||Plans that provide inpatient hospital coverage for sickness must cover inpatient treatment of alcoholism.
|Amino acid-based elemental formulas
||Plans must cover amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of:
• Eosinophilic disorders; and
• Short bowel syndrome.
This mandate applies when the prescribing physician has issued a written order stating that an amino acid-based elemental formula is medically necessary.
|Autism spectrum disorders
||Plans must provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals under age 21, subject to an inflation-adjusted maximum benefit of $36,000 per year. This coverage may not be subject to any limits on the number of visits to a service provider, and dollar limits and cost-sharing provisions may not be less favorable than those that apply to physical illness generally.
||Plans that cover miscellaneous hospital expenses must cover the processing and administration of blood and its components.
|Breast cancer pain
||Plans must cover all medically necessary pain medication and therapy related to the treatment of breast cancer on the same terms and conditions that are generally applicable to coverage for other conditions.
||Plans must cover clinical breast examinations as follows:
• At least every three years for women between ages 20 and 40; and
• Annually for women age 40 or older.
|Breast implant removal
||Plans must cover the removal of breast implants when the removal is medically necessary for the treatment of a sickness or injury. This mandate does not apply to implants inserted solely for cosmetic reasons, except for cosmetic surgery performed as reconstruction resulting from sickness or injury.
|Cancer treatment – prescription drugs (off-label drug use)
||Plans that cover prescription drugs approved by the federal Food and Drug Administration (FDA) for the treatment of certain types of cancer may not exclude any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the FDA. The drug, however, must be FDA-approved and must be recognized for the treatment of the specific type of cancer for which it has been prescribed. This coverage must also include medically necessary services associated with the administration of a drug.
|Cancer trials – routine patient care
||Plans must cover any routine patient care administered to an insured who is a qualified individual participating in a qualified clinical cancer trial, if the plan covers that same routine patient care for insureds who are not enrolled in a qualified clinical cancer trial. This coverage may be subject to all terms, conditions, restrictions, exclusions and limitations that apply to the same routine patient care received outside of a qualified clinical cancer trial. An insured individual’s out-of-pocket liability for these benefits may not be greater than they would be had the insured not enrolled in a qualified clinical cancer trial.
|Colorectal cancer screenings
||Plans must cover all colorectal cancer examinations and laboratory tests for colorectal cancer as prescribed by a physician, in accordance with certain guidelines. Plans may not impose any waiting period or cost-sharing requirement that is greater than that imposed on other coverage under the plan.
||Plans must cover all of the following without cost-sharing:
• Contraceptive drugs, devices and other products approved by the FDA, including those available over-the-counter (but excluding male condoms);
• Voluntary sterilization procedures;
• Contraceptive services, patient education and counseling on contraception; and
• Follow-up services related to the covered contraceptive drugs, devices, products and procedures.
|Criminal sexual assault
||Plans may not exclude coverage for examination and testing of a victim of a criminal sexual assault.
|Dental adjunctive services
||Plans must cover anesthesia and other charges incurred in conjunction with dental care that is provided in a hospital or an ambulatory surgical treatment center to:
• A child age six or under;
• A person with a medical condition that requires hospitalization or general anesthesia for dental care; or
• A disabled individual.
Plans must also cover anesthetics and other charges incurred in conjunction with dental care provided by a dentist to a covered individual in a dental office, oral surgeon’s office, hospital, or ambulatory surgical treatment center if the individual is under age 19 and has been diagnosed with an autism spectrum disorder or a developmental disability.
This coverage may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the plan. This mandate does not require coverage of dental services.
||Plans may not contain any exception or exclusion of benefits solely because the mother of the insured has taken DES.
|Diabetes self-management, equipment, supplies, etc.
||Plans must cover outpatient self-management training, equipment and supplies for the treatment of Type 1 diabetes, Type 2 diabetes and gestational diabetes mellitus. This coverage must include regular foot care exams by a physician, along with the following, when they are medically necessary and prescribed by a physician:
• Blood glucose monitors, including blood glucose monitors for the legally blind;
• Cartridges for the legally blind; and
• Lancets and lancing devices.
Cost-sharing for these benefits must be the same as those that apply for other services provided by the same type of provider.
