a surgeon who is a network provider.
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consider a surgeon who is a network provider.
(3) Undertake any communication or action, or impose
any provision, that has the effect of steering the enrollee to
choose a surgeon who is a network provider, including any
incentive, disincentive, or penalty related to the enrollee's
health benefit plan coverage.
(4) Impose additional administrative, licensure,
certification, or qualification requirements, including
documentation, in excess of what is required for
out-of-network providers for other coverages under the health
benefit plan.
(c) An insurer may not use any indirect means to
prevent, disincentivize, or discourage an enrollee from
receiving a health care service from an out-of-network
provider, including influencing, inducing, or pressuring a
hospital or other facility to require a surgeon to be a
network provider of the insurer as a condition for obtaining
or maintaining medical staff privileges to perform breast
reconstruction.
§27-50A-7
An insurer may not withdraw an approval of prior
authorization for breast reconstruction communicated to a
health care professional or enrollee, nor may an insurer
refuse or fail to reimburse a health care professional for a
health care service after it has communicated the approval of
prior authorization, unless an enrollee or health care
provider made a misrepresentation by statement or omission to
the insurer which was material to the approval of prior
authorization.
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authorization.
§27-50A-8
(a) If a health care service included in breast
reconstruction is rendered by an out-of-network provider, this
section shall govern the rate of reimbursement.
(b) If an enrollee selects an out-of-network provider,
the insurer shall initiate single case agreement negotiations
with the provider according to all of the following
conditions:
(1) The insurer shall initiate negotiations with the
provider within five business days of receiving notice of the
enrollee's selection.
(2) The insurer and the provider shall have 10 business
days from initiation of negotiations to agree on reimbursement
terms.
(3) If the insurer and provider reach agreement, the
agreed terms shall govern reimbursement for the health care
services covered by the single case agreement.
(4) If the insurer fails to initiate negotiations
within the time required, fails to negotiate in good faith, or
the insurer and provider do not reach agreement within 10
business days, the payment provisions of subsection (c) shall
govern the rate of reimbursement.
(5) An insurer's failure to respond to a provider's
communication within two business days during the negotiating
period shall be deemed a failure to negotiate in good faith.
(c) If the conditions provided in subsection (b) are
not met, the health benefit plan shall reimburse the provider
an amount that is the lesser of:
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an amount that is the lesser of:
(1) The provider's billed charges; or
(2) The 80th percentile of all charges for the same
provider service in the same core-based statistical area in
which the provider service is performed, as reported in a
database that is maintained by a nonprofit organization that
is unaffiliated or not otherwise financially supported by any
insurer.
(d) If the health benefit plan fails to reimburse an
out-of-network provider as required under subsection (a), in
addition to making the required payment, the health benefit
plan shall pay the out-of-network provider an amount that is
treble the difference between:
(1) The initial reimbursement, or in the case of denial
of payment, zero dollars ($0); and
(2) The reimbursement rate required under subsection
(c) less any cost-sharing amount to be paid by the insured.
(e) The payment required under subsection (d) shall be
subject to interest at a rate to be specified by rule adopted
by the department.
§27-50A-9
If an enrollee who has received prior authorization for
breast reconstruction subsequently enrolls in a different
health benefit plan offered by the same insurer, or in a
health benefit plan offered by a different insurer, any health
care service necessary to achieve the breast reconstruction
outcome determined appropriate by the enrollee and her health
care professional, including any health care service for
revision or to treat a complication, shall be covered.
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revision or to treat a complication, shall be covered.
§27-50A-10
(a) An enrollee or health care professional who is
injured as a result of an insurer's failure to comply with
this chapter may bring a civil action against the insurer in
the Circuit Court of Montgomery County or in the circuit court
of the county where the enrollee resides.
(b) In an action brought under this section, the court
may award to the plaintiff any of the following:
(1) Injunctive relief.
(2) Compensatory damages.
(3) Treble damages upon a finding that failure of an
insurer to comply with this chapter was knowing or in reckless
disregard of the provisions of this chapter.
(4) Reasonable costs and attorney fees.
(c) An action brought under this section may be
predicated upon any common law or statutory cause of action,
including breach of contract or any applicable tort, including
fraud or bad faith, or a deceptive trade practice under
Chapter 19 of Title 8.
§27-50A-11
The commissioner and the Attorney General have
concurrent jurisdiction to enforce this chapter, to include
any of the following measures:
(1) The commissioner may investigate complaints or
conduct compliance audits pursuant to Article 1 of Chapter 2.
