Health Plan Regulations

 
 

Benefits Summary Plan Description

Health Plan Regulations

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Health Plan Regulations

The following federally mandated regulations are required of all group health plans and health insurance issuers.

Breast Reconstruction Following a Mastectomy

Federal law requires that group health plans provide coverage for breast reconstruction in connection with mastectomy as follows:

  • Reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  • Prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas.

Hospitalization in Connection with Childbirth

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to:

  • Less than 48 hours following a vaginal delivery; or
  • Less than 96 hours following a Caesarean section; or
  • Require that a provider obtain authorization from the plan or insurance issuer for prescribing a length of stay that falls within that time period.

The law does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours after delivery, as applicable.