Plans that provide a drug benefit must also cover the following, which must be subject to the same cost-sharing provisions as other covered drugs:
• Syringes and needles;
• Test strips for glucose monitors;
• FDA-approved oral agents used to control blood sugar; and
• Glucagon emergency kits.
Finally, coverage for diabetes self-management training may be limited to the following:
• Three medically necessary visits to a qualified provider upon initial diabetes diagnosis; and
• Two medically necessary visits to a qualified provider when a significant change in the patient’s symptoms or medical condition has occurred.
|Emergency coverage – under the influence
||Plans may not, solely on the basis of the insured being intoxicated or under the influence of a narcotic, exclude coverage for any emergency or other medical, hospital or surgical expenses incurred as a result of (or related to) an injury acquired while the insured was intoxicated or under the influence of any narcotic, regardless of whether the intoxicant or narcotic is administered on the advice of a health care practitioner. Coverage for these services may be subject to cost-sharing and limits that are consistent with those applicable to other similar coverage under the plan.
|Fertility preservation services
||Effective Jan. 1, 2019, plans must cover medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee. Iatrogenic infertility means in impairment of fertility by surgery, radiation, chemotherapy or other medical treatment affecting reproductive organs or processes.
|Fibrocystic breast condition
||Plans may not contain any exception or exclusion of benefits solely because the insured has been diagnosed as having a fibrocystic breast condition, unless:
• The condition is diagnosed by a breast biopsy that demonstrates an increased disposition to the development of breast cancer; or
• The insured’s medical history confirms a chronic, relapsing, symptomatic breast condition.
|Habilitative services for children
||Plans must cover medically necessary and therapeutic habilitative services for children under age 19 with a congenital, genetic, or early acquired disorder diagnosed by a physician.
|HIV testing (prenatal)
||Plans that provide maternity coverage must cover prenatal HIV testing.
||Plans must cover an FDA-approved human papillomavirus vaccines.
||Plans that cover more than 25 employees and provide pregnancy-related benefits must cover the diagnosis and treatment of infertility, subject to certain conditions. An exception to this mandate is available for religious institutions and organizations.
|Mammography screening/breast ultrasound
||Plans must cover low-dose mammography (including digital mammography) screening for the presence of occult breast cancer as follows:
• A baseline mammogram for women 35 to 39 years of age;
• An annual mammogram for women 40 years of age or older; and
• A mammogram at the age and intervals considered medically necessary by the woman’s health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing or other risk factors; and
• A screening MRI when medically necessary, as determined by a licensed physician.
Plans must also provide coverage for a comprehensive ultrasound screening and MRI if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a licensed physician.
This coverage must be provided at no cost to the insured and may not be applied to an annual or lifetime maximum benefit.
|Mastectomy: breast reconstruction after surgery
||Plans that cover mastectomies must also cover prosthetic devices or reconstructive surgery incident to the mastectomy. Coverage for breast reconstruction must include:
• Reconstruction of the breast upon which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment for physical complications at all stages of mastectomy, including lymphedemas.
This coverage must be subject to the deductible and coinsurance conditions applied to the mastectomy. When a mastectomy is performed and there is no evidence of malignancy, coverage may be limited to the provision of prosthetic devices and reconstructive surgery within two years of the mastectomy.
|Mastectomy – post surgery care
||Plans that provide surgical coverage must cover inpatient services following a mastectomy for a length of time determined by the attending physician to be medically necessary, based on certain protocols and guidelines, and upon evaluation of the patient and the coverage for and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the patient in the first 48 hours after discharge.
|Maternity – post parturition care
||Plans that provide maternity coverage must provide the following amount of inpatient care:
• A minimum of 48 hours after a vaginal delivery for the mother and the newborn; or
• A minimum of 96 hours after a caesarian section delivery for the mother and newborn.
A shorter hospital stay may be provided if the attending physician determines it is appropriate, based on certain guidelines, and depending on the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.
||Plans must offer coverage for reasonable and necessary treatment and services for mental, emotional or nervous disorders or conditions, other than serious mental illnesses, consistent with mental health parity requirements.
|Mental health parity
|Plans that provide coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous or substance use disorders or conditions must provide that:
• The financial requirements and treatment limitations applicable to these benefits are no more restrictive than the predominant financial requirements and treatment limitations applied to substantially all hospital and medical benefits covered by the policy; and
• There are no separate cost-sharing requirements or treatment limitations that are applicable only to these benefits.
