Covers Labor Compliance 2014mx.pdf 1 11/19/2014 2:05:01 PM .
covers Labor Compliance 2014mx.pdf 1 11/19/2014 2:05:01 PMCompliance Assistance GuideHealth Benefits CoverageUnder Federal Law.The Affordable Care ActHealth Insurance Portabilityand Accountability ActCGenetic Information Nondiscrimination ActMYCMMental Health Parity ProvisionsMYCYCMYKNewborns' and Mothers'Health Protection ActWomen's Healthand Cancer Rights ActNovember 2014Employee Benefits Security AdministrationU.S. Department of Labor
Compliance Assistance GuideHealth Benefits CoverageUnder Federal Law.The Affordable Care ActThis publication has been developed by theU.S. Department of Labor, Employee BenefitsSecurity Administration (EBSA). To view this andother EBSA publications, visit the agency’s Website atdol.gov/ebsa.To order publications or to request assistance from abenefits advisor, contact us electronically ataskebsa.dol.gov.Or call toll free 1-866-444-3272.This material is available in alternative format topersons with disabilities upon request:Voice phone: (202) 693-8664TDD: (202) 501-3911Health Insurance Portabilityand Accountability Act of 1996Genetic Information Nondiscrimination ActMental Health Parity ProvisionsNewborns' and Mothers'Health Protection Act of 1996Women's Healthand Cancer Rights Act of 1998This publication constitutes a small entitycompliance guide for purposes of theSmall Business Regulatory EnforcementFairness Act of 1996.Employee Benefits Security AdministrationU.S. Department of Labor
covers Labor Compliance 2014mx.pdf 2 11/19/2014 2:05:11 PMCompliance Assistance GuideHealth Benefits CoverageUnder Federal Law.The Affordable Care ActCMYCMThis publication has been developed by theU.S. Department of Labor, Employee BenefitsSecurity Administration (EBSA). To view this andother EBSA publications, visit the agency’s Website atdol.gov/ebsa.To order publications or to request assistance from abenefits advisor, contact us electronically ataskebsa.dol.gov.Or call toll free 1-866-444-3272.MYCYCMYKThis material is available in alternative format topersons with disabilities upon request:Voice phone: (202) 693-8664TDD: (202) 501-3911Health Insurance Portabilityand Accountability ActGenetic Information Nondiscrimination ActMental Health Parity ProvisionsNewborns' and Mothers'Health Protection ActWomen's Healthand Cancer Rights ActThis publication constitutes a small entitycompliance guide for purposes of theSmall Business Regulatory EnforcementFairness Act of 1996.Employee Benefits Security AdministrationU.S. Department of Labor
Table of ContentsIntroduction.5The Affordable Care Act.9HIPAA Portability Provisions.17Special Enrollment.19Nondiscrimination Requirements.23HIPAA and the Affordable Care Act WellnessProgram Requirements.27The Genetic Information Nondiscrimination Act.33Mental Health Parity Provisions.41The Newborns’ and Mothers’ Health Protection Act.49The Women’s Health and Cancer Rights Act.53Applying and Enforcing Laws in Part 7 of ERISA.57AppendicesAppendix A: Self-Compliance Tools.61Appendix B: Chart of Required Notices.131Appendix C: Model Notices.137
IntroductionHealth Benefits Coverage Under Federal Law addresses the following laws thatcan affect the health benefits coverage provided by group health plans: The Patient Protection and Affordable Care Act (Affordable Care Act)The Health Insurance Portability and Accountability Act of 1996 (HIPAA)(portability and nondiscrimination provisions only)The Mental Health Parity and Addiction Equity Act (MHPAEA) and theMental Health Parity Act (MHPA) (Mental Health Parity Provisions)The Newborns’ and Mothers’ Health Protection Act of 1996 (theNewborns’ Act) The Women’s Health and Cancer Rights Act of 1998 (WHCRA) The Genetic Information Nondiscrimination Act of 2008 (GINA)These health care laws are included in Part 7 of Title I of the EmployeeRetirement Income Security Act of 1974 (Part 7 of ERISA). Also discussedin this booklet are provisions of the Children’s Health Insurance ProgramReauthorization Act (CHIPRA) related to special enrollment rights, which areincluded as part of the HIPAA Special Enrollment section on page 19.The rules described in the following pages generally apply to group healthplans and group health insurance issuers (i.e., insurance companies). Referencesin this booklet are generally limited to “group health plans” or “plans” forconvenience. In addition, the booklet will help employers, plan sponsors, planadministrators, third-party administrators, and other service providers to complywith Part 7 of ERISA.The requirements under Part 7 of ERISA generally apply to group healthplans with two or more participants who are current employees. 1 However, ifthe coverage is insured, parallel provisions in the Public Health Service Act applyto health insurance coverage offered in connection with group health plans withas few as one employee who is a current participant under the plan. In addition,The Mental Health Parity and Addiction Equity Act as included in Part 7 of ERISA exemptsgroup health plans of a small employer with 50 or fewer employees from its requirements.However, insured group health plans in the small group market are required to comply with therequirements of the Act in order to satisfy the essential health benefits requirements under theAffordable Care Act.15
