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Most individuals go through a number of life events that affect their
health benefit needs and the choices they make. There are several
important federal laws that affect your benefits under a job-based health
plan. Below is a list of life events and a brief description of federal
laws that may protect your rights when these events occur.
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The Health Insurance Portability and Accountability Act (HIPAA) offers
special enrollment rights for employees and spouses that allow them to
enroll in a group health plan upon marriage and provides protections for
individuals who have preexisting conditions or might suffer discrimination
on the basis of health status when they switch plans.
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ERISA Disclosure Provisions provide individuals with rights to important
information concerning benefits under their own or spouse’s group health
plan.
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HIPAA prohibits preexisting condition exclusions from being applied to
pregnancy, regardless of whether the mother had previous health coverage. In
addition, HIPAA does not permit preexisting condition exclusions to be
applied to newborns and adopted children who enroll within 30 days of birth
or adoption.
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HIPAA also offers special enrollment rights for employees, spouses and new
dependents allowing them to enroll in a group health plan upon birth,
adoption, or placement for adoption.
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ERISA Claims Procedures help ensure timely and fair review of maternity and
other claims under group health plans.
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The Newborns’ and Mothers’ Health Protection Act includes important new
protections for mothers and their newborn children with regard to the
lengths of hospital stays following the birth of a child.
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HIPAA protects individuals who have preexisting conditions, helping them to
keep coverage for those conditions or get coverage for them in no more than
12 or 18 months through limits on the length of preexisting condition
exclusions. HIPAA also helps individuals who might suffer discrimination in
health coverage on the basis of health status when they change jobs.
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COBRA generally requires that most group health plans of employers with at
least 20 employees offer employees and their dependents the opportunity to
continue their health plan coverage for limited periods of time when the
employee loses his or her job or has a reduction in hours that would result
in a loss of coverage.
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ERISA permits a parent to obtain a court order to provide coverage for
children under the noncustodial parent’s health plan (called a qualified medical child support
order).
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ERISA Disclosure Provisions help to ensure that individuals covered by group
health plans receive clear information about their rights, benefits, and
obligations under the plan, including information about COBRA continuation
coverage, access to urgent or specialized care, and composition of physician
and other provider networks.
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HIPAA includes protections for newborns and adopted children with
preexisting conditions. Specifically, HIPAA does not permit a preexisting
condition exclusion to be applied to a newborn or adopted child who enrolls
within 30 days of birth or adoption.
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ERISA Claims Procedures help ensure timely and fair review of plan denials
of claims.
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HIPAA offers special enrollment rights, generally allowing employees and
dependents who were covered under a spouse’s plan to obtain coverage under
the employee’s plan upon divorce or legal separation, if they are
otherwise eligible.
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COBRA generally requires that group health plans of employers with at least
20 employees offer spouses and dependent children the opportunity to
continue their health care coverage for limited periods of time in the event
of the spouse’s legal separation or divorce from the employee covered by
the plan.
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HIPAA offers protections for individuals who have
preexisting conditions, helping them to keep coverage for those conditions
or get coverage in no more than 12 or 18 months through limits on
preexisting condition exclusions.
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HIPAA includes protections to help ensure individuals are
not excluded from coverage under their group health plan or charged a higher
premium based on health status.
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COBRA generally requires that group health plans of
employers with at least 20 employees offer employees and their dependents
the opportunity to continue their health plan coverage for limited periods
of time when the employee loses his or her job due to retirement.
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ERISA Claims Procedures help ensure fair and timely
appeals process for covered individuals.
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ERISA Disclosure Provisions require that group health
plan disclosure material furnished to plan participants and beneficiaries
must contain information about specialists in the plan network and the
plan’s rules for accessing specialty care.
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ERISA Disclosure Provisions also require that plan
disclosure material must describe the ability of the employer to reduce plan
benefits or terminate the plan.
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