QUESTION: We understand that ERISA, COBRA, and HIPAA apply to our company’s group health plan, but should we consider any other federal mandates?
ANSWER: Many federal laws create mandates that may apply to your group health plan. Here are some to be aware of:
- Affordable Care Act (ACA). The ACA imposes numerous mandates on group health plans, including required coverage for children under age 26, coverage of certain preventive health services, and patient protections, such as protections against surprise medical billing for emergency and certain non-emergency items and services.
- Mental Health Parity Addiction Equity Act (MHPAEA). A group health plan that provides medical/surgical benefits and either mental health or substance use disorder benefits may be subject to the MHPAEA mental health parity requirements. These requirements include mandates regarding annual or lifetime limits, parity as to financial requirements and quantitative treatment limitations, and parity as to nonquantitative treatment limitations.
- Women’s Health and Cancer Rights Act (WHCRA). Group health plans with medical and surgical benefits for mastectomy must provide coverage for certain reconstructive surgery and other mastectomy-related benefits.
- Newborns’ and Mothers’ Health Protection Act (NMHPA). Group health plans may not restrict benefits for hospital lengths of stay in connection with childbirth for the mother or newborn child to less than certain time periods.
- Family and Medical Leave Act (FMLA). The FMLA allows eligible employees to take up to 12 weeks of unpaid, job-protected leave each year for the birth and care of a child, the placement of a child for adoption or foster care, to care for an immediate family member with a serious health condition, or because of their own serious health condition. Eligible employees may also take up to 12 weeks of job-protected qualifying exigency leave and up to 26 weeks of military caregiver leave. Employees who take a leave of absence covered by the FMLA are entitled to certain continuation and reinstatement rights under the employer’s group health plans.
- Uniformed Services Employment and Reemployment Rights Act (USERRA). This law establishes reemployment and benefits rights for employees who serve or have served in the “uniformed services,” including certain continuation and reinstatement rights under the employer’s group health plans.
- Medicare Secondary Payer (MSP). The MSP rules specify when a group health plan must pay primary and when it may pay secondary when an individual is covered under both a group health plan and Medicare. Plans are also required to coordinate prescription benefits with Medicare Part D plans.
- Medicare Prescription Drug, Improvement, and Modernization Act (MMA). Sponsors of plans that provide prescription drug coverage to Medicare Part D eligible individuals must disclose whether the plan’s coverage is “creditable coverage” for purposes of Part D.
- Federal Laws Prohibiting Employment Discrimination. These laws generally require that employee benefits be provided in a manner that does not discriminate against certain protected groups. For example, the Age Discrimination in Employment Act (ADEA) prohibits discrimination against individuals age 40 or over; the Americans With Disabilities Act (ADA) prohibits discrimination against certain qualified individuals with disabilities; Title VII of the Civil Rights Act, as amended by the Pregnancy Discrimination Act (PDA), prohibits discrimination based on race, color, religion, sex (including pregnancy), or national origin; and the Genetic Information Nondiscrimination Act (GINA) prohibits discrimination based on an individual’s genetic information.
Many of the above mandates have exceptions for small employers or certain types of plans. If an exception is not available for a particular mandate, you will, of course, need more detailed information than can be explained in this summary. For more information about these mandates and others, see EBIA’s Group Health Plan Mandates manual at Section IV (“What Employers and Plans Are Subject to Federal Group Health Plan Mandates?”).
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