the requirements of Part 7 of ERISA do not apply to excepted benefits, such ascertain dental and vision coverage*.The laws contained in Part 7 of ERISA (which is administered by the U.S.Department of Labor) generally also appear in the Internal Revenue Code(the Code), and the Public Health Service Act (PHSA). The Department of theTreasury and the Internal Revenue Service administer the requirements underthe Code, and the U.S. Department of Health and Human Services (HHS)administers the requirements under the PHSA.For ease of use, Health Benefits Coverage Under Federal Law is divided intofour sections: The first section includes general descriptions of the health care lawsmentioned above and frequently asked questions.Following are self-compliance tools that can help to determine a plan’scompliance with these laws. They include compliance tips that relate tosome common mistakes. (Note: please check the Website at dol.gov/ebsa/healthlawschecksheets.html for updates to the self-compliance tools.)Next, a chart summarizes the notices a plan must provide.Finally, the last section includes model notices providing language thatmay be used to comply with the various notice requirements.While the booklet does not cover all the specifics of these laws, it does assistthose involved in operating a group health plan to understand the laws andrelated responsibilities. It provides an informal explanation of the statutes andthe most recent regulations and interpretations. The information is presentedas general guidance, however, and should not be considered legal advice. Inaddition, some of the provisions discussed involve issues for which the ruleshave not yet been finalized as of the date of publication of this booklet. Theproposed rules are noted. Periodically check the Department of Labor’s Website(dol.gov/ebsa) under “Laws & Regulations” for publication of final rules.*See the Applying and Enforcing Laws in Part 7 of ERISA Section at page 57 of the Guide for a further discussion.6
Some general notes: As discussed later, States can change some of these Federal rules ifthe State law is more protective of individuals (i.e., imposes stricterobligations on health insurance issuers).If the plan provides benefits through an insurance policy or healthmaintenance organization (HMO), you also may contact your State’sinsurance department. Visit the National Association of InsuranceCommissioners’ Website at naic.org for contact information.If you have questions not specifically addressed in this booklet, pleasecontact the Employee Benefits Security Administration (EBSA) regionaloffice nearest you. A list of these offices is on the agency’s Website at dol.gov/ebsa (view “About EBSA”). Or you may contact EBSA electronicallyat askebsa.dol.gov or call toll free 1-866-444-3272.7
The Affordable Care ActThe Patient Protection and Affordable Care Act (Affordable Care Act) wassigned into law on March 23, 2010. The Affordable Care Act added certain marketreform provisions to ERISA, making those provisions applicable to employment-basedgroup health plans. These provisions provide additional protections for benefits underemployment-based group health plans. They include extending dependent coverage to age26; prohibiting preexisting condition exclusions for all individuals and prohibiting theimposition of lifetime and annual limits on essential health benefits. As of 2014, most ofthe Affordable Care Act protections are now in effect. The Departments of Labor, Healthand Human Services, and the Treasury (Departments) were tasked with issuing guidancefor the market reform provisions. The Departments continue to work with employers,issuers, States, providers and other stakeholders to help them come into compliance withthe law and are working with families and individuals to help them understand the lawand benefit from it, as intended.Under the Affordable Care Act, plans can make some routine changes and generallykeep the coverage under their plan the same as it was on March 23, 2010. Thesegrandfathered health plans are required to comply with some but not all of the marketreform provisions under ERISA.What is grandfathered status and how does a grandfathered planlose its status?Generally, grandfathered plans are plans that were in existence, and in whichat least one individual was enrolled, on March 23, 2010. Grandfathered healthplans are exempt from many but not all Affordable Care Act market reforms.Grandfathered plans lose their status if the plan makes one of the following sixchanges:1) Elimination of all or substantially all benefits to diagnose or treat aparticular condition.2) Increase in a percentage cost-sharing requirement (e.g., raising anindividual’s coinsurance requirement from 20% to 25%).3) Increase in a deductible or out-of-pocket maximum by an amount thatexceeds medical inflation plus 15 percentage points.4) Increase in a copayment by an amount that exceeds medical inflationplus 15 percentage points (or, if greater, 5 plus medical inflation).5) Decrease in an employer’s contribution rate towards the cost of coverageby more than 5 percentage points.9
