Mandated Insurance Benefit Laws: Important Health .

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Mandated Insurance Benefit Laws:Important Health Protections forWomen and Their FamiliesWhat Are Mandated Insurance Benefits, and Why Do They Exist?MakingRealProgressfor WomenMandated insurance benefits are benefits that,by law, mustbe includedin a healthinsurance and Healthpolicy or contract. Federal and state governments mandate specific health benefits to preventinsurance companies from excluding coverage for certain conditions and from placingstringent limits on covered services. Many laws that mandate health benefits are inspired byreal-life instances of insurance company practices driving health care decisions. For example,in the mid-1990’s—after learning of women who were sent home from the hospital too soonafter giving birth—federal and state policymakers alike responded to the disturbing trendof ‘drive-by deliveries’ by making new laws that established a minimum postpartum stay formothers and newborns.1Most insurers complain bitterly about mandated benefits and argue that they increase thecost of insurance, and some health reform proposals seek to limit or eliminate state mandatedbenefits. However, mandated insurance benefit laws are important: they improve the valueof insurance to women because they guarantee that the insurance policies women purchasewill include vital health services and procedures. Attempts to limit these laws as part of reformshould be rejected.How Do Mandated Insurance Benefit Laws Work?Mandated benefits generally fall into three categories: (1) types of health care services ortreatments that must be covered; (2) health care providers that are entitled to reimbursement;and (3) coverage eligibility requirements for dependents or other related individuals.2 Tables1 and 2 display a selected group of mandate laws enacted by each state, for the first twocategories.Mandate laws can be enacted at either the federal or state level, and they can apply tocoverage offered in either the group insurance market (where small or large employerspurchase insurance to offer to their workers), the individual insurance market (whereindividual people and families purchase insurance directly from insurers), or both. In someinstances, a benefit is regulated by both the federal and a state government.Do Mandated Benefits Increase the Cost of Health Insurance Premiums?The most common argument against the establishment of mandated health benefit lawsis that they increase the cost of private health insurance premiums, thereby discouragingemployers and individuals from offering or purchasing health coverage. Over the past twodecades, many studies have explored the cost and coverage impacts of mandated healthinsurance benefits, using different methodologies and reporting wide-ranging results.3 Thereis a general consensus that mandated health benefit laws do increase premium costs but onlyto a limited degree.The U.S. Congressional Budget Office (CBO), for example, has reported that the additionalcosts of mandated insurance benefits are modest. The CBO estimated that the marginal costs(i.e. the total costs of compliance for those health plans that did not previously offer theNational Women’s Law Center

