OTHER HEALTHCARE REGULATIONS

  • Mental Health Parity and Addiction Equity Act

  • Patient Protection and Affordable Care Act

  • Genetic Information Non-Discrimination Act (GINA)

  • Newborns' and Mothers' Health Protection Act

  • Women's Health and Cancer Rights Act

  • Michelle's Law

  • Domestic Partnership Requirements in California

  • Children's Health Insurance Program Reauthorization Act

  • SPD Compliance Issues (Foreign Language Assistance & SPD Electronic Distribution Requirements)

  • Never Events

  • Qualified (Eligible) Medical Expenses

  • Changing Coverage During the Year (Change in Status Events & Special Enrollment Rights)

Please select a topic from the list to the left.

Mental Health Parity and Addiction Equity Act of 2008

Requires full parity between mental health/substance abuse benefits and medical/surgical benefits offered under a group health plan.

  • Financial requirements and treatment exceptions
  • Network requirements
  • Cost sharing
  • Medical necessity

Does not require plans to provide MH/SA benefits; applies to groups over 50.

Note: A health plan may opt-out if it meets the cost exemption in the Act and files necessary paperwork.

View Detailed Information »

Patient Protection and Affordable Care Act:
Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections

Interim final rules with request for comments.

View Detailed Information »

Genetic Information Nondiscrimination Act (GINA)

  • Bans the use of genetic information for health insurance and employment purposes.
  • Prohibits group health plans from discriminating on the basis of genetic information with respect to eligibility, premiums and contributions.

View Detailed Information »

Newborns' and Mothers' Health Protection Act

Medically necessary treatment and services for Pregnancy and Complications of Pregnancy are covered the same as any other illness for the employee and spouse only. In addition, the plan, in compliance with the Newborns' and Mothers' Health Protection Act of 1996, also provides that:

  • Hospital stays will be covered for at least 48 hours following a normal vaginal delivery, or at least 96 hours following a Cesarean section,
  • The attending physician does not need to obtain authorization from the plan to provide the mother and newborn with this length of hospital stay, and
  • Shorter hospital stays are permitted if the attending health care provider, in consultation with the mother, determines that this is the best course of action.

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Women's Health and Cancer Rights Act

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 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and patient for:

  • All stages of reconstruction of the breast on which a mastectomy has been performed,
  • Surgery and reconstruction of the other breast to produce symmetrical appearance,
  • Breast prostheses, and
  • Treatment of physical complications of the mastectomy, including lymph edemas.

These benefits will be provided subject to the same deductible and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like additional information about WHCRA benefits, please contact the Human Resources Department.

Note: This benefit does not include any treatment or Surgery that is considered primarily cosmetic in nature. Breast implants are considered a Covered Expense only when following a Medically Necessary mastectomy. Breast reduction Surgery is not a Covered Expense.

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Michelle's Law

Requires group health plans to continue coverage for dependent college students who take a medically necessary leave of absence for up to one year (without additional costs).

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Domestic Partnership : Registry Requirements in CA

Currently, a couple that wishes to register must meet the following requirements:

  • Both persons have a common residence.
  • Neither person is married to someone else or is a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity.
  • The two persons are not related by blood in a way that would prevent them from being married to each other in California.
  • Both persons are at least 18 years of age.
  • Either of the following:
    1. Both persons are members of the same sex.
    2. The partners are of the opposite sex, one or both of whom is above the age of 62, and one or both of whom meet specified eligibility requirements under the Social Security Act.
  • Both persons are capable of consenting to the domestic partnership.

View Detailed Information »

Children's Health Insurance Program Reauthorization Act of 2009—Special Enrollment Rights

Effective 04/01/09

Group health plans must permit employees and dependents who are "eligible but not enrolled for coverage" under an employer if:

  • The employee's or dependent's Medicaid or CHIP coverage is terminated as a result of loss of eligibility, or
  • The employee or dependent becomes eligible for a Medicaid or CHIP subsidy

Notice of the event is required within 60 days of special enrollment.

