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:
        (a) 48 hours following a mastectomy, and
        (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