Women's Health Rights and Cancer Act - Maryland

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:

• Coverage for in-vitro fertilization. (§15-810)
• Plans must cover childbirth to the same extent as the hospitalization benefits provided in the policy for any covered illness. (§15-811)
• If the mother is required to remain hospitalized after childbirth for medical reasons and the mother requests that the newborn remain in the hospital, the insurer or nonprofit health service plan shall pay the cost of additional hospitalization for the newborn for up to 4 days. (§15-811)
• Plans must cover inpatient hospitalization services for a mother and newborn child for a minimum of 48 hours of inpatient hospitalization care after an uncomplicated vaginal delivery; and 96 hours of inpatient hospitalization care after an uncomplicated cesarean section. (§15-812)
• If a mother and newborn child have a shorter hospital stay the plan must cover one home visit within 24 hours after hospital discharge; and an additional home visit if prescribed. (§15-812)
• If a mother and newborn child remain in the hospital for the covered length of time, the plan must cover a home visit if prescribed. (§15-812)  
• The plan must provide notice annually to insureds and enrollees about the coverage of hospital stay for mothers and newborns. (§15-812)
• There is an exemption from current law that prohibits a health insurer, nonprofit health service plan, or HMO (carrier) from imposing any copayment, coinsurance, or deductible for specified home visits for mothers and newborn children. Senate Bill 521 (signed May 10, 2005) specifies that when an enrollee is covered under a high-deductible health plan, the enrollee is subject to the plan’s deductible. A high deductible plan may apply a smaller deductible or nor deductible for preventive care services; however, home visits for mothers and newborn children do not qualify as preventive care and would still be subject to a deductible. (§15-812)
• If the plan covers temporary disability, it must offer the optional benefits for temporary disability caused or contributed to by pregnancy or childbirth. (§15-813)
• Plans must cover baseline mammograms for women who are 35 to 39 years old; mammograms at least every 2 years, if recommended by a physician, for women who are 40 to 49 years old; and annual mammograms for women who are at least 50 years old. The plan may not impose a deductible for this coverage. (§15-814)
• Plans must cover reconstructive breast surgery, including coverage for all stages of reconstructive breast surgery performed on a non-diseased breast to establish symmetry with the diseased breast when reconstructive breast surgery is performed on the diseased breast, as well as physical complications of all stages of mastectomy. (§15-815)
• Plans must allow women classify an obstetrician/gynecologist as a primary care provider. If women do not choose an obstetrician/gynecologist as their primary care provider, the plan must allow women an annual visit to an in-network obstetrician/gynecologist for routine gynecological care without requiring the women to visit the woman's primary care provider first. (§15-816)
• Plans must cover annual routine chlamydia screening test for women who are under the age of 20 years if they are sexually active; and at least 20 years old if they have multiple risk factors; and men who have multiple risk factors. (§15-829)
• For patients who receive less than 48 hours of inpatient hospitalization following a mastectomy or who undergoes a mastectomy on an outpatient basis, the plan must cover one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and an additional home visit if prescribed by the patient's attending physician. The plan must provide notice annually to its enrollees and insureds about this coverage. (This coverage is subject to abrogation as of September 30, 2006.) (§15-832)
• Plans must cover prosthesis that has been prescribed by a physician for those who have undergone a mastectomy and has not had breast reconstruction. (§15-834)

State

 Contact

Maryland Insurance Administration

Regulations

Maryland Insurance Code; Title 15, Subtitle 8 §§810 – 834

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)