Affordable Care Act (ACA)
Required Annual Federal Health Insurance Notices
Click here to view the WHOI Required Notices:
1. Special Enrollment Rights
See the Plan Administrator for details about special enrollment.
You may also enroll yourself and your dependents in a group health plan if your or one of your eligible dependent’s coverage under Medicaid or the state Children’s Health Insurance Program (CHIP) is terminated as a result of loss of eligibility, or if you or one of your eligible dependents become eligible for premium assistance under a Medicaid or CHIP plan. Under these two circumstances, the special enrollment period must be requested within 60 days of the loss of Medicaid/CHIP coverage or of the determination of eligibility for premium assistance under Medicaid/CHIP.
See the Plan Administrator for details about special enrollment.
3. Grandfathered Status
The Plan believes that none of the group health plans available under the Plan are “grandfathered health plans” under the Patient Protection and Affordable Care Act (the “Affordable Care Act”).
4. Special Rule for Maternity and Infant Coverage
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 cesarean section. However, Federal law generally does not prohibit the attending provider or physician, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable).
5. Special Rule for Women’s Health Coverage
The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”) requires group health plans, insurance issuers and HMOs who already provide medical and surgical benefits for mastectomy procedures to provide insurance coverage for reconstructive surgery following mastectomies. This expanded coverage includes (i) reconstruction of the breast on which the mastectomy has been performed, (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (iii) prostheses and physical complications at all stages of mastectomy, including lymphedemas.
6. Notice Regarding Lifetime and Annual Dollar Limits
7. Patient Protection Disclosure
For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Plan Administrator.
8. Affordable Care Act Consumer Protections
The Affordable Care Act of 2010 requires that the Plan must make dependent coverage available to adult children, at a minimum, until they turn 26 regardless if they are married, a dependent or a student.
(b.) Prohibition of Lifetime Dollar Value of Benefits
The Affordable Care Act of 2010 prohibits the Plan from imposing a lifetime limit on the dollar value of benefits.
(c.)Your health Insurance Cannot be Rescinded
The Affordable Care Act of 2010 prohibits the Plan, or any insurer, from rescinding your health insurance coverage under the Plan for misrepresentation.
(d.) Prohibition of Pre Existing Conditions
Effective January 1, 2014 The Affordable Care Act of 2010 prohibits the Plan, or any insurer, from denying any health insurance claim for any person because of pre-existing condition.
(e.) Prohibition of Restrictions on Annual Limits on Essential Benefits
The Affordable Care Act of 2010 prohibits the Plan, or any insurer, effective January 1, 2014 from placing annual limits on the value of essential health benefits.
(f.) Notice of Marketplace/Exchange
If this health insurance is unaffordable (your cost of the premium exceeds 9.5% of your income) as defined under the Affordable Care Act , you may have the right to subsidized health insurance purchased through an exchange/marketplace created pursuant to the Affordable Care Act.
9. Michelle’s Law
Michelle’s Law provides continued health and dental insurance benefits under the Plan for dependent children who are covered under the Plan as a student but lose their student status in a post-secondary school or college because they take a medically necessary leave of absence from school. If your child is no longer a student because he or she is out of school because of a medically necessary leave of absence, your child may continue to be covered under the Plan for up to one year from the beginning of the leave of absence.
10. The Genetic Information Nondiscrimination Act (GINA)
GINA prohibits the Plan from discriminating against individuals on the basis of genetic information in providing any benefits under the Plan. Genetic information includes the results of genetic tests to determine whether someone is at increased risk of acquiring a condition in the future, as well as an individual’s family medical history.
If your Plan provides for a Wellness program that provides rewards or surcharges based on your ability to complete an activity or satisfy an initial health standard, you have the right to request a reasonable alternative should it be determined that it is not medically advisable for you to either complete the activity or satisfy the initial health standard.
W-2 Reporting of Health Coverage— begining in January 2013, employers are required to report the full value of employer-provided health coverage on an employee's W-2. This includes the total annual cost to the employee and employer. This will be provided to employees for informational purposes only and will have no bearing on their taxable income.
Effective January 1, 2014 under The Affordable Care Act ("ACA"), the new Health Insurance Marketplace (originally referred to as the "Exchange") will be made available to consumers. The "Marketplace" will allow individuals to compare and purchase medical coverage online from insurance carriers. Financial assistance will be available to families with household income below a certain dollar amount, however, individuals who are already eligible for employer-sponsored medical coverage that meets certain standards are not eligible for financial assistance through the Marketplace. WHOI's medical coverage meets the standards for "affordable coverage that meets the minimum value requirement".
Defense of Marriage Act (DOMA)
REGULATORY CHANGES: REPEAL OF THE DEFENSE OF MARRIAGE ACT (DOMA)
On June 26, 2013, the Supreme Court struck down as unconstitutional Section 3 of the Defense of Marriage Act (“DOMA”), which provided that only opposite-sex marriages would be recognized as valid for federal law purposes. As a result, individuals who are spouses in a same-sex marriage that is recognized under applicable state law are now considered to be married when applying federal statutes and regulations that refer to or involve marital status. The Institution, like the majority of employers, is reviewing the ruling and awaiting final guidance from the Federal government before taking any action to ensure appropriate administration and full compliance with the new regulations.
Last updated: October 27, 2016