Mandated Insurance Benefit Laws: Important Health Protections for Women and Their Familiesbenefit) for five of the most expensivemandated health benefits—includingrequirements to cover mental healthand substance abuse treatment—wouldincrease premiums anywhere from 0.28to 1.15 percent.4 Additionally, whenconsidering the establishment of newmandated health benefit laws—as wellas the preservation of existing laws—advocates should be aware of the costsavings that can result when women andtheir families have access to the healthservices that they need. If a womanforgoes necessary health care becauseit is not covered by her insurancepolicy, her health problems are likelyto become more complex and morecostly in the future. In contrast, whencoverage of a health service is mandatedby law and is thus included in a woman’shealth policy, she is more likely to seekthe appropriate care in a timely manner,saving costs in addition to improving herhealth and well-being.Federal MandatesThere are currently just a few federallymandated health benefit laws: The Pregnancy Discrimination Actof 1978 requires employers with 15or more workers who offer healthbenefits to provide the samelevel of coverage for pregnancyas is provided for other medicalconditions; The Newborns’ and Mothers’ HealthProtection Act of 1996 requireshealth plans that offer maternitycoverage to cover a minimumnumber of days in hospitalfollowing childbirth; The Mental Health Parity Actof 1996 requires the sameannual or lifetime dollar limitsfor mental health benefits as isprovided for other physical healthNational Women’s Law CenterA New Federally-Mandated Benefit? : The BreastCancer Patient Protection ActThe 110th Congress is considering The BreastCancer Patient Protection Act (H.R. 758,sponsored by Representative Rosa DeLauro)which would ensure that insurance companiescannot restrict a hospital stay in connection witha mastectomy to less than 48 hours. Importantly,the proposal does not mandate that every patientstay in a hospital for that length of time, but forthose patients whose physicians recommenda 48-hour stay, the mandate would ensure thatinsurance companies cannot deny coverage.The legislation addresses the phenomenon of‘drive-through mastectomies,’ whereby healthcareproviders—limited by health insurancecoverage—send a patient home too soon aftertheir surgeries, while they are still weak, fatigued,and in pain. During a Congressional hearing onthe bill in May 2008, a woman who had a drivethrough mastectomy shared her harrowingexperience, which highlights the need formandate laws that will protect women’s health:I was in shock—my God, my entire breast had justbeen removed! I felt like a butchered animal. Andthough my family really wanted to be there for me,they really couldn’t understand all of the feelings Iwas going through. I just wished that I had been inthe hospital, so I could have shared my fears witha doctor or a nurse The worst part was emptyingthe drainage tubes We had to empty the drainsand then measure and record the bloody fluid Iended up getting a staph infection and had toseek medical help and in the end, I was six weekslate starting my chemotherapy It’s not right foran insurance company to dictate how a physicianmust treat a patient. I pay for health insuranceto protect myself, in case the worst happens. Andwhen it did happen to me, I found out just howlittle coverage I really had.5In September 2008, the U.S. House ofRepresentatives voted to pass the Breast CancerPatient Protection Act by a wide margin. The U.S.Senate has yet to take up the bill.2

Mandated Insurance Benefit Laws: Important Health Protections for Women and Their Familiesbenefits when offered by group health plans and insurers; The Paul Wellstone and PeteDomenici Mental Health Parity and Addiction Equity Act of 2008 (enacted as part of theEmergency Economic Stabilization Act) goes further and requires the same deductibles,co-payments and out-of-pocket expenses, and treatment limitations for mental healthand physical health benefits; and, The Women’s Health and Cancer Rights Act of 1997 requires coverage for breastreconstruction following a health plan-covered mastectomy or lumpectomy, as well asprostheses and treatment of physical complications in all stages of mastectomy.State MandatesStates have generally gone much further than the federal government in mandating benefitsto protect their residents’ health care needs. Today, all 50 states and the District of Columbiahave enacted various mandate laws that protect patients with dozens of different health careneeds. Just two benefits are mandated in all 51 jurisdictions: newborn and maternal lengthsof stay and breast reconstruction after mastectomy or lumpectomy. Other benefits, such asdiabetic supplies and education, or mammography screening, have been mandated by alarge majority of the states. Importantly, a mandate law only applies to the health insuranceplans sold in the particular state that has passed the law.While states play a primary role in regulating health insurance companies, they have limitedability to regulate health benefits when an employer is self-insured. Many large businessesself-insure, and more than half of all workers with job-based coverage are covered by a selfinsured health plan.6 Instead of paying premiums to an insurance company for coverage, aself-insured employer assumes risk itself and pays medical claims for employee plan enrolleesas they arise.Federal law exempts self-insured health plans from state regulation.7,8 However, federalinsurance mandates do apply to self-insured plans; thus, even self-insured employer plansmust adhere to the few federal insurance mandates, including those that require coveragefor pregnancy-related care, minimum hospital stays after birth, mental health parity, andreconstructive breast surgery after covered mastectomies.How Do Mandate Laws Protect Women and Their Families?Some mandated insurance benefit laws guarantee that health insurance policies coverthe types of care that women need to stay healthy. Many of the health insurance mandatesthat states have adopted (and continue to adopt) relate to health care services that womenneed to lead healthy and productive lives. As Table 1 demonstrates, state mandates includerequirements to cover important preventive health care benefits like mammography andcervical cancer screenings, as well as services that help women manage chronic physical andmental illnesses, such as diabetes education and supplies or mental health parity.9 Mandatedbenefit laws also guarantee that women have access to the safe and reliable contraceptionthat is an essential component of their reproductive health care—over half of all statesrequire insurers to cover contraceptive prescriptions at the same level as other coveredprescription drugs.10It is important to note that though a mandate law may address coverage for a certainimportant health service, it could still fall short of providing women with full coverage forthe care they need. For example, a mandate law may require that health plans cover mentalhealth services, but still allow the plans to impose unrealistically-low annual limits on thatNational Women’s Law Center3

