['Employee Benefits']
["Women's Health Rights and Cancer Act"]
04/15/2024
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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:
- A baseline mammogram for women 35 to 40 years old, a mammogram every year for women 40 and older, or women of any age who have a family history of breast cancer or other breast cancer risk factors. Mammograms at such age and intervals as deemed medically necessary by the woman's health care provider.
- Policies that provide maternity benefits must provide for a minimum of 48 hours of in-patient care following a normal delivery and a minimum of 96 hours of in-patient care following a cesarean section.
- Plans that provide hospital or medical expense benefits for groups with greater than 50 persons must provide for expenses incurred in conducting a Pap smear.
- Plans must provide for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy.
- Plans must provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses. If the policy provides outpatient x-ray or radiation therapy, it must cover the costs of outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer.
- Plans with more than 50 participants, which include pregnancy-related benefits, must cover medically necessary expenses incurred in the diagnosis and treatment of infertility.
State
Contact
New Jersey Banking and Insurance Department
Regulations
New Jersey Statutes; Title 17B Insurance;
§17B:27-46
§17B:27-46.1a (reconstructive breast surgery)
§17B:27-46.1f (mammograms)
§17B:27-46.1k (birth and natal care)
§17B:27-46.1n (pap smears)
§17B:27-46.1p (inpatient care following mastectomy)
§17B:27-46.1x (infertility)
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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