(2) The Attorney General may investigate complaints
pursuant to Section 8-19-9 and cooperate with the department
in conducting investigations.
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in conducting investigations.
(3) The commissioner or the Attorney General may bring
a civil action against an insurer in the Circuit Court of
Montgomery County for injunctive relief to enforce compliance
with this chapter, or in a representative capacity on behalf
of aggrieved enrollees to include recovery of compensatory
damages.
(4) The commissioner or the Attorney General may
intervene as a plaintiff in any private action brought under
Section 27-50A-10 if the issues raised are broad or
significant enough in application to be in the public
interest.
§27-50A-12
(a) An insurer shall provide a written notice to an
enrollee which contains a summary of the enrollee's rights
under this chapter when any of the following occurs:
(1) Upon initial enrollment in a health benefit plan.
(2) Upon annual renewal of a health benefit plan.
(3) Within five business days of the insurer receiving
notice that an enrollee has been diagnosed with breast cancer
or has undergone a mastectomy or lumpectomy.
(b)(1) The notice required under subsection (a) shall
include, at a minimum, a plain-language summary of the
enrollee's right: (i) to choose any qualified plastic surgeon
for breast reconstruction; (ii) to receive coverage for health
care services from out-of-network providers at in-network
cost-sharing rates; and (iii) to appeal any denial of
coverage.
(2) The commissioner shall develop a model notice for
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(2) The commissioner shall develop a model notice for
use by an insurer to comply with this section.
§27-50A-13
The commissioner shall adopt rules to implement and
administer this chapter.
Section 2. Sections 10A-20-6.16 and 27-21A-23, Code of
Alabama 1975, are amended to read as follows:
"§10A-20-6.16
(a) No statute of this state applying to insurance
companies shall be applicable to any corporation organized
under this article and amendments thereto or to any contract
made by the corporation; except the corporation shall be
subject to the following:
(1) The provisions regarding annual premium tax to be
paid by insurers on insurance premiums.
(2) Chapter 55 of Title 27.
(3) Article 2 and Article 3 of Chapter 19 of Title 27.
(4) Section 27-1-17.
(5) Chapter 56 of Title 27.
(6) Rules adopted by the Commissioner of Insurance
pursuant to Sections 27-7-43 and 27-7-44.
(7) Chapter 54 of Title 27.
(8) Chapter 57 of Title 27.
(9) Chapter 58 of Title 27.
(10) Chapter 59 of Title 27.
(11) Chapter 54A of Title 27.
(12) Chapter 12A of Title 27.
(13) Chapter 2B of Title 27.
(14) Chapter 29 of Title 27.
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(14) Chapter 29 of Title 27.
(15) Chapter 62 of Title 27.
(16) Chapter 63 of Title 27.
(17) Chapter 45A of Title 27.
(18) Chapter 50A of Title 27.
(b) The provisions in subsection (a) that require
specific types of coverage to be offered or provided shall not
apply when the corporation is administering a self-funded
benefit plan or similar plan, fund, or program that it does
not insure."
"§27-21A-23
(a) Except as otherwise provided in this chapter,
provisions of the insurance law and provisions of health care
service plan laws shall not be applicable to any health
maintenance organization granted a certificate of authority
under this chapter. This provision shall not apply to an
insurer or health care service plan licensed and regulated
pursuant to the insurance law or the health care service plan
laws of this state except with respect to its health
maintenance organization activities authorized and regulated
pursuant to this chapter.
(b) Solicitation of enrollees by a health maintenance
organization granted a certificate of authority shall not be
construed to violate any provision of law relating to
solicitation or advertising by health professionals.
(c) Any health maintenance organization authorized
under this chapter shall not be deemed to be practicing
medicine and shall be exempt from the provisions of Section
34-24-310, et seq., relating to the practice of medicine.
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34-24-310, et seq., relating to the practice of medicine.
(d) No person participating in the arrangements of a
health maintenance organization other than the actual provider
of health care services or supplies directly to enrollees and
their families shall be liable for negligence, misfeasance,
nonfeasance, or malpractice in connection with the furnishing
of such services and supplies.
(e) Nothing in this chapter shall be construed in any
way to repeal or conflict with any provision of the
certificate of need law.
(f) Notwithstanding the provisions of subsection (a), a
health maintenance organization shall be subject to all of the
following:
(1) Section 27-1-17.
(2) Chapter 56.
(3) Chapter 54.
(4) Chapter 57.
(5) Chapter 58.
(6) Chapter 59.
