The medical treatments and drugs that your health insurance
company must pay for depend a lot on where you live.
Ten states require health insurance plans to cover antipsychotic
drugs. Nine states say health plans must cover bone marrow
transplants. Clinical trials for cancer patients are required
benefits in 29 states.
Those are just a few examples of state health insurance
mandates. As of Dec. 31, 2011, states had enacted 2,262 such laws,
according to the "Health Insurance Mandates in the States 2011"
report by the Council for Affordable Health Insurance (CAHI) in
These mandates apply to both
health insurance for individuals
and fully insured group plans, but not to self-insured group plans.
Most large employers self-insure their plans, which means they pay
their employees' medical claims even though the plan benefits may
be administered by a health insurer. The federal government, not
states, regulates self-insured plans.
Mandates require health insurance companies to cover certain
types of health care providers, such as chiropractors or
dieticians, or particular benefits, such as maternity care or
hormone replacement therapy. In addition, some state health
insurance mandates require health insurance companies to extend
coverage to certain dependents, such as adopted children,
grandchildren or domestic partners.
The mandates vary in scope. One state's mandate to cover
chiropractors might require health plans to pay for a certain
number of visits each year; a mandate in another state might
require insurers to cover chiropractors along the same lines as
they cover physicians, according to the council's report.
Insurance mandates multiply
The number of state health insurance mandates nationwide grew
from only a few in the early 1960s to about 850 in 1992, when the
CAHI began tracking them.
The trend accelerated in the late 1980s and through the 1990s
with the evolution of managed care, says Richard Cauchi, program
director for health at the National Conference of State
Managed care introduced more oversight and tighter controls on
benefits to control costs. Consumer advocates and health care
providers pushed for laws to force health insurance companies to
provide certain types of coverage.
State health insurance mandates continue to increase, but the
rate of growth has slowed, Cauchi says. A few types of
mandates, though, are bucking the trend.
What do you have to buy?
Most common mandates
Mammography screening (50 states)
Maternity minimum stay (50 states)
Breast reconstruction (49 states)
Mental health parity (48 states)
Alcohol and substance abuse (46 states)
Least common mandates
Breast implant removal (1 state)
Cardiovascular disease screening (1 state)
Circumcision (1 state)
Gastric electrical stimulation (1 state)
Organ transplant donor coverage (1 state)
Source: The Council for Affordable Health
State laws requiring health insurance companies to cover
treatment for autism have multiplied in the last few years.
Twenty-nine states have enacted laws requiring health insurance
companies to cover medically necessary treatment for autism,
including applied behavior analysis, according to Autism Speaks, a
national advocacy group for people with autism and their families.
The intensive therapy is based on behavior conditioning techniques
to help children with autism develop communication skills, social
interaction and other skills.
Effective grassroots organizing, compelling statistics and
personal stories have helped Autism Speaks
get autism insurance mandates passed
"We know with early and appropriate intervention, almost 50
percent of children are able to be mainstreamed in school by early
elementary education," says Michael Wasmer, associate director of
state government affairs for Autism Speaks. "Another 40 percent
improve enough to need significantly less special education than
they would have otherwise."
Wasmer was a veterinarian in Kansas when his daughter was
diagnosed on the autism spectrum 10 years ago. As a 3-year-old, she
did not speak and was unresponsive to social interaction. The
family's health plan did not cover behavior therapy. The family
paid $35,000 to $40,000 out of pocket annually for three years to
cover it, he says. His daughter was fully mainstreamed in school in
first grade and now, as a seventh-grader, earns straight As,
participates in school activities and has a circle of friends.
"I saved my local school district the cost of special
education," he says.
Wasmer is among parents who helped get a state health insurance
mandate to cover autism treatment passed in Kansas.
The birth of a health insurance mandate
A variety of factors lead to mandates, says Victoria Craig
Bunce, director of research and policy for the CAHI. Medical
breakthroughs, increasing prevalence of certain conditions, media
attention, lobbying by special interest groups and societal
concerns all play a role.
For instance, a recent advance in cancer treatment allows
chemotherapy to be administered as a liquid, tablet or capsule on
an outpatient basis or at home, instead of at a clinic or hospital.
The new development has led at least 15 states to pass cancer oral
and infusion chemotherapy mandates, Bunce says.
The growing number of patients with diabetes has led to more
diabetes-related mandates. Forty-six states have mandated coverage
for diabetic supplies, and 41 states have passed mandates to cover
help for patients to manage their conditions.
The council is not opposed to mandates in general, but says
legislators should consider the consequences before voting on
Generally mandates increase
premiums because they force insurers to cover costs that patients
had paid out of pocket. Insurance companies then pass on those
costs to consumers. Most mandates raise premiums by a tiny amount,
usually less than 1 percent, Bunce says.
But even small increases add up, Bunce says. "It's that
combination of benefits that adds to the cost of health insurance."
Looking across the country:
- Most states have at least 40 health insurance mandates.
- Rhode Island and Virginia (each with 70) have the most
mandates. Idaho (13) and Alabama (19) have the least number of
- Legislators are paying closer attention to the impact of
mandates on health insurance costs. At least 30 states now
require that a mandate's cost be analyzed before the requirement
is enacted, according to CAHI.
The question of whether to pass a mandate is a tricky balancing
act for legislators, Cauchi says.
"They face a complicated dilemma deciding on one mandate versus
another," he says. "People come to the legislature and bring not
only facts and figures but patients facing the conditions."
What about health care reform?
Starting in 2014, the federal
Patient Protection and Affordable Care Act
will require all health plans sold through state insurance
exchanges to include certain essential health benefits. That,
of course, is assuming the health care reform law remains intact.
Twenty-six states and other groups have challenged portions of the
law's constitutionality. The U.S. Supreme Court heard arguments in
April and is expected to rule in June.
The health insurance exchanges will serve as marketplaces where
individuals and small groups can buy policies. States will have
some flexibility in folding in their own mandates to health
insurance plans, according to the U.S. Department of Health and