Managed Care & Health Insurance - United States

United States: Mandated Benefits in Private Insurance

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Mandated Benefits in Private Insurance

State Mandated Benefits: Cancer Screening for Women, 2008
	US	US
Mandates Any Type of Cancer Screening for Women?	49 + DC Yes	49 + DC Yes
Breast Cancer Screening?	49 + DC Yes	49 + DC Yes
Cervical Cancer Screening?	28 + DC Yes	28 + DC Yes
Ovarian Cancer Screening?	3 Yes	3 Yes

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Notes:	Data as of March 15, 2008. These requirements apply to managed care organizations and to the large group market (50+ employees) only.
Sources:	Health Policy Tracking Service, a service of Thomson West, April 2008, available at http://www.netscan.com.
Definitions:

State Mandated Benefits: Inpatient Mastectomy Stay, 2008
	US	US
Mandates Coverage of Mastectomy Stay?	20 Yes	20 Yes
Notes

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Notes:	Data as of March 15, 2008 These requirements apply to managed care organizations and to the large group market (50+ employees) only.
Sources:	Health Policy Tracking Service, a service of Thomson West, available at http://www.netscan.com.
Definitions:	Minimum stay: Requires insurers that provide coverage for mastectomies to provide coverage for at least the specified number of hours of inpatient care following the mastectomy.

State Mandated Benefits: Reconstructive Surgery After Mastectomy, 2008
	US	US
Mandates Reconstructive Surgery After Mastectomy?	35 + DC Yes	35 + DC Yes
Notes

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Notes:	Data as of March 15, 2008. States are noted if they provide broader coverage for reconstructive surgery following a mastectomy than is required by federal law under WHCRA. Reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty, and mastopexy. These requirements apply to managed care organizations and to the large group market (50+ employees) only.
Sources:	Health Policy Tracking Service, a service of Thomson West, available at http://www.netscan.com.
Definitions:	WHCRA: The Women's Health and Cancer Rights Act (WHCRA) sets minimum federal standards for coverage of reconstructive surgery following a mastectomy. The law requires group health plans that provide medical and surgical mastectomy benefits to also provide coverage for reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prosthesis and treatment for physical complications during all stages of mastectomy, including lymphedemas in a manner determined by the attending physician in consultation with the patient.

State Mandated Benefits: Osteoporosis Screening, 2008
	US	US
Mandates Osteoporosis Screening?	13 Yes	13 Yes
Notes

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Notes:

Data as of March 15, 2008
These requirements apply to managed care organizations and to the large group market (50+ employees) only.

Sources:

Health Policy Tracking Service, a service of Thomson West, available at http://www.netscan.com.

Definitions:

Bone mass measurement: A radiologic or radioistopic procedure or other scientifically proven technology performed on an individual for the purpose of identifying bone mass or detecting bone loss.
High-risk or qualified individuals: Estrogen-deficient individuals who are at clinical risk for the disease; individuals with vertebral abnormalities; individuals receiving long-term glucocorticoid (steroid) therapy; individuals who have primary hyperparathyroidism; individuals being monitored to assess the efficacy of approved osteoporosis drug therapies; or those with a family history.
Specialized health benefit plans: May include accident-only, disability income, hospital indemnity, Medicare supplement, long-term care, specified disease and other limited benefit health insurance policies or short-term medical policies of six months or less.

NA: Data not available.

State Mandated Benefits: Direct Access to OB/GYNs, 2008
	US	US
Mandates Direct Access to OB/GYNs?	36 + DC Yes	36 + DC Yes
Notes

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Notes:	Data as of February 2008. These requirements apply to managed care organizations and to the large group market (50+ employees) only.
Sources:	Health Policy Tracking Service, a service of Thomson West, available at http://www.netscan.com.

State Mandated Benefits: OB/GYNs as Primary Care Providers, 2008
	US	US
Mandates OB/GYNs as Primary Care Providers?	22 + DC Yes	22 + DC Yes

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Notes:

U.S. total does not include territories.

Data as of February 2008.
These requirements apply to managed care organizations and to the large group market (50+ employees) only.

