['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:
- If your plan contains maternity benefits, including benefits for childbirth, it must cover a mother and her newborn child for a minimum of 48 hours of inpatient length of stay following a normal vaginal delivery, and a minimum of 96 hours of inpatient length of stay following a cesarean section, without requiring the attending provider to obtain authorization from the insurer or its representative.
- Plans must provide benefits for the necessary care and treatment related to maternity that are no less favorable than benefits for physical illness.
- Plans must cover surveillance tests for women age 25 and older at risk for ovarian cancer.
- Plans must allow female participants or beneficiary age 13 or older direct access within the health benefit plan, without prior referral, to the services of an obstetrician-gynecologist participating in the health benefit plan.
- Plans must cover examinations and laboratory tests for the screening for the early detection of cervical cancer and for low-dose screening mammography. One baseline mammogram for women 35 through 39 years old, A mammogram every other year for women 40 through 49 years old, or more frequently upon recommendation of a physician, and a mammogram every year for any woman 50 years old or older.
- Coverage for the screening for the early detection of cervical cancer, including the examination, the laboratory fee, and the physician's interpretation of the laboratory results.
- Coverage for all stages and revisions of reconstructive breast surgery performed on a nondiseased breast to establish symmetry if reconstructive surgery on a diseased breast is performed, as well as coverage for prostheses and physical complications in all stages of mastectomy, including lymphademas.
State
Contact
North Carolina Department of Insurance
Regulations
NC General Statutes
§58-3-169Required coverage for minimum hospital stay following birth
§58-3-170 Requirements for maternity coverage
§58-3-270 Coverage for surveillance tests for women at risk for ovarian cancer
§58-51-38Direct access to obstetrician-gynecologists
§58-51-57 Coverage for mammograms and cervical cancer screening
§58-51-62 Coverage for reconstructive breast surgery following mastectomy
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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