Stricken language would be deleted from and underlined language would be added to present law.
Act 424 of the Regular Session
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State of Arkansas As Engrossed: S3/4/25 S3/19/25 1
95th General Assembly A Bill 2
Regular Session, 2025 SENATE BILL 83 3
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By: Senator J. Bryant 5
By: Representative K. Moore 6
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For An Act To Be Entitled 8
AN ACT TO MANDATE COVERAGE FOR BREAST RECONSTRUCTION 9
SURGERIES; TO REQUIRE PRIOR AUTHORIZATION FOR BREAST 10
RECONSTRUCTION SURGERIES; TO ESTABLISH A MINIMUM 11
REIMBURSEMENT RATE FOR BREAST RECONSTRUCTION 12
SURGERIES; AND FOR OTHER PURPOSES. 13
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Subtitle 16
TO MANDATE COVERAGE FOR BREAST 17
RECONSTRUCTION SURGERIES; TO REQUIRE 18
PRIOR AUTHORIZATION FOR BREAST 19
RECONSTRUCTION SURGERIES; AND TO 20
ESTABLISH A MINIMUM REIMBURSEMENT RATE 21
FOR BREAST RECONSTRUCTION SURGERIES. 22
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BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF ARKANSAS: 24
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SECTION 1. Arkansas Code Title 23, Chapter 79, is amended to add an 26
additional subchapter to read as follows: 27
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Subchapter 29 — Coverage for Breast Reconstruction Surgery 29
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23-79-2901. Definitions. 31
As used in this subchapter: 32
(1) "Ambulatory surgery center" means an entity certified by: 33
(A) Medicare as an ambulatory surgical center that 34
operates for the purpose of providing surgical services to patients and that 35
is eligible to receive reimbursement from Medicaid for ambulatory surgery 36 As Engrossed: S3/4/25 S3/19/25 SB83
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services; 1
(B) The Joint Commission, an entity for the accreditation 2
of healthcare organizations; 3
(C) The Accreditation Association for Ambulatory Health 4
Care; or 5
(D) The American Association for Accreditation of 6
Ambulatory Surgery Facilities; 7
(2)(A) "Breast reconstruction surgery" means all stages of 8
surgery to repair physical defects caused by the extirpation or medical 9
treatment of diseased breast tissue and all stages of surgery to reconstruct 10
a breast mound or to create a new breast mound and to reestablish symmetry 11
between two (2) breasts: 12
(i) Following: 13
(a) Trauma; 14
(b) The loss of breast tissue due to 15
congenital or noncongenital diseases; or 16
(c) A mastectomy; or 17
(ii) For prophylaxis against a future disease of the 18
breast. 19
(B) "Breast reconstruction surgery" includes without 20
limitation: 21
(i) Augmentation, reduction, and mastectomy and all 22
procedures for a contralateral breast necessary for symmetry; 23
(ii) All breast reconstruction modalities, including 24
without limitation implant -based breast reconstruction, tissue -based breast 25
reconstruction, and any breast reconstruction modalities that are developed 26
subsequent to the effective date of this act that are recognized within Level 27
I of the Healthcare Common Procedure Coding System codes and are determined 28
by rule of the Insurance Commissioner to qualify under this subchapter; 29
(iii) All types of breast reconstruction contained 30
within the modalities under subdivision (2)(B)(ii) of this section, including 31
without limitation: 32
(a) Immediate implant -based breast 33
reconstruction; 34
(b) Delayed implant -based breast 35
reconstruction; 36 As Engrossed: S3/4/25 S3/19/25 SB83
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(c) Myocutaneous flap tissue -based breast 1
reconstruction; 2
(d) Microvascular free flap tissue -based 3
breast reconstruction; 4
(e) Structural fat grafting tissue -based 5
breast reconstruction; 6
(f) Combined implant -based and tissue-based 7
breast reconstruction; and 8
(g) Any type of breast reconstruction that is 9
developed subsequent to the effective date of this act that is recognized 10
within Level I of the Healthcare Common Procedure Coding System codes and is 11
determined by rule of the commissioner to qualify under this subchapter; 12
(iv) All procedural variations, iterations, or 13
approaches associated with the breast reconstruction types under subdivision 14
(2)(B)(iii) of this section, as noted within the short descriptor or the 15
description for the Level I Healthcare Common Procedure Coding System code 16
covering the modalities and types of breast reconstruction; 17
(v) Chest wall reconstruction, including without 18
limitation an aesthetic flat closure; 19
(vi) Custom fabricated breast prostheses, including 20
without limitation replacement of such breast prostheses; and 21
(vii) Coverage for the mechanical, medical, and 22
surgical treatment of physical complications of a mastectomy, breast 23
reconstruction surgery, chest wall reconstruction, radiation, and lymph node 24
surgery; 25
(3) "Enrollee" means an individual entitled to coverage of 26
healthcare services from a healthcare insurer; 27
(4) "Facility reimbursement rate" means the amount paid to a 28
healthcare facility by a healthcare insurer for certain procedures and 29