(7) Rules adopted by the Commissioner of Insurance
pursuant to Sections 27-7-43 and 27-7-44.
(8) Chapter 12A.
(9) Chapter 54A.
(10) Chapter 2B.
(11) Chapter 29.
(12) Chapter 62.
(13) Chapter 63.
(14) Chapter 45A .
(15) Chapter 50A ."
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(15) Chapter 50A ."
Section 3. Sections 16-25A-6 and 36-29-5, Code of
Alabama 1975, are amended to read as follows:
"§16-25A-6
Such health insurance The Public Education Employees'
Health Insurance Plan shall not include coverage for any of
the following:
(1) Expenses incurred by or on account of an individual
prior to the effective date of the plan as to him; .
(2) Hearing aids and examinations for the prescription
or fitting thereof ;-.
(3) Cosmetic surgery or treatment, except to the extent
necessary for correction of damage caused by accidental injury
or for breast reconstruction as required pursuant to Section
16-25A-6.1 while covered by the plan , or as a direct result of
disease covered by the plan ;.
(4) Services received in a hospital owned or operated
by the United States government for which no charge is made ;.
(5) Services received for injury or sickness due to war
or any act of war, whether declared or undeclared, which war
or act of war shall have occurred after the effective date of
this plan ;.
(6) Expenses for which the individual is not required
to make payment ;.
(7) Expenses to the extent of benefits provided under
any employer group plan other than this plan in which the
state participates in the cost thereof ;.
(8) Such other expenses as may be excluded by
regulations rule of the board ; and.
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regulations rule of the board ; and.
(9) Coordination of benefit of basic hospital/medical
coverage provided herein and any supplemental hospital
indemnity, cancer or dental coverage provided herein under the
provisions of this article or as may privately be purchased by
any employee."
"§36-29-5
(a) Such health insurance The State Employees' Health
Insurance Plan shall not include coverage for any of the
following:
(1) Expenses incurred by or on account of an individual
prior to the effective date of the plan.
(2) Cosmetic surgery or treatment, except to the extent
necessary for correction of damages caused by accidental
injury or for breast reconstruction as required pursuant to
Section 36-29-4.1 while covered by the plan , or as a direct
result of disease covered by the plan.
(3) Services received in a hospital owned or operated
by the United States government for which no charge is made.
(4) Services received for injury or sickness due to war
or any act of war, whether declared or undeclared, which war
or act of war shall have occurred after the effective date of
this plan.
(5) Expenses for which the individual is not required
to make payment.
(6) Expenses to the extent of benefits provided under
any employer group plan other than the plan in which the state
participates in the cost thereof.
(7) Such other expenses as may be excluded by
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HB453 INTRODUCED
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(7) Such other expenses as may be excluded by
regulations rule of the board.
(b) This section shall not mandate the coverage of
hearing assistance devices except that the State Employees'
Health Insurance Board may determine by a majority vote of the
board to cover such expenses in part or in whole on or after
April 11, 2000."
Section 4. Sections 16-25A-6.1, 22-6-11.1, and
36-29-4.1 are added to the Code of Alabama 1975, to read as
follows:
§16-25A-6.1
(a) On and after January 1, 2027, the Public Education
Employees' Health Insurance Plan shall provide coverage for
breast reconstruction subject to the same terms and conditions
as those provided in Chapter 50A of Title 27.
(b) If there is a conflict between this chapter and
Chapter 50A of Title 27, this chapter shall be given effect.
§22-6-11.1
(a) The Alabama Medicaid Agency shall provide coverage
for breast reconstruction as defined in Section 27-50A-2 to
any woman who is accepted for participation in a Medicaid
program for delivery of medical services which exists on the
effective date of this act.
(b) Breast reconstruction benefits shall commence on
and after January 1, 2027, and to the degree consistent with
this chapter, Medicaid rules, and policies, including those
governing Medicaid-approved providers, shall be according to
the same coverage provided in Chapter 50A of Title 27.
(c) The Alabama Medicaid Agency may adopt rules to
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HB453 INTRODUCED
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(c) The Alabama Medicaid Agency may adopt rules to
implement this section.
§36-29-4.1
(a) On and after January 1, 2027, the State Employees'
Health Insurance Plan shall provide coverage for breast
reconstruction subject to the same terms and conditions as
those provided in Chapter 50A of Title 27.
(b) If there is a conflict between this chapter and
Chapter 50A of Title 27, this chapter shall be given effect.
Section 5. This act shall become effective on October
1, 2026.
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