6) Imposition of annual limits on the dollar value of all benefits belowspecified amounts.Additionally, plans must include a statement in any plan materials providedto a participant or beneficiary describing the benefits provided under the plan,that the plan or coverage believes it is a grandfathered health plan and it mustprovide contact information for questions and complaints.Which provisions of the Affordable Care Act apply to a grandfatheredhealth plan?Grandfathered health plans are exempt from many, but not all Affordable CareAct market reforms. Some of the new provisions applicable to grandfatheredplans include: prohibition on preexisting condition exclusions prohibition on excessive waiting periods prohibition on lifetime/restricted annual limits prohibition on rescissions extension of dependent coverage summary of benefits and coverage and uniform glossarySome of the new provisions not applicable to grandfathered plans include: coverage of preventive services internal claims and appeals and external review patient protectionsWhen do the provisions in the Affordable Care Act becomeapplicable?The following provisions became effective for plan years beginning on or afterSeptember 23, 2010. prohibition on preexisting condition exclusions - only for individualsunder age 1910
prohibition on lifetime limits (and restrictions on annual limits) prohibition on rescissions coverage of preventive services extension of dependent coverage internal claims and appeals and external review patient protectionsThe Summary of Benefits and Coverage and Uniform Glossary requirementbecame effective as of September 23, 2012.Other provisions became effective for plan years beginning on or after January 1,2014. prohibition on preexisting condition exclusions - for all individuals wellness programs prohibition on excessive waiting periods prohibition on annual limitsCan plans require dependent children to be full-time students inorder to receive coverage to the age of 26?No. Plans that offer dependent coverage for children are required to make thecoverage available until a child reaches the age of 26. Plans and issuers that offerdependent coverage of children must offer coverage to enrollees’ adult childrenuntil age 26, even if the young adult no longer lives with his or her parents, is nota dependent on a parent’s tax return, or is no longer a student. This provisionapplies to all group health plans regardless of grandfather status and becameeffective for plan years beginning on or after September 23, 2010.Can plans impose preexisting condition exclusions on newenrollees?No. Group health plans are prohibited from imposing any preexisting conditionexclusion. This prohibition generally is effective for plan years beginning onor after January 1, 2014, but for enrollees who are under 19 years of age, thisprohibition became effective for plan years beginning on or after September 23,2010. This provision applies to all group health plans regardless of grandfatheredstatus.11
Can plans place lifetime or annual limits on the dollar value ofessential health benefits?Generally group health plans are prohibited from offering coverage thatestablishes any lifetime or annual limits on the dollar value of essential healthbenefits. This prohibition became effective for plan years beginning on or afterSeptember 23, 2010 for lifetime limits and January 1, 2014 for annual limits.For more information regarding what benefits are considered essential healthbenefits, visit HealthCare.gov. This provision applies to all group health plansregardless of grandfathered status.Are plans prohibited from rescinding group health plan coverage?In general, a rescission is a retroactive cancellation of coverage. A group healthplan or a health insurance issuer can only rescind coverage in the case of fraudor an intentional misrepresentation of a material fact, regardless of whether thecoverage is insured or self-insured, or whether the rescission applies to an entiregroup or only to an individual within the group. Plans and issuers must provideat least 30 days advance written notice to each participant who would be affectedby the rescission. The prohibition against rescissions became applicable for planyears beginning on or after September 23, 2010 and applies to all group healthplans regardless of grandfathered status.Are plans required to provide preventive services?Group health plans must provide benefits for certain recommended preventiveservices and generally may not impose any cost-sharing for such services. Therecommended services, including immunizations and colonoscopies, are setforth by the United States Preventive Services Task Force (USPSTF), the HealthResources and Services Administration (HRSA) and the Advisory Committeeon Immunization Practices (ACIP) of the Centers for Disease Control andPrevention. A complete list of recommendations and guidelines that specifythe services that are required to be covered can be found at HealthCare.gov/center/regulations/prevention.html. The preventive services provision becameapplicable for plan years beginning on or after September 23, 2010, and does notapply to grandfathered plans.My plan requires participants to designate, among others, aprimary care provider. Is my plan required to comply with certainrequirements related to this designation?If a group health plan requires the participant to choose a participating primarycare provider, the plan or issuer must allow the participant to choose anyparticipating primary care provider who is available to accept the participant.With respect to a child, the plan or issuer must allow the designation of a12