Foreign Language Assistance: Notice to Spanish Speaking Plan Participants

If a plan has participants who are literate only in a particular foreign language, the plan administrator may be required to provide a notice written in that language, along with the SPD, stating that assistance in understanding the SPD is available. (The employer need not provide an SPD written in that language.) The notice must include:

  • The plan administrator's phone number, and
  • Information about where and when the assistance will be made available.

The foreign language requirement applies for plans with 100 or more participants if the lesser of 500 participants or 10% of the total number of participants are literate only in a particular language.

SAMPLE: This booklet contains a summary in English of your rights and benefits under the Plan. If you have difficulty understanding any part of this booklet, or if you have any questions regarding your benefits, rights or obligations under the Plan, please contact the Plan Sponsor and/or Contract Administrator at the following telephone numbers for assistance: <List Employer and DHS's Phone Numbers>

SPD Electronic Distribution Rrequirements

Requirements for employees with work-related computer access:

Definition of work-related computer access: The employee has the ability to access documents at any location where they reasonably could be expected to perform employment duties. In addition, access to the employer's electronic information system must be an integral part of their employment duties.

  • Electronic materials must be prepared and elivered in accordance with otherwise applicable requirements (e.g., timing and format requirements for SPDs as outlined under ERISA.)
  • A notice must be provided to each recipient, at the time that the electronic document is furnished, detailing the significance of the document.
  • The notice must advise the participant of their rights to have the opportunity, at their work site, to access documents furnished electronically and to request and receive (free of charge) paper copies of any documents received electronically.
  • The employer must take appropriate measures to ensure the electronic distribution will result in actual receipt of information by the participants (i.e. return-receipt).
  • If the disclosure includes personal information relating to an individual's accounts and benefits, the plan must take reasonable and appropriate steps to safeguard the confidentiality of the information.

Additional requirements for non-employees or employees with non-work related computer access:

  • Affirmative consent for electronic distribution must be obtained from the individual. Before consent can be obtained, a pre-consent statement must be furnished that explains:
    1. The types of documents that will be provided electronically;
    2. The individual's right to withdraw consent at any time without charge;
    3. The procedures for withdrawing consent and updating information (e.g. updating the address for receiving electronic disclosure);
    4. The right to request a paper version and its cost (if any); and
    5. The hardware and software requirements needed to access the electronic document.
  • The regulatioins permit the pre-consent statement to be provided electronically if teh employer has a current and reliable e-mail address.
  • If system hardware or software requirements change, a revised statement must be provided and renewed consent from each individual must be obtained
  • If the documents are to be provided via the Internet, the affirmative consent must be given in a manner that reasonably demonstrates the individual's ability to access the information in electronic form, and the individual must have provided an address for the receipt of electronically distributed documents.
  • The Employer must keep track of individual electronic delivery addresses, individual consents and the actual receipt of e-mailed documents by recipients.
  • Steps 1, 2, 4, and 5 outlined above under requirements for employees with work-related computer access must also be followed.

To use electronic media to distribute plan-related materials, the plan administrator must also inform participants and beneficiaries that they have the right to receive paper copies of each document free of charge.

View Detailed Information »

Never Events

The following list was developed by the Natioinal Quality Forum (NQF). Never events are medical errors that should never happen, but when they do, typically cause serious consequences for the patient. By excluding these events, the plan reduces unnecessary costs and eliminates payment for expenses which should not have been incurred. Never events include:

Surgical Events:

  • Surgery performed on the wrong body part,
  • Surgery performed on the wrong patient,
  • Wrong surgical procedure on a patient,
  • Retention of a foreign object in a patient after surgery or other procedure, or
  • Intraoperative or immediately post-operative death in a normal, healthy patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative).

Product or Device Events:

  • Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility,
  • Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended, or
  • Patient death or serious disability associated with intravascular air embolism that occurs while being care for in a health care facility.

