Benefits Mandates

VII. Key Issues: Regulation & Reform >> B. Health Care Regulation >> Health Insurance Regulation >> Benefits Mandates (last updated 12.20.15)

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 MHPA was largely superseded by the Mental Health Parity and Addiction Equity Act (MHPAEA), signed into law by President George W. Bush in October 2008.
  • See 2012 Report to Congress: Compliance With the Mental Health Parity and Addiction Equity Act of 2008.
  • Department of Labor. Mental Health Parity. Includes links to fact sheets and interim and final regulations.
  • Milliman and the American Psychiatric Association. Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act. January, 2015.
• Newborns’ and Mothers’ Protection Health Act. The 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

• Council for Affordable Health Insurance. Health Insurance Mandates in the States 2008.
• Council for Affordable Health Insurance.  Health Insurance Mandates in the States 2010.
• CA. California Health Benefits Review Program. Health Insurance Benefit Mandates in California State and Federal Law (Oakland:University of California, 2012).

General Analysis

• Bailey, James. The Effect of Health Insurance Benefit Mandates on Premiums. Eastern Economic Journal, 2013, (1–9). This paper examines the effects of laws mandating that health insurance cover specific conditions, procedures, providers, and beneficiaries. Unlike previous work, this paper considers the market for employer-based health insurance rather than the much smaller individual market, and uses a panel data approach to account for unobserved heterogeneity among states. Using a fixed effects model, I find that the average mandate increases premiums by 0.44–1.11 percent annually. This implies that new mandates were responsible for 9–23 percent of all premium increases over the 1996–2011 period.
• Bailey, James and Douglas Webber.Do Health Insurance Benefit Mandates Discourage Employment? Mercatus Center (6.17.15). A new empirical study for the Mercatus Center at George Mason University shows that while health insurance benefit mandates do not reduce overall employment, they do benefit large firms at the expense of small firms. Large firms can self-insure, which allows them to take advantage of a federal law exempting self-insured companies from state benefit mandates. State legislatures should carefully consider the unintended consequences of passing new health insurance regulations.
• Blue Cross Blue Shield of Tennessee. Effects of Government Mandated Benefits on Health Care Costs, A White Paper Detail on Higher Health Care Costs from Well-Intentioned Laws. September, 2004.
• Cauchi, Richard. Memo on: State Insurance Mandates and the ACA Essential Benefits Provisions. (Updated May 4, 2011).
• Cubanski, Juliette, and Helen H. Schauffier. California Health Policy Roundtable Issue Brief,
  Mandated Health Insurance Benefits: Tradeoffs Among Benefits, Coverage, and Costs? (July,2002).
• Monheit, Alan and Jasmine Rizzo. Mandated Health Insurance Benefits: A Critical Review of the Literature. January 2007. This is a very thorough review of the literature as of early 2007.

