Benefits Mandates

VII. Key Issues: Regulation & Reform >> B. Health Care Regulation >> Health Insurance Regulation >> Benefits Mandates (last updated July 12, 2014)

 

Overview

This includes mandated standards of care and other mandated health services imposed by states and the federal government, including:

  • Mental Health Parity Act (MHPA: 1996)
  • Mental Health Parity and Addiction Equity Act (MHPAEA: 2008)
  • Newborns’ and Mothers’ Protection Health Act (1996)
  • Women’s Health and Cancer Rights Act (WHCRA: 1998)

The Duke Center for Health Policy and Inequalities Research has developed a draft working paper on the benefits and costs of mandated health benefits: (pdf)

 

Specific Benefits Mandates

Federal

  • Maternity Benefits. Under the 1978 Pregnancy Discrimination Act, employers with 15 or more workers must offer maternity coverage. Some states have tighter regulations, including 12 states that mandate maternity coverage in the individual market and 17 that require it in the small-group market. See also Maternity Coverage in the Individual Health Insurance Market (House Energy and Commerce Committee, 10.12.2010).
  • Mental Health Parity Act. The Mental Health Parity Act of 1996 was effective from January 1, 1998-September 30, 2001 (The original sunset provision (providing that the parity requirements would not apply to benefits for services furnished on or after September 30, 2001) was extended six times through 2007). The law did not mandate that any employers provide mental health coverage but for employers that already offered such coverage, the law in various ways made mental health benefits more comparable to benefits related to physical health. MHPA was largely superseded by the Mental Health Parity and Addiction Equity Act (MHPAEA), signed into law by President George W. Bush in October 2008.
  • Newborns’ and Mothers’ Protection Health ActThe law was signed into law on September 26, 1996, requiring plans that offer maternity coverage to pay for at least a 48-hour hospital stay following childbirth (96-hour stay in the case of a cesarean section). This law was effective for group health plans for plan years beginning on or after January 1, 1998.
  • Women’s Health and Cancer Rights Act. Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage also must provide coverage for certain services relating to the mastectomy in a manner determined in consultation with your attending physician and you. This required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema.

 State Mandates

 

General Analysis

 

Analysis of Specific Mandates

 

Analysis of Specific Mandates

Accidental Ingestion or Consumption of Controlled Drug

  • CT Mandate. 2010 Vol. III report estimates this increases group premiums by 0.01% (excludes administrative load)

Alcoholism: Treatment of Medical Complications of Alcoholism

  • CT Mandate. 2010 Vol. III report estimates this increases group premiums by 0.10% (excludes administrative load)

Attention Deficit / Hyperactivity Disorder

    • LA Mandate2008 report estimates this increases premiums by 0.08%.

 

Autism Spectrum Disorder Therapies

Autism, Expanded Autism Spectrum Disorder Mandate

  • CT Mandate. 2012 report estimates this increases group premiums by $0.40 PMPM (excludes administrative load)

Autism, Alternative Autism Spectrum Disorder Therapy

  • CT Mandate. 2012 report estimates this increases group premiums by $0.08 PMPM (excludes administrative load)

Birth to Three Program

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.07% (excludes administrative load)

Blood Lead Screening and Risk Assessment

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by less than 0.01% (excludes administrative load)
  • See also analysis of Preventive Pediatric Care and Blood Lead Screening

Bone Mass Measurement for Diagnosis and Treatment of Osteoporosis

  • LA Mandate2008 report estimates this increases premiums by 0.08%.

Breast Cancer Screening Cost-sharing: Ultrasound

  • CT Mandate. 2012 report estimates this increases group premiums by $0.20 PMPM (excludes administrative load)

Breast Cancer Screening Cost-sharing: MRI

  • CT Mandate. 2012 report estimates this increases group premiums by $0.10 PMPM (excludes administrative load)

Breast Cancer Screening by Thermography

  • CT Mandate. 2012 report estimates this increases group premiums by $0.05 PMPM (excludes administrative load)

Cancer Clinical Trials

  • CT Mandate. 2011 report estimates this increases group premiums by $0.00 PMPM (excludes administrative load)
  • LA Mandate2008 report estimates this increases premiums by 0.04%.

Cancer Drugs

  • LA Mandate. Prohibits plans that cover treatment of cancer from excluding coverage for any drug prescribed for treatment of cancer on the grounds that the drug is not approved by the US FDA for a particular indication if that drug is recognized for treatment of the covered indication in a standard reference
    compendia or in substantially accepted peer-reviewed medical literature and; mandates coverage for all medically necessary services associated with administration of the drug. 2008 report estimates this increases premiums by 1.09%.

Cleft Lip and Cleft Palate Treatment

  • LA Mandate. 2008 report estimates this increases premiums by 0.01%.

Colonoscopy

  • CT Mandate. 2009 report estimates this increases group premiums  by $0.01 PMPM

Colorectal Cancer Screening

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 1.10% (excludes administrative load)
  • LA Mandate2008 report estimates this increases premiums by 0.35%.

