Women's Health Rights and Cancer Act - California

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

California Department of Insurance

Regulations

Every policy of disability insurance that provides coverage for hospital, medical, or surgical expenses that is issued, amended, delivered, or renewed shall provide coverage for screening for, diagnosis of, and treatment for, breast cancer.

Employees with a family history of breast cancer cannot be denied enrollment.

Treatment for breast cancer must include coverage for prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits.

California Insurance Code §10123.8

Group policies of disability insurance or self-insured employee welfare benefit plans that must provide coverage for at least the following, upon the referral of a nurse practitioner, certified nurse midwife, or physician, providing care to the patient and operating within the scope of practice provided under existing law for breast cancer screening or diagnostic purposes:

• A baseline mammogram for women age 35 to 39, inclusive.
• A mammogram for women age 40 to 49, inclusive, every two years or more frequently based on the women's physician's recommendation.
• A mammogram every year for women age 50 and over.

California Insurance Code §10123.81

Policies of disability insurance that cover hospital, medical, or surgical expenses must include obstetrician-gynecologists as eligible primary care physicians provided they meet the insurer's written eligibility criteria for all specialists seeking primary care physician status.

California Insurance Code §10123.83

Disability policies that cover hospital, medical, or surgical expenses must allow a policyholder the option to seek obstetrical and gynecological physician services directly from an obstetrician and gynecologist or directly from a participating family practice physician and surgeon designated by the plan as providing obstetrical and gynecological services.

California Insurance Code §10123.84

Disability policies covering hospital, surgical, or medical expenses that provide coverage for surgical procedures known as mastectomies and lymph node dissections, must do all of the following:

• Allow the length of a hospital stay associated with those procedures to be determined by the attending physician and surgeon in consultation with the patient, consistent with sound clinical principles and processes.  No disability insurer shall require a treating physician and surgeon to receive prior approval in determining the length of hospital stay following those procedures.
• Cover prosthetic devices or reconstructive surgery, including devices or surgery to restore and achieve symmetry for the patient incident to the mastectomy.  Coverage for prosthetic devices and reconstructive surgery shall be subject to the deductible and coinsurance conditions applicable to other benefits.
• Cover all complications from a mastectomy, including lymphedema.

California Insurance Code §10123.86

Disability policies that provide coverage for hospital, medical, and surgical benefits that provide maternity coverage, must do any of the following:

• Restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section.  However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if certain conditions are met.
• Reduce or limit the reimbursement of the attending provider for providing care to an individual insured in accordance with the coverage requirements.
• Provide monetary or other incentives to an attending provider to induce the provider to provide care to an individual insured in a manner inconsistent with the coverage requirements.
• Deny a mother or her newborn eligibility, or continued eligibility, to enroll or to renew coverage solely to avoid the coverage requirements.
• Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum coverage requirements.
• Restrict inpatient benefits for the second day of hospital care in a manner that is less than favorable to the mother or her newborn than those provided during the preceding portion of the hospital stay.
• Require the treating physician to obtain authorization from the insurer prior to prescribing any services covered.

California Insurance Code §10123.87

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)