Mandated Insurance Benefit Laws: Important Health Protections for Women and Their FamiliesLessons from the States:Oregon Enhances Access toContraceptive ServicesIn May 2007, Oregon Governor Ted Kulongoskisigned the Access to Birth Control Act, makingOregon the 24th state to require insurers toprovide equitable coverage of prescriptioncontraceptives (additional states mandateinsurers to offer equitable coverage ofcontraceptives or have interpreted state antidiscrimination laws as requiring contraceptiveequity). The measure, which applies to employersponsored group health plans, requires healthinsurance plans to provide the same level ofcoverage for birth control as they do for otherprescription drugs. In addition to contraceptiveequity, the Act requires hospital emergencyrooms in Oregon to offer women who have beenvictims of sexual assault, or that they believehave been a victim of sexual assault, informationabout and access to emergency contraception.coverage. Or, a law may mandate aspecific level of coverage for a serviceonly if a plan offers the service in thefirst place. For example: a mandate formaternity coverage may state that ifa plan covers maternity care then itmust cover a certain type of prenatalscreening test as part of that care.Some mandated insurance benefitlaws require insurers to reimbursecertain non-medical or nonphysician providers. State insurancemandates also include requirementsthat insurance policies reimbursenon-medical providers such as socialworkers, and non-physician providerssuch as nurse-midwives and nursepractitioners. These laws help ensurethat women and their families, whenpossible, have a choice in health careproviders; for example, some women ofchildbearing age prefer to receive theirgynecological or obstetric care from acertified nurse-midwife rather than an obstetrician. In areas where physician providers are inshort supply, laws that require insurance policies to reimburse health care services providedby non-physician and non-medical providers can also improve access to timely health care.In addition, most states have mandate laws that make it easier for women enrolled inmanaged care plans to get health care from an obstetrician or gynecologist. While managedcare arrangements typically require enrollees to access specialists through a referral froma primary care provider, these mandates—commonly called ‘Direct Access to OB/GYN’mandates—allow women to seek health care from an obstetrician or gynecologist directly,without first obtaining a referral.Some mandated insurance benefit laws also require insurers to extend health benefitsto dependent family members. Mandated insurance benefit laws do more than guaranteeimportant health services for women—these laws also provide protections for families byrequiring health insurance policies to cover certain types of dependents. For example, overthree-quarters of the states mandate that health insurance policies cover adopted childrenon the same terms and conditions as biological children, and the majority of states requireinsurers to continue coverage for dependent children with disabilities, even after the child hasreached maturity.Mandated benefit laws that require insurers to merely offer a health benefit may notbe very beneficial to women and their families. Mandated insurance benefit laws canbe classified according to whether they require the insurer or plan to provide coverage inall policies (meaning that the benefit must be included in the policy) or merely offer one ormore policies with the specific coverage to potential enrollees (meaning that the benefitNational Women’s Law Center4

