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Health Laws That Can Save You Money - Or Your Life

By: Rhonda D. Orin
The Washington Post, June 19, 2001 

In her book "Making Them Pay: How To Get the Most from Health Insurance and Managed Care" (St. Martin's Press), Washington lawyer Rhonda D. Orin, a partner with Anderson Kill & Olick, offers advice on how to evaluate health plans and maximize consumer benefits. She adapted this article from a chapter in her book.

A few years ago, a friend of mine was struggling with infertility problems. She and her husband had attempted a number of infertility treatments, without success. The next step was in vitro fertilization, but they couldn't afford it and their insurance policy excluded the coverage.

Then they found out about Section 15-810 of the Maryland Insurance Code, which obligated the insurance company to pay for the procedure, regardless of the exclusion written into the policy. They told the insurance company about the law and immediately received approval. Nine months later, their twins were born.

The Maryland law that guarantees coverage for in vitro fertilization is far from unique. All 50 states have "mandatory benefits" laws that force insurance companies and health plans to cover specific illnesses and conditions. These laws apply even when the insurance policies and health plans seem to exclude the mandated coverage.

But these mandates do not apply to everyone. For example, they do not apply to insurance programs run by the federal government, such as Medicare and the Federal Employees Health Benefits Program. They also do not apply to fully self-funded health plans run by employers; those health plans are governed exclusively by a federal law known as the Employees' Retirement Income Security Act (ERISA).

Still, the state mandates affect more than 100 million people at least half of the people in this country who have health coverage. The list of those who are protected includes more than 80 million people who are covered under insurance policies purchased by their employers, more than 15 million people who purchase insurance policies directly and, for many mandates, more than 20 million people on Medicaid.

The state mandates vary wildly. Most states require coverage for common health care procedures, such as screening tests for breast and cervical cancer. Others have mandates that are extremely specialized, like removal of port-wine stain birthmarks (in Minnesota) and attention deficit disorder treatment (in Louisiana and Hawaii). Lists of all current and pending mandates in Maryland, Virginia and the District of Columbia accompany this story.

Maryland is among the nation's leaders in the number of mandates, including some that are pioneering. For example, it was the first state to force health plans to cover 90-day supplies of prescription drugs for chronic conditions such as high blood pressure, rather than the 30-day supplies that the plans prefer. This mandate enabled consumers to avoid monthly trips to the drugstore, which can be a particular inconvenience for elderly people.
Maryland also was the first state to compel health plans to offer coverage for Alzheimer's disease. And its infertility mandate is cutting-edge; not only does Maryland require coverage for in vitro fertilization, but in 2000 it added coverage for treatment of male reproductive abnormalities, such as persistently low sperm counts.

Maryland even mandates coverage for "hair prostheses" toupees. But if you are hirsutely challenged, don't start planning your move to the Free State just yet. Maryland limits the coverage to hair loss that results from chemotherapy or radiation treatments, and caps it at $350. Similarly, conditions apply to virtually all mandates.

Come July, Maryland will join Virginia in mandating coverage for colorectal cancer screening. By fall, like its southern neighbor, it will mandate coverage for morbid obesity.

Virginia is getting close to Maryland in its number of mandates, and it has some interesting ones of its own. Hemophilia care must be covered, along with hospice care and screenings for prostate cancer.

Like Maryland and many other states, Virginia mandates coverage for anesthesia and hospital charges for dental procedures, if the covered person is a young child, requires general anesthesia for dental care treatment or has a severe disability.

The District has relatively few mandates, all of which are available in Maryland and Virginia as well. So, whether you live in Maryland, Virginia or the District, you're entitled to receive: screening tests for breast and cervical cancer; limited coverage for drug and alcohol abuse and mental illness; basic preventive care for children, such as annual doctor's visits; coverage for postpartum care; reconstructive surgery after mastectomies; and diabetes equipment, supplies and self-management training.

Often, the hardest part about using the mandates is finding them. It can be surprisingly difficult to figure out what coverage is guaranteed in your state.
If you know how to do legal research, you can look up the mandates in the law books. Virginia's are available on the Internet.

That is not the case, though, in Maryland or the District of Columbia.
You also can try calling the insurance regulators of these jurisdictions and asking for help in figuring out the mandates. I've made such requests, with varying success. The offices in Maryland and Virginia were very helpful. They both offered to investigate my situation and determine if there is a mandate that applies. The insurance commissioner's office in the District, however, did not respond to my request.

You also may receive assistance from the many consumer groups that help patients grapple with health care issues. Some organizations even provide legal assistance.

Once you discover that a particular mandate exists, the next question is whether it applies to you. In most cases, the mandates that cover you are only the ones ordered by the state where your employer is located (assuming your employer's health plan is not self-funded, as noted above). Occasionally, though, you'll be covered by a mandate regardless of where your employer is based. The bottom line: Check the law in the state where you live as well as where you work.

To be sure that a mandate applies to you, read it every word. With a careful reading and some further verification from your employer or your insurer, you should be able to tell whether you're protected or not.
Once you find out about a mandate that applies to you, it's easy to get the coverage. All you need to do, in most cases, is call your insurance company, tell them about the mandate and ask for the coverage. I know because I've done it.

When I was pregnant with one of my children, my insurer paid for only 24 hours in the hospital after a birth. At that time, Maryland mandated a 48-hour hospital stay. (A similar law has applied nationwide since 1996.)
When I called my insurer for pre-certification, I asked how much hospital time I was eligible to receive. The customer service representative said 24 hours, which was the time set forth in the plan. I told her I lived in Maryland. She paused, then asked me to wait on hold. After about 10 minutes, she returned with the news that I was approved for 48 hours.

It may take a bit of time and energy to find out about your state's mandates and to enforce the ones that apply to you. But the effort should be worth it. The mandates can save you money. They can improve your health. They can spare you the embarrassment and discomfort of a disfiguring condition. And the right mandate such as cancer screening or participation in clinical trials can even save your life.