Resources

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.

patient protection and affordable care act

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

Interim final rules with request for comments.

genetic information non-discrimination 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.

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.

womens’ 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.

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).

domestic partnership requirements in california

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.

children’s health insurance program reauthorization act

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.

SPD compliance issues (foreign language assistance & spd electronic distribution requirements)

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 Requirements

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 delivered 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 regulations permit the pre-consent statement to be provided electronically if the 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.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment,coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance,and deductible that you would pay if the provider or facility was in-network). Your healthplan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services inadvance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network servicestoward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact: 1-800-985-3059.

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Transparency in Coverage

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