Can state and federal laws require that certain health insurance benefits be provided?
States have the authority to regulate insurance companies and the contracts they issue, including those covering health and other welfare benefit plans. Many states require health benefits to be covered in a certain way in order for the state to approve the insurance contract. These are called state-mandated benefits. Well over a thousand state mandates are on the books today. These mandates do not require that an employer provide health insurance benefits, but if the employer does provide benefits, they require benefits to be covered in a certain way. Check State Laws for specifics on state-mandated coverage requirements.
Mandates vary among the states. An example of a typical state mandate is requiring insurers to offer medical plan benefits for mental health, newborn baby coverage, or length of in-patient post-partum stays. Mandated coverage of mammography screening and alcoholism treatment also are common. In other cases, states have legislated minimum benefit coverage rules but do not mandate them. Instead, these rules are optional guidelines.
Length of maternity stay mandates.
A majority of states have mandated the length of inpatient coverage after the birth of a child. In general, a state mandate does not require that a health plan provide maternity benefits. Rather, if maternity benefits are provided, coverage must be provided for inpatient care for a mother and her newborn baby for a specified period of time after the birth of the child. Typically, this minimum is 48 hours of inpatient coverage following a normal delivery and 96 hours after a Cesarean section.
Most states allow the minimum stay to be reduced in certain situations, but how the decision is to be made varies from state to state. In many cases, it must be made by the physician (or attending health care provider) in consultation with the mother, but there are variations on this. Often, if an early discharge decision is made, post-discharge visits must be covered by the plan-again, the exact terms (involving number and location of covered visits) vary from state to state.
Federal mandate. Federal law bars group health plans from restricting postpartum hospital stays to less than 48 hours following a normal delivery and 96 hours following a Cesarean section and from requiring prior authorization for these minimums. An attending health care provider, in consultation with the mother, can approve an earlier discharge. However, a health plan may not provide monetary incentives for the mother or the health care provider to reduce the minimum stay. The federal length-of-stay mandate applies to both insured and self-insured plans. However, it does not apply to health plans that do not provide benefits for hospital stays. If the delivery occurs in a hospital, the length of stay begins at the time of delivery (or, for multiple births, at the time of the last delivery). However, if the delivery occurs outside of the hospital, the length of stay begins at the time the mother or newborn is admitted.
Interaction of state and federal law. The federal mandate will not override any state law that provides at least the 48/96 hour minimums and leaves decisions regarding the appropriate hospital length of stay in connection with childbirth entirely to the attending health care provider in consultation with the mother. This federal mandate does not preempt state laws that provide more favorable treatment of maternity coverage.
Mandated alcohol/drug treatment.
Almost all states have minimum requirements relating to the treatment of alcoholism. Many states mandate coverage to treat substance abuse as well. These are minimum levels. Provisions of benefit plans that provide more generous benefits than the mandates are acceptable. Benefits include both inpatient and outpatient care. Some states stipulate that the treatment be provided by certain types of health care providers or at certain places of treatment. Parity in substance use disorder benefits is also required by federal law for plan years beginning after October 3, 2009 (see ¶41,112
).
Mandated mental health coverage.
Some states have mandated medical benefits that include mental health provisions. Mental health parity is also required by federal law (see ¶41,112
). Benefit plans that provide more generous benefits than the mandates are acceptable.
Dependent coverage.
Most states require that coverage be available for children of subscribers "from the moment of birth." Additional premiums may be required. In addition, a time limit sometimes exists within which the plan beneficiary must report the child's birth to the insurance company or administrator. These are minimum levels. Provisions of benefit plans that provide more generous benefits than the mandates are acceptable. Some states have also mandated coverage for adopted children and when this coverage must begin.
Cessation of coverage. Coverage for dependents often ends at a designated time or age (such as age 18). Often, the coverage can be extended (such as to age 25) if the dependent is a full-time student. Some states require coverage for dependents who remain dependent for a longer period of time (for example, children who are physically or mentally disabled). An annual or biannual verification requirement might be imposed.
Federal mandates. ERISA imposes several mandatory coverage rules relating to children on group health plans.
Coverage for adopted children must be provided in the same manner as coverage for natural children.
Specific coverage for pediatric vaccines is mandated.
Coverage for college students on medical leave must be continued for up to one year (see ¶42,040
).
<p>States have the authority to regulate insurance companies and the contracts they issue, including those covering health and other welfare benefit plans.</p>
Can state and federal laws require that certain health insurance benefits be provided?
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