includes the costs of healthcare services; 30
(5)(A) "Health benefit plan" means: 31
(i) An individual, blanket, or group plan, policy, 32
or contract for healthcare services issued, renewed, or extended in this 33
state by a healthcare insurer, health maintenance organization, hospital 34
medical service corporation, or self -insured governmental or church plan in 35
this state; and 36 As Engrossed: S3/4/25 S3/19/25 SB83
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(ii) Any health benefit program receiving state or 1
federal appropriations from the State of Arkansas, including the Arkansas 2
Medicaid Program and the Arkansas Health and Opportunity for Me Program 3
established by the Arkansas Health and Opportunity for Me Act of 2021, § 23 -4
61-1001 et seq. 5
(B) "Health benefit plan" includes: 6
(i) Indemnity and managed care plans; and 7
(ii) Plans providing health benefits to state and 8
public school employees under § 21 -5-401 et seq. 9
(C) "Health benefit plan" does not include: 10
(i) A plan that provides only dental benefits or eye 11
and vision care benefits; 12
(ii) A disability income plan; 13
(iii) A credit insurance plan; 14
(iv) Insurance coverage issued as a supplement to 15
liability insurance; 16
(v) Medical payments under an automobile or 17
homeowners insurance plan; 18
(vi) A health benefit plan provided under Arkansas 19
Constitution, Article 5, § 32, the Workers' Compensation Law, § 11 -9-101 et 20
seq., or the Public Employee Workers' Compensation Act, § 21 -5-601 et seq.; 21
(vii) A plan that provides only indemnity for 22
hospital confinement; 23
(viii) An accident-only plan; 24
(ix) A specified disease plan other than a cancer 25
insurance plan or cancer supplemental policy; or 26
(x) A long-term-care-only plan; 27
(6) "Healthcare facility" means: 28
(A) An ambulatory surgery center; 29
(B) A hospital; or 30
(C) An outpatient surgery center; 31
(7)(A) "Healthcare insurer" means any insurance company, 32
hospital and medical service corporation, health maintenance organization, or 33
a nonprofit agricultural membership organization as defined under § 23 -60-104 34
that issues or delivers health benefit plans in this state. 35
(B) "Healthcare insurer" does not include an entity that 36 As Engrossed: S3/4/25 S3/19/25 SB83
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provides only dental benefits or eye and vision care benefits; 1
(8) "Healthcare professional" means a person who is licensed, 2
certified, or otherwise authorized by the laws of this state to administer 3
health care in the ordinary course of the practice of his or her profession; 4
(9) "Healthcare professional reimbursement rate" means the 5
amount paid to a healthcare professional by a healthcare insurer for 6
procedures and includes the costs of healthcare services; 7
(10) "Healthcare service" means an item or service provided to 8
an individual for the purposes of alleviating, curing, healing, or preventing 9
human illness, injury, or physical disability; 10
(11) "Hospital" means a facility licensed as a hospital by the 11
Division of Health Facility Services under § 20 -9-213; 12
(12) "Mastectomy" means the removal of all or part of the breast 13
for medically necessary reasons as determined by a healthcare professional; 14
(13) "Out-of-network provider" means a healthcare professional 15
that provides healthcare services to an enrollee but is not a participating 16
provider; 17
(14)(A) "Outpatient surgery center" means a facility in which 18
surgical services are offered that require the use of general or intravenous 19
anesthetics, and where, in the opinion of the attending physician, 20
hospitalization, as defined in the present licensure law, is not necessary. 21
(B) "Outpatient surgery center" does not include: 22
(i) A medical office owned and operated by a 23
physician or more than one (1) physician licensed by the Arkansas State 24
Medical Board, if the medical office does not bill a facility fee to a third -25
party payor; or 26
(ii) A dental office that has a Moderate Sedation 27
Facility Permit or a Deep Sedation -General Anesthesia Facility Permit issued 28
by the Arkansas State Board of Dental Examiners; and 29
(15) "Participating provider" means a healthcare professional 30
that has a healthcare contract with a contracting entity to provide 31
healthcare services to an enrollee with the expectation of receiving payment 32
either directly from the contracting entity or from a healthcare insurer 33
affiliated with the contracting entity. 34
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23-79-2902. Coverage for breast reconstruction surgery. 36 As Engrossed: S3/4/25 S3/19/25 SB83
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(a) On and after January 1, 2026, a health benefit plan that is 1
offered, issued, or renewed in this state shall provide coverage for all 2
modalities, types, and techniques of a healthcare service provided for a 3
breast reconstruction surgery and shall cover any surgery determined as the 4
best course of treatment by a healthcare professional, consistent with 5
prevailing medical standards, and in consultation with the patient. 6
(b) The coverage for breast reconstruction surgery under this section: 7
(1) Shall be subject to policy deductibles, copayment 8
