Women's Health Rights and Cancer Act - Colorado

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA). Laws for women specifically include the Women’s Health and Cancer Rights Act of 1998, and Newborns’ and Mothers’ Health Protection Act of 1996. State insurance laws, however, do apply. The federal laws regarding women’s health rights include the following provisions:

• If the plan covers mastectomies, it must cover all stages of reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and physical complications of mastectomy, including lymphedemas in a manner determined in consultation with the attending physician and the patient. (Women’s Health Rights and Cancer Act)
• If the group health plan provides maternity coverage, it must cover at least a 48-hour hospital stay following childbirth (96-hour stay in the case of Cesarean section). (Newborns' and Mothers' Health Protection Act)

The state provisions are called out below, and represent where the state goes beyond the federal requirements under ERISA.

State

Contact

Division of Insurance

Regulations

Managed care plans that provides coverage for reproductive health or gynecological care (for married or unmarried women) must not be issued or renewed unless such plan either:

• Provides a woman covered by the plan direct access to an obstetrician, gynecologist, or an advanced practice nurse who is a certified nurse midwife; or
• Has procedures in place that ensure that, if a woman covered by the plan requests a timely referral to an obstetrician, gynecologist, or an advanced practice nurse, the request for referral must not be unreasonably withheld.

Plans must insure against the expense of normal pregnancy and childbirth or provide coverage for maternity care in the same manner as any other sickness, injury, disease, or condition. Plans must not exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition.

Like the federal law, coverage for a hospital stay following a normal vaginal delivery shall not be limited to less than 48 hours. If forty-eight hours following delivery falls after 8 p.m., coverage shall continue until 8 a.m. the following morning.

Coverage for a hospital stay following a cesarean section shall not be limited to less than 96 hours. If ninety-six hours following the cesarean section falls after 8 p.m., coverage shall continue until 8 a.m. the following morning.

Plans must provide coverage for routine and certain diagnostic screening by low-dose mammography for the presence of breast cancer in adult women. Such coverage must be the lesser of $60 per mammography screening, or the actual charge for such screening.

Mammograms must be provided according to the following guidelines:

• A single baseline mammogram for women between 35 and 40 years of age;
• Screening at least once every two years for women between 40 and 50 years of age, or but at least once year for women with risk factors to breast cancer as determined by her physician;
• Annual screening for women who are 50 to 65 years of age.

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

See the text of the Women’s Health and Cancer Rights Act under Acts/Laws, Title 1, Subtitle B, Part 7, Subpart B; and the U.S. Code, Title 29, chapter 18, §1185b.

See also U. S. Code Title 29, chapter 18, §1185 for laws regarding mothers.

29 CFR 1604.10 (Employment policies relating to pregnancy and childbirth)

29 CFR chapter XXV (Parts 2509 – 2590)