Contraception

Craniofacial Disorders

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.02% (excludes administrative load)

Dental Services: Inpatient, Outpatient or One-day

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.02% (excludes administrative load)
  • LA Mandate (Anesthesia and associated hospital charges when the mental or physical condition of the insured requires dental treatment to be rendered in a hospital setting, except for treatment of TMJ). 2008 report estimates this increases premiums by 0.02%.

Diabetes Testing and Treatment

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 1.50% (excludes administrative load)
  • LA Mandate (Treatment of insulin-dependent diabetes). 2008 report estimates this increases premiums by 0.12%.

Diabetes Self-Management Training

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.02% (excludes administrative load)

Eye Drops, Prescription

  • CT Mandate. 2011 report estimates this increases group premiums by $0.07 PMPM (excludes administrative load)

Fertility Preservation

  • CT Mandate. 2013 report estimates this increases premiums by $0.059 PMPM group; $0.062 PMPM non-group (excludes administrative load)

Gastric Bypass

  • CT Mandate. 2011 report estimates this increases group premiums by $0.50 PMPM (excludes administrative load)

Hearing Aids

  • CT Mandate. 2009 report estimates this increases group premiums  by $0.06 PMPM (excludes administrative load)

Hearing Aids for Children

  • CT Mandate (children 12 and under). 2010 Vol I report estimates this increases group premiums  by less than 0.01% (excludes administrative load)
  • LA Mandate (children under 18). 2008 report estimates this increases premiums by 0.01%.

Hearing Impaired Interpreter Expenses

  • LA Mandate2008 report estimates this increases premiums by less than 0.01%.

HLA Testing

  • CT Mandate. 2009 report estimates this increases group premiums  by $0.06 PMPM (excludes administrative load)

Immunizations for Dependent Children from Birth to Age 6

    • LA Mandate2008 report estimates this increases premiums by 0.51%.

 

Infertility Diagnosis and Treatment

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.90% (excludes administrative load)

Low Protein Modified Food Products, Amino Acid Modified Preparations and Specialized Formulas

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.10% (excludes administrative load)
  • LA Mandate (Low protein food products for treatment of inherited metabolic diseases). 2008 report estimates this increases premiums by 0.03%.

Lung Cancer Screening

  • CT Mandate. 2013 report estimates this increases premiums by $0.266 PMPM group; $0.247 PMPM non-group (excludes administrative load)

Lyme Disease Treatments

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.09% (excludes administrative load)

Mammography and Breast Ultrasound

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.80% (excludes administrative load)

Mastectomy or Lymph Node Dissection Minimum Stay

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.03% (excludes administrative load)

Maternity Minimum Stay

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.60% (excludes administrative load)
  • LA Mandate2008 report estimates this increases premiums by 1.3%.

Mental or Nervous Conditions

  • CT Mandate. 2010 Vol. III report estimates this increases group premiums by 2.80% (excludes administrative load)
  • LA Mandate (severe mental illnesses (does not include alcohol and substance
    abuse). 2008 report estimates this increases premiums by 1.37%.

Mental Disorders, Court-ordered Treatment for

  • CT Mandate. 2013 addendum estimates this increases premiums by $0.374 PMPM group; $0.30 PMPM non-group (excludes administrative load)

MRI Screening for Breast Cancer

  • CT Mandate. 2011 report estimates this increases group premiums by $0.92 PMPM (excludes administrative load)

Neuropsychological Testing for Children Diagnosed with Cancer

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by less than 0.01% (excludes administrative load)

Occupational Therapy

  • CT Mandate. 2010 Vol. III report estimates this increases group premiums by 0.30% (excludes administrative load)

Ostomy Supplies

  • CT Mandate. 2009 report estimates this increases group premiums  by $0.01 PMPM (excludes administrative load)

Ostomy-Related Supplies

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.02% (excludes administrative load)

PANDAS

  • CT Mandate. 2013 report estimates this increases premiums by $0.013 PMPM group; $0.014 PMPM non-group (excludes administrative load)

Pap Test (Annual) and Minimum Mammography Examination

  • LA Mandate2008 report estimates this increases premiums by 0.77%.

Preventive Pediatric Care and Blood Lead Screening

  • CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.60% (excludes administrative load)

Prostate Cancer Screening

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 0.06% (excludes administrative load)
  • LA Mandate2008 report estimates this increases premiums by 0.07%.

Prostate Cancer Treatment

  • CT Mandate. 2012 report estimates this increases group premiums by $0.00 PMPM (excludes administrative load)

Prosthetics

  • CT Mandate. 2009 report estimates this increases group premiums  by $0.35 PMPM (excludes administrative load)

Psychotropic Drug Availability

  • CT Mandate. 2010 Vol. III report estimates this increases group premiums by 2.50% (excludes administrative load)

Reconstructive Breast Surgery Following a Mastectomy

  • LA Mandate2008 report estimates this increases premiums by 0.15%.

Tumors and Leukemia

  • CT Mandate. 2010 Vol I report estimates this increases group premiums  by 3.70% (excludes administrative load)

Wigs, Alopecia Areata

  • CT Mandate. 2009 report estimates this increases group premiums by $0.02 PMPM (excludes administrative load)