pediatrician as a child’s primary care provider if the provider participates in thenetwork of the plan or issuer. Furthermore, plans or issuers may not requireauthorization or referral for a female participant who seeks coverage for OB/GYN care provided by an OB/GYN specialist. The plan must provide a noticeinforming the participants of the terms of the plan or health insurance coverageregarding designation of a primary care provider. This provision becameapplicable for plan years beginning on or after September 23, 2010, and does notapply to grandfathered health plans.Can plans continue to limit payments for out-of-network emergencyroom services?A group health plan that provides emergency services benefits must coveremergency services without preauthorization, even if the hospital or provideris out-of-network. If the emergency services are provided out-of-network,special rules related to cost-sharing requirements apply. Copayment amountor coinsurance rates cannot exceed the cost-sharing requirements that would beimposed if the services were provided in-network. Additionally, any other costsharing requirement, such as a deductible or out-of-pocket maximum, can onlybe imposed with respect to out-of-network emergency services if the cost-sharingrequirement generally applies to out-of-network benefits. This provision becameapplicable for plan years beginning on or after September 23, 2010, and does notapply to grandfathered health plans.Are all employment-based wellness programs subject to AffordableCare Act requirements?No. Many employers offer a wide range of programs to promote health andprevent disease. For example, some employers may choose to provide orsubsidize healthier food choices in the employee cafeteria, provide pedometersto encourage employee walking and exercise, pay for gym memberships, or bansmoking on employer facilities and campuses. A wellness program is subject tothe Affordable Care Act and HIPAA nondiscrimination rules only if it is, or ispart of, a group health plan. If an employer operates a wellness program separatefrom its group health plan(s), the program may be subject to other Federalor State nondiscrimination laws, but it is generally not subject to the HIPAAnondiscrimination regulations.For a detailed discussion of the Affordable Care Act and HIPAAnondiscrimination requirements that may apply to wellness programs offeredin connection with employment-based group health plan coverage, see page 27.These provisions apply to both grandfathered and non-grandfathered plans andbecame applicable for plan years beginning on or after January 1, 2014.13
What requirements apply under the Affordable Care Act regardingthe claims and appeals processes that must be made available undera group health plan?All group health plans must maintain internal claims and appeals processes setforth in the Department of Labor Claims Procedure rules. Additional protectionswere added to ensure that participants have access to an effective appealsprocess. The scope of adverse benefit determinations eligible for internal claimsand appeals now includes a rescission of coverage. If an initial adverse benefitdete
The Affordable Care Act The Patient Protection and Affordable Care Act (Affordable Care Act) was signed into law on March 23, 2010. The Affordable Care Act added certain market reform provisions to ERISA, making those provisions applicable to employment-based group health plans. These provisions provide additional protections for benefits under
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Page 1 of 9 Rapid Regulatory Courses in HealthStream Getting Started Tip Sheet Please note: Everyone is required to take two compliance trainings titled: Rapid Regulatory Compliance: Non-clinical I Rapid Regulatory Compliance: Non-clinical II Depending on your position at CHA, you may have more courses on your list. One must complete them all.File Size: 1MBPage Count: 9Explore furtherRapid Regulatory Compliance: Clinical II - KnowledgeQ .quizlet.comRapid Regulatory Compliance: Clinical I - An HCCS .quizlet.comRapid Regulatory Compliance: Non-clinical II-KnowledgeQ .quizlet.comThe Provider Compliance Tip fact sheets are now available .www.cms.govRapid Regulatory Compliance - Non-Clinical - Part Istudyres.comRecommended to you b
The three major labor relations statutes in the United States are the Railway Labor Act, the National Labor Relations Act, and the Federal Service Labor-Management Relations Statute. Each law governs a distinct population of the U.S. workforce. The Railway Labor Act (RLA) was enacted in 1926, and its coverage extends to railway and
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