Federal mandated benefits

Benefit

Description

How WA law differs

Applies to employer health plans with 20 or more employees. It protects covered employees and their covered dependents who would otherwise lose coverage as the result of a qualifying event by allowing them to continue coverage for a maximum of 18 to 36 months.

Group policies must
offer the contract holder
the option of permitting
persons covered under the
plan, who become ineligible
for coverage, the option to
continue the plan for a period
of time at an agreed upon charge.

Group health plans must cover adopted children under the same terms and conditions that apply to natural children, regardless of whether the adoption has become final.

All individual and group
plans must cover adoptive
children on the same basis as
other dependents.

If a large group plan covers mental health and substance abuse disorders, the coverage must be the same as for other medical and surgical services.

All plans must cover mental
health benefits at the same level they cover medical and surgical services.

Large group plans also must
cover substance abuse
benefits at the same level they cover medical and surgical services.

Group health plans cannot restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a vaginal delivery, to less than 48 hours, or following cesarean section, to less than 96 hours.

Also, they cannot require a provider get prior approval for authorizing the minimum stay for the mother or newborn.

All plans that provide
coverage for maternity
services must permit an
attending provider and
mother to decide on the
length of stay.

Also, plans cannot deny covered follow-up care, if ordered by the mother's provider.

Group health plans must provide coverage for individuals who've had a mastectomy and who elect breast reconstruction with coverage for:

• All stages of reconstruction of the breast on which a mastectomy has been performed

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

• Prostheses and physical complications of mastectomy, including lymphedemas

All individual and group
health plans must provide
coverage for reconstructive
breast surgery resulting from
a mastectomy and coverage
for all stages of reconstructive
breast reduction on the
nondiseased breast to make
it equal in size with the
diseased breast.

Disabled and nondisabled individuals must be provided benefits on the same terms with regard to premiums, deductibles, caps on coverage, and waiting periods.

No state mandate

Requires an employer to maintain group health plan coverage for the duration of a FMLA leave at the level and under the conditions that coverage would have been provided if the employee had continued in employment for the duration of the FMLA leave.

No state mandate

Requires group healths plan subject to ERISA to comply with judgments, decrees, or orders that require a group health plan to provide coverage to a participant's child and meet other specific requirements.

No state mandate

ERISA group health plans and group health plans of state and local governmental employers may not reduce their coverage of the costs of pediatric vaccines below the coverage that was provided as of May 1, 1993.

No state mandate

Gives an employee the right to continue the employer's health plans while absent from work due to service in the
uniformed services. This applies to covered dependents.

Provides for immediate reinstatement in an employer's health plan if coverage was terminated as a result of uniformed services and the employee is reemployed following the completion of the service.

No state mandate

Group Health plans maintained by employers who have 15 or more employees must provide the same level of coverage for pregnancy as for other conditions, including but not limited to the same deductibles and co-insurance payments.

Benefits for pregnancy may not be more or less comprehensive than benefits provided for any other covered condition.

No state mandate. But,
see prenatal diagnosis of
congenital disorders.

Plans may not establish lifetime limits on the dollar value of essential benefits. Plans may only establish restricted limits prior to January 1, 2012 on essential benefits as determined by the Secretary of HHS.

Annual limits on essential benefits are limited to:

• $750,000 for plan years beginning 9/23/2010-9/23/2011

• $1.25 million for plan years beginning 9/23/2011-9/23/2012

• $2 million for plan years beginning 9/23/2012-12/31/2013

No State Mandate

Plans must provide coverage without cost-sharing for:

• Services recommended by the US Preventive Services Task Force

• Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC

• Preventive care and screening for infants, children and adolescents supported by the Health Resource and Services Administration

• Preventive care and screenings for women supported by the Health Resource and Services Administration

No State Mandate

Plans that provide dependent coverage must extend coverage to adult children up to age 26.

Effective July 22, 2011 individual and group health plans must offer to cover unmarried dependents up to age 26

Coverage may be rescinded only for fraud or intentional misrepresentation of material fact as prohibited by the terms of the coverage.

Prior notification must be made to policyholders prior to cancellation.

Health carriers can cancel or non-renew covered persons coming fraudulent acts or who materially breach the health plan

Plans may not impose any exclusion of benefits (including a denial of coverage) limit coverage based upon a preexisting condition, for an individual under age 19.

No state mandate