Analysis of Specific Mandates

• Connecticut Mandated Health Insurance Benefits Reviews. These reviews by the University of Connecticut Center for Public Health and Health Policy are based on a literature review and actuarial estimates by Ingenix. The reviews must include both the social and financial impacts of mandating health benefits and the law outlines 25 different factors that must be analyzed, to the extent information is available, for each existing or proposed mandated health benefit. Figures shown in parentheses represent the average percentage increase in group premiums due to medical costs associated with each mandate.
  • 2009 report includes: a) Ostomy supplies; b) Prosthetics; c) Hearing aids; c) Wigs, Alopecia areata; d) HLA testing; and e) Colonoscopy.
  • 2010 Vol I report includes: a) Diabetes Self-Management Training; b) Prostate Cancer Screening; c) Ostomy-Related Supplies; d) Hearing Aids for Children Twelve and Under; e) Craniofacial Disorders; f) Inpatient, Outpatient or One-day Dental Services; g) Diabetes Testing & Treatment; h) Birth to Three Program; i) Lyme Disease Treatments; j) Colorectal Cancer Screening; k) Tumors and Leukemia.
  • 2010 Vol. II report includes: a) Mammography and Breast Ultrasound; b) Maternity Minimum Stay; c) Mastectomy or Lymph Node Dissection Minimum Stay; d) Prescription Contraceptives; e) Infertility Diagnosis and Treatment; e) Autism Spectrum Disorder Therapies; f) Coverage for Newborn Infants; g) Blood Lead Screening and Risk Assessment; h)Preventive Pediatric Care and Blood Lead Screening; i) Low Protein Modified Food Products, Amino Acid Modified Preparations and Specialized Formulas; j) Neuropsychological Testing for Children Diagnosed with Cancer.
  • 2010 Vol. III report includes: a) Psychotropic Drug Availability; b) Mental or Nervous Conditions; c) Accidental Ingestion or Consumption of Controlled Drug; d) Denial of Coverage Prohibited for Health Care Services to Persons with an Elevated Blood Alcohol Content; e) Treatment of Medical Complications of Alcoholism; f) Occupational Therapy; g) Services of Physician Assistants and Certain Nurses; h) Services Provided by the Veterans’ Home; i) Direct Access to OB/GYNs; j) Chiropractic Services.
  • 2011 report includes: a) Prescription Eye Drops; b) MRI Screening for Breast Cancer; c) Cancer Clinical Trials; d) Gastric Bypass.
  • 2012 report includes: a) Expanded autism spectrum disorder mandate; b) Alternative autism spectrum disorder therapy; c) Extension of autism spectrum disorder mandate to certificate holders; d) Prostate cancer treatment; e) Breast cancer screening cost-sharing: ultrasound; f) Breast cancer screening cost-sharing: MRI; g) Breast cancer screening by thermography.
  • 2013 report includes estimates of the cost impact on fully insured group plans and non-group plans: a) PANDAS; b) Lung Cancer Screening; c) Fertility Preservation.
  • 2013 addendum includes estimates for court-ordered treatment for mental disorders ($0.374 PMPM group; $0.30 PMPM non-group)
• Louisiana. Department of Insurance, Office of Health Insurance. Mandated Healthcare Benefits Study 2005-2007. (2008). Located in Appendix IV.
• Maryland
  • Maryland Health Care Commission. Annual Mandated Health Insurance Services Evaluation.
    (January, 2011).
  • Maryland Health Care Commission. Study of Mandated Health Insurance Services: A
    Comparative Evaluation. (January, 2008).
• Massachusetts. Mandated Health Benefits Evaluation Reports
  • Review and Evaluation of Proposed Legislation Entitled: An Act Relative to Establishing the Mass. Childhood Vaccine Program and the Mass. Immunization Registry Senate Bill 2195 House Bill 3453 (PDF) | Word
  • Review and Evaluation of Proposed Legislation Entitled: An Act to Provide Coverage for Hearing Aids House Bill 3598 (PDF) | Word
  • Review and Evaluation of Proposed Legislation Entitled: An Act Relative to Insurance Coverage for Autism (PDF) | Word
  • Review and Evaluation of Senate Bill 485: An Act Relative to Increasing Coverage for Infertility Treatments (August 2009) (PDF) | Word
  • Review and Evaluation of House Bill 4557: An Act Relative to Coverage for Cleft Palate and Cleft Lip (May 2009) (PDF) | Word
  • Paper Related to Senate Bill 433: An Act Regarding Continuity of Prescription Drug Coverage (May 2009) (PDF) | Word
  • Review and Evaluation of House Bill 2058: An Act Relative to Urea Cycle Disorders (May 2009) (PDF) | Word
  • Review and Evaluation of House Bill 3931: An Act Relative to Providing for Insurance Coverage for Vision Screening for Children (May 2009) (PDF) | Word
  • Review and Evaluation of Senate Bill 564: An Act Relative to Coverage for Prescription Drug Voice Synthesizers (May 2009) (PDF) | Word
  • Children’s Mental Health (July 2008) (PDF) | Word
    • Appendix by Compass Health Analytics (PDF) | Word
  • Comprehensive Review of Mandated Benefits in Massachusetts (July 2008) (PDF) | Word
    • Appendix by Compass Health Analytics (PDF) | Word
  • Mental Health Parity (July 2008) (PDF) | Word
    • Appendix by Compass Health Analytics (PDF) | Word
  • Eating Disorders (October 2007) (PDF) | Word
    • Actuarial Assessment by Compass Health Analytics (PDF)
  • Educational Psychologists (August 2005) (PDF) | Report only (Word)
    • Appendix I only (Word) | Appendix II only (Word)
  • Certain Prosthetic Devices (April 2005) (PDF) | Word
  • Ectodermal Dysplasia (March 2005) (PDF) | Report only (Word)
    • Actuarial Report only (Word)
  • Marriage and Family Therapists (January 2005) (PDF) | Word
  • Chiropractic Services (January 2005) (PDF) | Word
• Tennessee. Cost of State and Federally Mandated Health Benefits. Report to the Tennessee General Assembly Prepared by the Fiscal Review Committee Staff, June 29, 2011.
• Texas.
  • Albee, Susan K., Esther Blount, Tim D. Lee, Mark Litow, and Mike Sturm. Cost Impact Study of Mandated Benefits in Texas, Report # 1 (Revised August, 2000).
  • Albee, Susan K., Esther Blount, Tim D. Lee, Mark Litow, and Mike Sturm. Cost Impact Study of Mandated Benefits in Texas, Report # 2 (September, 2000).

