Health Care Reform Changes
Required Annual Federal Health Insurance Notices
For Benefit Eligible Employees
1. Special Enrollment Rights
If you do not enroll yourself and your dependents in a group health plan after you become eligible or during annual enrollment, you may be able to enroll under the special enrollment rules under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) that apply when an individual declines coverage and later wishes to elect it. Generally, special enrollment is available if (i) you declined coverage because you had other health care coverage that you have now lost through no fault of your own (or employer contributions to your other health care coverage terminate); or (ii) you have acquired a new dependent (through marriage or the birth or adoption of a child) and wish to cover that person. When you have previously declined coverage, you must have given (in writing) the alternative coverage as your reason for waiving coverage under the group health plan when you declined to participate. In either case, as long as long you meet the necessary requirements, you can enroll both yourself and all eligible dependents in the group health plan if you provide notice to the Plan Administrator within 30 days after you lose your alternative coverage (or employer contributions to your alternative coverage cease) or the date of your marriage or the birth, adoption, or placement for adoption of your child.
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
In accordance with applicable law, none of the lifetime dollar limits and annual dollar limits set forth in the Plan shall apply to “essential health benefits,” as such term is defined under Section 1302(b) of the Affordable Care Act. The law defines “essential health benefits” to include, at minimum, items and services covered within certain categories including: emergency services, hospitalization, prescription drugs, rehabilitative and habilitative services and devices, and laboratory services, but currently provides little further information. Accordingly, a determination as to whether a benefit constitutes an “essential health benefit” will be based on a good faith interpretation by the Plan Administrator of the guidance available as of the date on which the determination is made.
7. Patient Protection Disclosure
You have the right to designate any participating primary care provider who is available to accept you or your family members (for children, you may designate a pediatrician as the primary care provider). For information on how to select a primary care provider and for a list of participating primary care providers, contact the Plan Administrator. You do not need prior authorization from the Plan or from any other person, including your primary care provider, in order to obtain access to obstetrical or gynecological care from a health care professional; however, you may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.
For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Plan Administrator.
8. Affordable Care Act Consumer Protections
(a.) Coverage For Children Up To Age of 26
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.
Last updated: October 15, 2014