Sources:

Health Policy Tracking Service, a service of Thomson West, available at http://www.netscan.com.

State Mandated Benefits: Eating Disorder Parity, 2007
	US	US
Requires Private Insurers to Cover Treatment for Eating Disorders?	24 Yes	24 Yes
Strength of 2007 Policy	17 Meet Policy	17 Meet Policy
Change from 2004	6 Better	6 Better

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Notes:	Data as of February, 2007.
Sources:	National Women's Law Center. Making the Grade on Women''s Health: A National and State-by-State Report Card, 2007. http://hrc.nwlc.org/Policy-Indicators/Womens-Access-to-Health-Care-Services/Mental-Health.aspx#16
Definitions:	States that require insurers to cover anorexia and bulimia on the same basis as other health conditions receive a meets policy. States that require coverage in a limited way (i.e., they only require parity in spending limits or only for certain populations such as state employees) receive a limited policy. Those states with no laws requiring insurers to cover anorexia and bulimia on par with other health conditions receive a no policy.

Mandated Coverage of Infertility Treatment, January 2009
	US	US
State Mandates Coverage of Infertility Treatment?	15 Yes	15 Yes
Individual Market	12 Yes	12 Yes
Type of Mandate	NA	NA
Small Group Market	14 Yes	14 Yes
Type of Mandate	NA	NA

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Notes:

Data as of January 2009.

A range of treatments may be available to those facing infertility, including prescription drugs (e.g., to stimulate ovulation) and surgery (e.g., to repair blocked fallopian tubes or seminal vessels). In addition, several assisted conception techniques include, among others, artificial insemination (AI), in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and egg or embryo donation. 14 states mandate coverage of at least some kind of infertility treatment in policies sold through the individual market, the small group market, or both. State mandates vary considerably. Some apply only to certain kinds of health insurance policies, for example, HMOs. Others specify certain types of infertility treatment, such as IVF, that must be, or not be, covered under the mandate.

Sources:

Data compiled through review of federal and state law.
Data collection and analysis by researchers at the Health Policy Institute, Georgetown University.

Definitions:

Sometimes, state law require health insurance plans sold by licensed insurers to include coverage for a specific benefit. This is called a "mandate to cover". As an alternative, a state law may require health insurers to offer coverage for a specific benefit, but the person or group buying the policy does not have to elect coverage for that specific benefit. This is a "mandate to offer".

NA: Data are not available.

Mandated Coverage of Maternity Care, January 2009
	US	US
State Mandates Coverage of Maternity Care?	18 Yes	18 Yes
Individual Market	14 Yes	14 Yes
Type of Mandate	NA	NA
Small Group Market	16 Yes	16 Yes
Type of Mandate	NA	NA

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Notes:

Data as of January 2009.

The vast majority of group health plans provide coverage for maternity care, including prenatal care. This is due in large part to the Pregnancy Discrimination Act of 1978 (PDA), an amendment to Title VII of the 1964 Civil Rights Act, that prohibits discrimination based on gender, pregnancy, childbirth, or pregnancy-related conditions. The PDA requires health plans sponsored by employers with 15 or more employees to cover pregnancy, childbirth, and pregnancy-related conditions in the same way as other temporarily disabling conditions. Though the PDA is not a mandated benefit law, per se, it has the effect of promoting maternity coverage under most employer sponsored health plans. Enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) effectively broadened the reach of the PDA. HIPAA requires all health insurance policies for small employer groups (defined as firms with 2 to 50 employees) to be sold on a guaranteed issue basis. This means small employers not subject to the PDA nonetheless have the opportunity to buy policies with maternity benefits sold to larger employers.

Sources:

Data compiled through review of federal and state law.
Data collection and analysis by researchers at the Health Policy Institute, Georgetown University.

Definitions:

Sometimes, state law require health insurance plans sold by licensed insurers to include coverage for a specific benefit. This is called a "mandate to cover". As an alternative, a state law health inusrers to offer coverage for a specific benefit, but the person or group buying the policy does not have to elect coverage for that specific benefit. This is a "mandate to offer".

NA: Data are not available.


	US	US

Notes/Sources(show)