Patient Protection Events:

  • Infant discharged to the wrong person,
  • Patient death or serious disability associated with patient elopement (disappearance) for more than four hours, or
  • Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility.

Care Management Events

  • Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration),
  • Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products,
  • Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a health care facility,
  • Patient death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates,
  • Stage 3 or 4 pressure ulcers acquired after admission to a health care facility, or
  • Patient death or serious disability due to spinal manipulative therapy.

Environmental Events:

  • Patient death or serious disability associated with an electric shock while being cared for in a health care facility,
  • Any incident in which a line disgnated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances,
  • Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility,
  • Patient death associated with a fall while being cared for in a health care facility, or
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.

Criminal Events:

  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider,
  • Abduction of a patient of any age,
  • Sexual assault on a patient within or on the grounds of a health care facility, or
  • Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care facility.

View Detailed Information »

Health Savings Account—Eligible Expenses

The following lists are examples of what medical expenses can/cannot be paid for out of your HSA account. For a complete list and detailed definitions, refer to: IRS Publication 502 »

Qualified Medical Expenses:
CAN be paid out of your HSA account

  • Abortion
  • Acupuncture
  • Alcoholism Treatment
  • Ambulance
  • Artificial Limb/Prosthesis
  • Artificial Teeth
  • Autoette Wheelchair
  • Bandages
  • Breast Reconstruction
  • Birth Control
  • Brailed Books and Magazines
  • Capital Expenses/Home Improvement (special equipment installed in a home to accommodate a disability)
  • Chiropractor
  • Christian Science Practitioner
  • Contact Lenses
  • Crutches
  • Dental Treatment
  • Diagnostic Devices
  • Disabled Dependent Care Expenses
  • Drug Addiction
  • Eye Glasses
  • Eye Surgery
  • Fertility Enhancement
  • Guide Dog or Other Animal
  • Health Institute
  • Health Maintenance Organization (HMO)
  • Hearing Aids
  • Home Care/Nursing Services
  • Hospital Services
  • Insurance Premiums (not paid for on a before-tax basis or by an employer)
  • Laboratory Fees
  • Lead-Based Paint Removal
  • Learning Disabilities/Special Education
  • Legal Fees
  • Lodging/Meals (essential to medical care; not a part of inpatient care)
  • Long-Term Care
  • Medical Services (provided by a physician, surgeon, specialist or other medical practitioner)
  • Medicines
  • Nursing Home
  • Operation/Surgery
  • Optometrist
  • Organ Donors
  • Osteopath
  • Oxygen
  • Psychiatric Care/Psychologist
  • Special Education/Tuition
  • Sterilization
  • Stop-Smoking Programs
  • Telepone Equipment (specialized for hearing impaired, TTY and TDD)
  • Transplants
  • Transportation (essential to medical care)
  • Vasectomy
  • Vision Correction Surgery
  • Weight Loss Program (for a specific disease diagnosed by a physician)
  • Wheelchair
  • Wig
  • X-ray

Non-Qualified Medical Expenses:
CANNOT be paid out of your HSA account

  • Babysitting
  • Childcare
  • Nursing Services (for a normal, healthy baby)
  • Controlled Substances
  • Cosmetic Surgery
  • Dancing Lessons
  • Diaper Service
  • Electrolysis or Hair Removal
  • Flexible Spending Account
  • Funeral Expenses
  • Future Medical Care
  • Hair Transplants
  • Health Club Dues
  • Health Coverage Tax Credit
  • Health Savings Account
  • Household Help
  • Illegal Operations and Treatments
  • Insurance Premiums (paid for on a before-tax basis or by the employer)
  • Maternity Clothes
  • Medical Savings Account
  • Medicines and Drugs From Other Countries
  • Non-prescription Drugs and Medicines (except insulin)
  • Nutritional Supplements
  • Personal Use Items
  • Swimming Lessons
  • Teeth Whitening
  • Veterinary Fees
  • Weight Loss Program (for improvement of appearance, general health, or sense of well-being)

Note: This list is subject to change in accordance with the Patient Protection and Affordable Care Act and Education Reconciliation Act of 2010.