requirements, or coinsurance requirements of a healthcare insurer at a cost 9
that is no more than those costs associated with the health benefit plan's 10
in-network rate for the healthcare service; 11
(2) Does not diminish or limit benefits otherwise allowable 12
under a health benefit plan; and 13
(3) Shall not affect an enrollee's eligibility or continued 14
eligibility to enroll or renew coverage under the terms of the health benefit 15
plan solely for the purpose of avoiding the requirements of this subchapter. 16
(c) If an enrollee is forced to use an out -of-network provider due to 17
a healthcare insurer's network inadequacy, the enrollee's financial 18
responsibility shall remain at an in -network rate. 19
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23-79-2903. Prior authorization required for breast reconstruction 21
surgery — Single case agreements. 22
(a) A healthcare insurer shall require prior authorization for breast 23
reconstruction surgery. 24
(b) If a healthcare insurer does not have a participating provider who 25
provides a breast reconstruction surgery that has been determined as the best 26
course of treatment by a healthcare professional and is consistent with 27
prevailing medical standards and in consultation with the patient, then the 28
healthcare insurer that provides a prior authorization or predetermination of 29
the healthcare service shall automatically approve a single case agreement at 30
the same rate as specified under § 23 -79-2904(a). 31
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23-79-2904. Reimbursement rate — Penalties for late payment or 33
nonpayment. 34
(a) If a healthcare insurer does not have a participating provider who 35
provides a breast reconstruction surgery that has been determined as the best 36 As Engrossed: S3/4/25 S3/19/25 SB83
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course of treatment by a healthcare professional and is consistent with 1
prevailing medical standards and in consultation with the patient, then the 2
healthcare insurer shall reimburse the out -of-network provider who performs 3
the breast reconstruction surgery at an amount that is the lesser of: 4
(1) The healthcare professional's billed charges for the 5
healthcare services; or 6
(2) The eightieth percentile of all charges for the particular 7
healthcare service performed by a healthcare professional in the same or 8
similar specialty and provided in the same or similar geographical area as 9
reported in a benchmarking database that is maintained by a nonprofit 10
organization if that nonprofit organization is not affiliated with, 11
financially supported by, or otherwise supported by a healthcare insurer. 12
(b) A healthcare insurer shall provide a fair and reasonable facility 13
reimbursement rate for healthcare services performed by a healthcare 14
professional in a healthcare facility under this subchapter. 15
(c)(1) In the case of a healthcare insurer that does not reimburse an 16
out-of-network provider or a healthcare facility as required under this 17
section, the healthcare insurer, in addition to making the required payment 18
for the healthcare services, shall pay the out -of-network provider or 19
healthcare facility an amount that is three (3) times the difference between: 20
(A) The initial payment, or in the case of a notice of 21
denial of payment, zero dollars ($0.00); and 22
(B) The out-of-network reimbursement rate required under 23
this section, less any cost -sharing required to be paid by the enrollee. 24
(2) The payment that is required under subdivision (c)(1) of 25
this section is subject to interest in a manner specified by the Insurance 26
Commissioner by rule. 27
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23-79-2905. Coverage eligibility. 29
A healthcare insurer providing benefits under this subchapter shall not 30
deny an enrollee eligibility or continued eligibility to enroll or renew 31
coverage under the terms of the health benefit plan solely for the purpose of 32
avoiding the requirements of this subchapter. 33
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23-79-2906. Waiver prohibited. 35
(a) The provisions of this subchapter shall not be waived by contract. 36 As Engrossed: S3/4/25 S3/19/25 SB83
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(b) A contractual arrangement or action taken in conflict with this 1
subchapter or that purport to waive any requirement of this subchapter is 2
void. 3
(c) This subchapter shall not be used by a healthcare insurer to lower 4
reimbursement rates for other healthcare services involving breast 5
reconstruction provided by a participating provider. 6
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23-79-2907. Rules. 8
(a) The Insurance Commissioner shall develop and promulgate rules for 9
the implementation and administration of this subchapter. 10
(b) The State Board of Finance shall develop and promulgate rules for 11
the administration of this subchapter for the plans providing health benefits 12
to state and public school employees under § 21 -5-401 et seq. 13
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/s/J. Bryant 15
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APPROVED: 4/3/25 18
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