Health and Welfare Summary Plan Description

 
  • Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.11 Federal Mandates

  1. Newborn's and Mother's Health Protection Act. The Self-Funded PPO generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child less than 48 hours following a normal delivery, or less than 96 hours following a Cesarean section. Federal law does not, however, prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother and her newborn earlier than the 48 hours, or 96 hours as applicable. In any event, the PPO may not require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

  2. Reconstructive Surgery After Mastectomy. Under the Women's Health and Cancer Rights Act of 1998 ("WHCRA"), when the PPO provides medical and surgical benefits in connection with a mastectomy, the PPO must provide coverage in a manner determined in consultation with the attending Physician and the patient for (i) reconstruction of the breast on which the mastectomy was performed, (ii) surgery and reconstruction on the other breast to produce a symmetrical appearance and (iii) prostheses and physical complications of all stages of mastectomy, including lymphedemas. This coverage is subject to the PPO's annual deductibles and coinsurance provisions.

  3. Other Federal Mandates. In addition to compliance with other federal mandates discussed in this document, and to the extent applicable, the Self-Funded PPO will provide coverage and benefits in accordance with the requirements of the Affordable Care Act, the Genetic Information Nondiscrimination Act of 2008 ("GINA," the provisions of which are explained in a poster titled "Equal Employment Opportunity is the Law" that is posted in your work area), the Mental Health Parity Act ("MHPA"), the Mental Health Parity and Addiction Equity Act ("MHPAEA"), and any other applicable federal law. Both HMOs will similarly comply with these and other federal mandates, and state law requirements, as set forth in the HMO contracts and as required by federal and state law.