Changing Coverage During the Year

There are two sets of regulations, established by the Federal government, that control the types of coverage changes you can make during a plan year. The regulations classify the changes as follows:

  1. Change in Status Events:
    As provided by the Internal Revenue Code

    As a result of allowing you to pay for benefits on a before-tax basis, the government has established rules that control when you can change or enroll for coverage. Based on your situation, you may be able to:

    • Change your coverage during the plan year (i.e., add or remove dependents to your existing coverage), or
    • Late Enroll, which refers to enrolling yourself and/or your dependents for coverage during the plan year, even though you declined coverage when you were first eligible or during a previous open enrollment period.
      Note: You must enroll for coverage in order to enroll your dependents.
  2. Special Enrollment Rights:
    As provided by the Health Insurance Portability and Accountability Act—HIPAA

    Under certain circumstances, even if you or your eligible dependents are not currently enrolled in a plan, the government requires that you and your eligible dependents be allowed to late enroll—enroll during the plan year even though you declined coverage when you were first eligible or during a previous open enrollment period.

    Note: You must enroll for coverage in order to enroll your dependents.

    View Detailed Information »

    During the Year

    Change in Status Events:
    As Provided by the Internal Revenue Code

    Enrollment Requirements:
    You must change (enroll/drop) coverage within 31 days of the following events:

    • Change in your legal marital, including marriage, death of your spouse, divorce, legal separation or annulment.
    • Change in the number of your dependents, including birth, adoption, placement for adoption or death of your dependent.
    • Change in your employment status, including termination or commencement of employment of you, your spouse or your dependent.
    • Change in work schedule for you or your spouse, including an increase or decrease in the number of hours of employment, a switch between full-time and part0time status, a strike, lockout or commencement or return from an unpaid leave of absence.
    • your dependent satisfies or no longer meets the eligibility requirements for unmarried dependents, as described under Who Is Eligible, including age or other similar circumstances.
    • A change in the place of residence or worksite of you or your spouse.
      Note: This move must affect your coverage options.
    • You, your spouse, or your dependents lose COBRA coverage.
    • You, your spouse, or your dependents enroll for Medicare or Medicaid or lose coverage under Medicare or Medicaid.
    • If the plan receives a decree, judgment or court order, including a QMCSO pertaining to your dependent, you may add the child to the plan (if the decree, judgment or court order requires coverage) or drop the child from the plan (if the ex-spouse is required to provide coverage).
    • A significant change in benefit or cost of coverage for you or your spouse. Your spouse's employer provides the opportunity to enroll or change benefits during an open enrollment period.

    Special Enrollment Rights:
    As Provided by HIPAA

    • You initially declined coverage under the plan because you had coverage under another plan, and subsequently incurred a loss of overage under the other plan*
      Enrollment Requirements: You must change (enroll/drop) coverage within 31 days of the event.
    • Occurrence of certain events such as birth, adoption, placement for adoption or marriage**
      Enrollment Requirements: You must change (enroll/drop) coverage within 31 days of the event.
    • Eligibility for state premium subsidies under the Children's Health Insurance Program or State Children's Health Insurance Program (also known as Healthy Families in California)
      Enrollment Requirements: You must change (enroll/drop) coverage within 60 days of the event.
    • Loss of coverage under Medicaid, the Children's Health Insurance Program or State Children's Health Insurance Program (also known as Healthy Families in Callifornia)
      Enrollment Requirements: You must change (enroll/drop) coverage within 60 days of the event.

*Loss of coverage means:

  • COBRA coverage has been exhausted for reasons other than non-payment of premiums or fraud,
  • Loss due to legal separation, divorce, death, termination of employment or reduction in the number of hours of employment, or
  • Loss of coverage due to attaining a plan's lifetime maximum for all benefits.

**There is no requirement that protected individuals in this category must have had other coverage prior to the existence of their special enrollment rights.