RI lawmaker wants to close ‘loophole’ in breast cancer coverage

LINCOLN, R.I. (WPRI) – Joan Milas couldn’t believe the diagnosis. She had breast cancer.

“I was panic-stricken,” she said. “I have no genetic history. I eat blueberries more than anyone. I read Prevention [magazine] for pleasure, and exercise regularly. It was just the luck of the draw that happens to a lot of people.”

Milas and her doctors decided the best course of treatment was a bilateral mastectomy. For her, it was a months-long process.

“They had to go back in because part of the process wasn’t as successful as it could have been – no fault of the doctor’s. It was the fault of my body, so they had to go back in.”

Milas says her insurance company didn’t want to pay for it. She found out the company was battling the hospital and even stopped her coverage.

“I stood at my kitchen counter in tears going, ‘I can’t stay like this!'” Joan recalled. “It’s a continuum of care. It’s all the same process, so it can not be treated, it should not be treated as individual components.”

In 2005, the R.I. General Assembly passed a law requiring insurance companies to cover mastectomy procedures.

R.I. House Majority Leader Joe Shekarchi says over the years insurance companies have chipped away at that coverage. He claims companies are taking advantage of a loophole in state law by dramatically increasing co-pays and deductibles.

“What the insurance companies have been able to do, legitimately and legally under the current law, is to increase co-pays and co-shares and also limit what they cover as far as the mastectomy procedure,” Shekarchi said.

“While the actual procedure is still covered, all of the ancillary materials, equipment, and stuff that goes along with it is not covered,” he added. “The intent of the general assembly was to have that procedure covered and everything that goes along with it. I want to do that.”

Federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. Thirty-seven states, including Rhode Island, and Connecticut also have laws that require insurance companies to cover procedures related to mastectomy and reconstruction surgery.

“We as a state should give women who go through that procedure the protection they deserve,” Shekarchi said.

In an email to Target 12, Albert Charbonneau, executive director of the R.I. Business Group on Health said the organization has not yet evaluated Shekarchi’s bill.

Charbonneau said, in general, all mandated benefits should be scrutinized to assess the value versus the cost “because the additional cost impacts someone else’s coverage.”

Milas is now eight years cancer free.

“I’m grateful I’m able to advocate for myself, and I can’t help but think about all of the poor people who can’t,” she said. “Those are the people that a bill like this really benefits.”

“Nobody predicted that co-pays would reach the thousands of dollars that they are today,” she added.

Milas is hopeful that in the future, the proposed law could also help people facing other diagnoses.

“I’m certain that it’s not exclusive to mastectomy,” she said. “A lot of surgeries have multiple components. Well, each component shouldn’t be considered a separate procedure. You can’t stay like that. It has to be from start to finish.”

Leader Shekarchi expects the bill to be scheduled for a hearing in the coming weeks.

Susan Campbell (scampbell@wpri.com) is the Call 12 for Action and Target 12 consumer investigator for WPRI 12 and Fox Providence. Follow her on Twitter and on Facebook.