Mandated Insurance Benefit Laws: Important Health Protections for Women and Their Familiesmust be offered to the prospective buyer in one of more policies made available by theinsurer). A mandate to offer coverage simply makes the coverage available—usually with anadditional or higher premium, and perhaps at a high and unaffordable cost for those whoneed the benefit. Why would an employer who is purchasing coverage for a group of workersinclude a benefit within a plan just because an insurer must offer it? Hence, an offer law is acompromise that precludes a full coverage law and, from a consumer’s perspective, may bethe same as having no mandate at all.11Even when a health benefit is mandated by state law, insurers may not be in compliancewith state regulations. There is some evidence that health insurance companies do notalways comply with a state’s mandated health benefit laws. For example, a 1995 study of statemandates for mental health services across the states reported a non-compliance rate of 10to 15 percent.12 The laws must be enforced for mandated benefit laws to truly protect womenand their families from financial risk and unmet health needs.The Wrong Direction for Health Reform: Proposals That Would Eliminate Mandated HealthBenefitsSome types of health reform plans, if implemented, would limit or eliminate laws thatmandate health benefits and other important consumer health protections, such asregulations that limit premium rates or that prohibit insurers from taking pre-existingconditions into account. These proposals are based on the premise that 1) mandate lawsand other insurance regulations increase the cost of health insurance and are unnecessaryfor certain populations and 2) policies that are exempt from many mandates will be moreaffordable, encouraging more people who cannot find a more comprehensive health plan tobuy the plans. These proposals might allow: Buying and Selling Insurance ‘Across State Lines’: Currently, state residents can purchasehealth insurance sold only within their own state. Federal and state policymakers alike,however, have proposed health reforms that would essentially allow individuals topurchase health insurance products licensed in any state, regardless of the consumerprotections that the individual’s home state government has adopted. A proposedfederal bill called the Health Care Choice Act of 2007 (H.R. 4460, introduced byRepresentative John Shadegg of Arizona), for example, would allow an insurancecompany to declare a ‘home state’ (likely to be the state with the fewest mandate andconsumer protection laws) and offer insurance plans approved in that state to peopleacross the country. Association Health Plans: Another health reform proposal considered at the federallevel would create purchasing coalitions known as Association Health Plans (AHPs).AHPs could buy coverage from insurance companies or become insurance providersthemselves by paying claims from their own funds. Since AHPs would be created atthe federal level, they would be exempt from state benefit mandates and consumerprotection laws and would be subject only to very minimal federal regulations. ‘Mandate-Lite’ Health Insurance: Some states have passed laws that permit healthinsurers to offer products commonly referred to as ‘mandate-lite,’ ‘minimum (or limited)benefit,’ or ‘affordable’ plans. These products are exempt from many of a state’s benefitmandate laws, allowing insurers to sell less expensive policies—with leaner benefitpackages—to certain populations. Mandate-lite policies are typically designed for smallbusinesses, since they often face challenges in securing affordable coverage for theirNational Women’s Law Center5

Mandated Insurance Benefit Laws: Important Health Protections for Women and Their Familiesworkers, or for previously uninsured individuals. In some cases, a state may even providepublicly-funded subsidies for small businesses or individuals to purchase a mandate-liteplan, essentially undermining its protections for those who can least afford to pay formore comprehensive coverage.Insurance plans that are exempt from state regulations may be less expensive than morecomprehensive insurance products, but they also provide less value to consumers and—bylimiting or excluding coverage for certain conditions—expose policyholders to greaterlevels of financial risk. Proposals that eliminate mandate laws might raise the number ofinsured people, but they would also reduce the number of people insured against chronic orexpensive conditions like diabetes, depression, or breast cancer.The number of underinsured Americans (i.e. those with insufficient coverage that leaves themvulnerable to financial risk and unmet health needs) is increasing rapidly—a disturbing trendgiven that underinsured adults are almost as likely as the uninsured to go without neededmedical care and incur medical debt—and these proposals will only add to this growingproblem.13 So-called “reforms” that permit insurers to sell health insurance products that areexempt from state mandate and consumer protection laws will undermine states’ efforts tomeet the needs of their residents and will put women’s health at risk. Without strong nationalstandards for comprehensive health coverage, we will continue to need mandated insurancebenefit laws.What Can Women’s Advocates Do to Establish or Preserve ImportantHealth Insurance Protections?Women’s advocates can find out which health insurance benefits are mandated in their state,and ensure that their community members understand the protections that do or do not existunder their current state law.Tables 1 and 2 of this toolkit piece will help women’s advocates determine whether their statehas a law in place that mandates (selected) health benefits or providers. To fully understandthe scope or limitations of a mandate law, however, it may be necessary for advocates to digdeeper with regards to their state insurance laws and r

Mandated insurance benefits are benefits that, by law, must be included in a health insurance policy or contract. Federal and state governments mandate specific health benefits to prevent insurance companies from e

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