Plan Requirements

• Provides medical and surgical benefits with respect to a mastectomy shall provide coverage for:

              – Reconstruction of the breast on which the mastectomy is performed

              – Surgery and reconstruction of the other breast to produce a symmetrical appearance

              – Prosthesis and physical complications for all stages of mastectomy 

Newborns & Mothers Health Protection Act

• Maternity Stay Mandate Effective January 1, 1998
• Requires health plans which provide maternity inpatient benefits to cover a minimum of 48 hours of inpatient hospitalization for a mother and newborn child following a normal vaginal delivery and 96 hours following a Caesarean Section

               – Plans may not requireURpre-certification within these timelines

               – Attending physicians may discharge mother and child earlier than 48 (or 96) hours if done in consultation with the mother

• Prohibits plans from providing monetary payments or rebates to mothers to encourage their leaving the hospital earlier than the required 48 or 96 hours
• Prohibits plans from penalizing or reducing provider reimbursement because the provider prescribed a maternity stay of 48 or 96 hours
• Allows use of deductibles, co-insurance or cost sharing arrangements, and allows plans to negotiate with providers the level and type of reimbursement

Mental Health Parity Act 

• Requires fully insured and self insured health plans providing mental health benefits to give those benefits the same annual and lifetime limits as those for medical and surgical benefits
• Applies to groups 51+, ERISA and non-ERISA plans
• A plan is not required to offer mental health benefits
• Substance abuse and chemical dependency are not included in the mandate
• Number of days maximums for inpatient and outpatient mental health do not appear to violate the law
• The law does not impact plans, terms, conditions regarding amount, duration or scope of mental health benefits, including cost sharing, limits on number of days or coverage and medical necessity requirements
• The law exempts groups which would experience cost increases of 1% or more due to the implementation of this mandate
• Congress is given a one-year grace period in which to change its mind or make modifications
• Sunset clause on September 30, 2001 unless extended by Congress