['Employee Benefits']
["Women's Health Rights and Cancer Act"]
06/11/2024
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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:
- Expense-incurred plans must cover mammograms for asymptomatic women, including a baseline mammogram for women 35 to 39 years old, mammograms every two years (or more frequently based on the recommendation of the patient's physician) for women 40 to 49 years old, annual mammograms for women 50 years old and over, and mammograms for any woman, upon the recommendation of a physician, where such woman, her mother or her sister has a prior history of breast cancer. §376.782
- If the plan covers obstetrical/gynecological benefits and pharmaceuticals, it must allow direct access to an obstetrician/gynecologist of her choice within the provider network. §376.1199
- Expense-incurred plans must cover breast cancer by dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants. §376.1200
- Expense-incurred plans must cover prosthetic devices or reconstructive surgery necessary to restore symmetry as recommended by the oncologist or primary care physician for the patient incident to the mastectomy. §376.1209
- Expense-incurred plans that provide maternity benefits must cover a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a cesarean section for a mother and her newly born child. §376.1210
- Expense-incurred plans must cover a pelvic examinations and Pap smears for any nonsymptomatic women. §376.1250
State
Contact
Missouri Department of Insurance
Regulations
Missouri Revised Statutes, Title XXIV Business and Financial Institutions
Chapter 376 - Life, Health and Accident Insurance
§376.782 Mammography—low-dose screening, defined—health care policies to provide required coverage.
§376.1199 Coverage for certain obstetrical/gynecological services—exclusion of contraceptive coverage permitted, when—rulemaking authority.
§376.1200 Certain policies to offer coverage for treatment of breast cancer—limitation on deductible, lifetime maximum benefit—administration of benefits—application, effect.
§376.1209 Mastectomy—mandatory insurance coverage for prosthetic devices and reconstructive surgery—no time limit to be imposed.
§376.1210 Maternity benefits, minimum hospital stays, exceptions—notice of benefits, contents—attending physician defined—rulemaking.
§376.1250 Cancer screening, health insurance coverage required, when, types.
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)
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