Women's Health Rights and Cancer Act - West Virginia

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:

• The plan must cover birthing center services charges, and care rendered by a licensed nurse midwife or midwife. (§16-2E-4)
• If the plan covers laboratory or X-ray services, it must cover mammograms when medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force (§33-16-3g)
• If the plan covers laboratory or X-ray services, it must cover pap smears, either conventional or liquid-based cytology, whichever is medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists, for women age eighteen or over. (§33-16-3g)
• If the plan covers laboratory or X-ray services, it must cover tests for the human papilloma virus (HPV)for women age eighteen or over, when medically appropriate and consistent with the current guidelines from either the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists for women age eighteen and over. (§33-16-3g)
• Plans may apply the same deductibles, coinsurance and other limitations to mammograms, pap smears, or human papilloma virus (HPV) test as apply to other covered services. (§33-16-3g)
• If the plan covers laboratory or X-ray services, it must cover mammograms or pap smears. This includes a baseline mammogram for women age 35 to 39, inclusive; a mammogram for women age 40 to 49, inclusive, every two years or more frequently based on the woman's physician's recommendation; and a mammogram every year for women age 50 and over. It also includes a pap smear annually or more frequently based on the woman's physician's recommendation for women age 18 or over. (§33-16-3g)
• If the plan covers childbirth for a mother or her newborn child, it may not restrict benefits for any hospital stay following a normal vaginal delivery to less than 48 hours, or following a cesarean section to less than 96 hours, or require a provider to obtain authorization for such length hospital stays. The mother and her newborn child may be discharged prior to the expiration of the minimum length of stay required under this section only in those cases in which the decision to discharge is made by an attending provider in consultation with the mother. (§33-16-3j)
• If the plan covers mastectomies, it must cover, for those who elect breast reconstruction in connection with such mastectomy, 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. (§33-16-3p)
• The plan may not require, as a condition to the coverage of basic primary and preventative obstetrical and gynecological services, that a woman first obtain a referral from a primary care physician. (§33-42-4)
• The plan may not require as a condition to the coverage of prenatal or obstetrical care, that a woman first obtain a referral for those services by a primary care physician. (§33-42-4)
• If the plan covers surgical services in a hospital inpatient or outpatient setting, it may not deny coverage for reconstruction of the breast following mastectomy; or reconstructive or cosmetic surgery required as a result of an injury caused by an act of family violence. (§33-42-4)

State

Contact

West Virginia Insurance Commission

Regulations

West Virginia Code;
www.legis.state.wv.us/WVCODE/Code.cfm

Chapter 16 Public Health, Article 2E: Birthing Centers
www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=16&art=2E

Chapter 33 Insurance;

Article 16 Group Accident and Sickness Insurance
www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=33&art=16

Article 42 Women's Access to Health Care Act
www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=33&art=42

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)