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Employee Health Plan Compliance

Most of these laws require notices and disclosures.  Please consult the specific regulations for more information:

The Consolidated Omnibus Budget Reconciliation Act (COBRA) may allow an employee to temporarily keep health coverage after their employment ends, they lose coverage as a dependent of the covered employee, or another qualifying event. If the employee elects COBRA coverage, they will pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.

The Employment Retirement Income Security Act (ERISA) sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.

ERISA requires plans to provide participants with plan information, including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.

The Family and Medical Leave Act (FMLA) applies to private-sector employers with 50 or more employees in 20 or more workweeks in the current or preceding calendar year, as well as to public agencies and public and private elementary and secondary schools.

Eligible employees are entitled to job-protected leave for certain family and medical reasons. An employer must maintain group health coverage during the FMLA leave at the level and under the conditions that coverage would have been provided if the employee had not taken leave.

Genetic Information Nondiscrimination Act (GINA) prohibits health plans and health insurance issuers from discriminating based on genetic information. GINA generally prohibits group health plans and health insurance issuers from:

  • Adjusting group premium or contribution amounts based on genetic information.
  • Requesting or requiring an individual or an individual’s family members to undergo a genetic test; and
  • Collecting genetic information, either for underwriting purposes or prior to or in connection with enrollment.

Health Insurance Portability and Accountability Act (HIPPA) portability rules that apply to group health plans and health insurance issuers that allow a covered person to maintain certain benefits when switching employers or leaving the workforce. Certain benefits are not subject to the portability requirements, such as coverage for accidents, disability, liability, and workers’ compensation and limited-scope benefits (for example, limited-scope dental and vision benefits.

HIPPA Privacy and Security applies to health plans, health care clearinghouses, and health care providers that transmit health information electronically (covered entities) unless an exception exists. The rules also apply to business associates (service providers to covered entities) that use protected health information (PHI). A self-funded health plan with fewer than 50 participants that is administered by the employer that established and maintains the plan is exempt.

Children’s Health Insurance Program Reauthorization Act (CHIPRA) If an employer’s group health plan covers residents in a state that provides a premium subsidy to low-income children and their families, the employer must send an annual notice about the available assistance to all employees residing in the state.

Medicare Part D Disclosures Employer-sponsored health plans offering prescription drug coverage to individuals who are eligible for coverage under Medicare Part D must comply with requirements on disclosure of creditable coverage.

The Mental Health Parity and Addiction Equity Act (MHPAEA) imposes parity requirements on group health plans that provide benefits for mental health or substance use disorder benefits. For example, plans must offer the same access to care and patient costs for mental health and substance use disorder benefits as those that apply to general medical or surgical benefits.

The MHPAEA applies to group health plans offering mental health and substance use disorder benefits. There are some exceptions.

Michelle’s Law ensures that dependent students who take a medically necessary leave of absence do not lose health insurance coverage. Michelle’s Law applies to employer-sponsored group health plans that condition dependent eligibility on student status. With the inception of the ACA, this law has limited applicability.

The Newborns’ and Mothers’ Health Protection Act (NMHPA) applies to group health plans that provide maternity or newborn infant coverage. Under the NMHPA, group health plans may not restrict mothers’ and newborns’ benefits for hospital stays to less than 48 hours following a vaginal delivery and 96 hours following a delivery by cesarean section.

The Women’s Health and Cancer Rights Act (WHCRA) applies minimum requirements to group health plans that provide coverage for mastectomy benefits and certain post-mastectomy benefits, including reconstructive surgery.

If you need help understanding, complying, or getting helpful information about these laws, please contact us.

Copyright © 2020 Smarts Publishing

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