This mandate also contains specific parity requirements for aggregate lifetime limits and annual limits and must be interpreted in a manner consistent with federal regulations issued under the federal Mental Health Parity and Addiction Equity Act of 2008.
|Mental health – serious mental illness
||Plans must cover treatment of serious mental illness and substance use disorders, consistent with mental health parity requirements.
This mandate does not apply to small employers. A “small employer” is one that employed an average of 50 or fewer employees during the preceding calendar year.
This mandate requires coverage based on medical necessity and consistent with the mental health parity requirements, provided coverage for each calendar year may not be less than the following:
• 45 days of inpatient treatment, including substance use disorder treatment in a licensed residential treatment center;
• 60 visits for outpatient treatment including group and individual outpatient treatment;
• 20 additional outpatient visits for speech therapy for treatment of pervasive developmental disorders.
Plans may not include a lifetime limit on the number of days of covered inpatient treatment or the number of covered outpatient visits.
|Multiple Sclerosis – preventative physical therapy
||Plans must cover medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis, if prescribed by a physician and if the therapy includes reasonably defined goals. This coverage must be subject to the same deductible, coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum or other limitations as those that apply to other physical or rehabilitative therapy benefits.
||Plans may not deny reimbursement for an otherwise covered expense incurred for any organ transplantation procedure solely because the procedure is experimental or investigational.
|Organ transplants – immunosuppressive drugs
||When a prescribing physician has indicated “may not substitute” on a prescription, a plan that covers drugs may not require or cause a pharmacist to interchange another immunosuppressant drug or formulation issued to inhibit or prevent the activity of the immune system of a patient to prevent the rejection of transplanted organs and tissues, without notification and the documented consent of the prescribing physician and the patient, or the parent or guardian if the patient is a child, or the spouse of a patient who is authorized to consent to the treatment of the person.
|Osteoporosis & bone mass measurement
||Plans must cover medically necessary bone mass measurement and the diagnosis and treatment of osteoporosis on the same terms and conditions that generally apply to coverage for other medical conditions.
|Ovarian cancer screening
||Plans must cover surveillance tests for ovarian cancer for female insureds who are at risk for ovarian cancer.
||Plans must cover an annual cervical smear or Pap smear test for female insureds.
|Pediatric autoimmune neuropsychiatric disorders
||Plans must cover treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome.
||Plans that cover prescription drugs must cover prescription inhalants for persons with asthma or other life-threatening bronchial ailments, as often as needed, if medically appropriate and prescribed by the treating physician. Restrictions on refill limits may not apply to these drugs.
|Prostate specific antigen testing
||Plans must cover an annual digital rectal examination and a prostate-specific antigen test for male insureds upon the recommendation of a physician for:
• Asymptomatic men age 50 and over;
• African American men age 40 and over; and
• Men age 40 and over with a family history of prostate cancer.
|Prosthetic and orthotic devices
||Plans must cover prosthetic and orthotic devices, subject to the plans’ other general exclusions, limitations and financial requirements, under terms and conditions that are no less favorable than those that apply to substantially all medical and surgical benefits under the plan. Repairs and replacements of prosthetic and orthotic devices must also be covered, subject to the copayments and deductibles, unless necessitated by misuse or loss.
||Plans must cover an FDA-approved shingles vaccine when ordered by a physician for an enrollee who is 60 years of age or older.
||Plans that cover telehealth services may not require:
• That in-person contact occur between a health care provider and a patient;
• The health care provider to document a barrier to an in-person consultation for coverage of services to be provided through telehealth;
• The use of telehealth when the health care provider has determined that it is not appropriate; or
• The use of telehealth when a patient chooses an in-person consultation.
Cost-sharing applicable to services provided through telehealth may not exceed the cost-sharing required for the same services provided through in-person consultation.
|Temporomandibular joint disorder (TMJ)
||Plans must offer coverage for the treatment of TMJ and craniomandibular disorder. The maximum lifetime benefit for these services may be limited to no less than $2,500.