Women's Health Rights and Cancer Act - Maine

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 laws include the following provisions:

• Plans shall provide the same maternity benefits for unmarried women, and the minor dependents of those with dependent or family coverage, as they provided married women with maternity coverage and the wives of those with maternity coverage. (§2832)
• Plans shall provide coverage for services related to maternity and routine newborn care, including coverage for hospital stay, in accordance with the attending physician's or attending certified nurse midwife's determination in conjunction with the mother that the mother and newborn meet the criteria outlined in the "Guidelines for Perinatal Care," published by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. (§2834-A)
• Plans that cover radiologic procedures, except those that cover only dental procedures, accidental injury or specific diseases, must provide coverage for screening mammograms performed by providers that meet the standards established by the Department of Health and Human Services rules relating to radiation protection. Coverage includes screening mammograms performed at least once a year for women 40 years of age and over. (§2837-A)
• Plans that provide coverage, except other limited benefit health coverage, must ensure that inpatient coverage with respect to the treatment of breast cancer is provided for a period of time determined by the attending physician, in consultation with the patient, to be medically appropriate following a mastectomy, a lumpectomy or a lymph node dissection for the treatment of breast cancer. (§2837-C)
• Plans that cover mastectomy surgery must provide coverage for reconstruction of the breast on which surgery has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance if the patient elects reconstruction and in the manner chosen by the patient and the physician. (§2837-C)
• With respect to managed care plans that require group members to select primary care physicians, the plan must permit a physician who specializes in obstetrics and gynecology to serve as a primary care physician. (§2847-F)
• The plan must provide coverage for an annual gynecological examination, including routine pelvic and clinical breast examinations, performed by a physician, certified nurse practitioner or certified nurse midwife participating in the plan, without requiring the prior approval of the primary care physician. (§2847-F)

State

Contact

Bureau of Insurance

Regulations

Maine Revised Statutes; Title 24-A (Maine Insurance Code):

Chapter 33 - Health Insurance Contracts:
http://www.mainelegislature.org/legis/statutes/24-A/title24-Ach33sec0.html

Chapter 35 - Group And Blanket Health Insurance:
http://www.mainelegislature.org/legis/statutes/24-A/title24-Ach35sec0.html

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)