Health Laws That Can Save You Money - Or Your Life
By: Rhonda D. Orin
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
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
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
That is not the case, though, in Maryland or the District of Columbia.
You also may receive assistance from the many consumer groups that help
patients grapple with health care issues. Some organizations even provide
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.
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.)
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.