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 Mandate. 2008 report estimates this increases premiums by 0.08%.

Autism Spectrum Disorder Therapies

• CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.01% (excludes administrative load)
• VA Mandate. Virginia General Assembly, Joint Legislative Audit and Review Commission, Evaluation of
  House Bill 83: Mandated Coverage of Autism Spectrum Disorders (September, 2008)

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 Mandate. 2008 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 Mandate. 2008 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 Mandate. 2008 report estimates this increases premiums by 0.35%.

Contraception

• CT Mandate. 2010 Vol. II report estimates this increases group premiums  by 0.4% (excludes administrative load).
• HI Mandate. Based on an examination of just four health plans, the state’s insurance commissioner concluded in a 2001 report on the 1999 mandate that the mandate “did not appear to have a direct effect on an increase in the cost of health insurance.” However, according to health economist Austin Frakt, “this conclusion is hedged; the detailed results from each of those four plans do not unambiguously support it.”

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 Mandate. 2008 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 Mandate. 2008 report estimates this increases premiums by 0.51%.

Infertility Diagnosis and Treatment

• Background. Only 15 states, including New York, California, Illinois and Texas, mandate some form of fertility coverage, and many insurance companies don’t cover any fertility treatments. “In the U.S., about 85 percent of all infertility care is paid out of pocket,” said Judith F. Daar, a professor of law at Whittier Law School in Costa Mesa, Calif., and chairwoman of the reproductive medicine society’s ethics committee. “And only about 50 percent of all people who experience infertility actually visit professionals to follow up, because of the financial stranglehold” (New York Times, 11.2.15).
• CT Mandate. 2010 Vol. II report estimates this increases group premiums by 0.90% (excludes administrative load)
• Potential Sexual Orientation Discrimination. “Jennifer C. Pizer, the law and policy project director for Lambda Legal, a gay rights advocacy organization, said that it was not clear whether gay couples could win a legal challenge against insurance companies, but that a double standard of reimbursement for straight and same-sex couples smacked of discrimination. “I do think it’s sex or sexual orientation discrimination to treat a man with a female partner and a very low or absent sperm count differently than a lesbian with a female partner and nonexistent sperm count,” Ms. Pizer said (New York Times, 11.2.15).

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 Mandate. 2008 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 Mandate. 2008 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 Mandate. 2008 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 Mandate. 2008 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)