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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

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1988 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for:  

  • All states of reconstruction of the breast on which the mastectomy was performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance;  
  • Prosthesis; and
  • Treatment of physical complications of all stages of mastectomy, including lymphedemas

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.  Please consult your group health benefits booklet for additional information.  If you would like more information on WHCRA benefits, please call your plan administrator, at the contact information listed at the back of this SPD.

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 not in excess of 48 hours (or 96 hours)

Federal law generally 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.

Selection of Primary Care Provider

The plan generally allows the designation of a primary care provider.  You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members.  For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the plan administrator for your group medical benefit, as listed at the end of this SPD.

For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization for the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology.  The health care professionals, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.  For a list of participating health care professionals who specialize in obstetrics or gynecology, contract the plan administrator for your group medical benefit, as listed at the end of this SPD.