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In February 2003, the Department of Labor’s Employee Benefits Security Administration (EBSA) released its Health Disclosure and Claims Issues: Fiscal Year 2001 Compliance
Project Report. The report sets forth results from EBSA’s FY 2001
Compliance
Project, during which 1,267 investigations were conducted of group health
plans and
their compliance with Part 7 of Title I of the Employee Retirement Income
Security
Act (ERISA). Part 7 is comprised of provisions of the Health Insurance
Portability
and Accountability Act of 1996 (HIPAA), the Mental Health Parity Act of 1996
(MHPA), the Newborns’ and Mothers’ Health Protection Act of 1996
(Newborns’
Act), and the Women’s Health and Cancer Rights Act of 1998 (WHCRA).
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Data from the Project revealed that implementation by group health plans has
progressed
gradually and that some plans could use additional compliance assistance
with respect to the notice requirements of Part 7 of ERISA.
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This guide
includes a
chart that summarizes these notice requirements and sample language that may
be
used by group health plans, issuers, and third party administrators when
providing
these notices. References to a checklist in this summary are to a
self-compliance
tool, which is being published simultaneously. Both are available at:
www.dol.gov/ebsa.
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Type of Disclosure |
Applicability |
Content Summary |
When Provided |
HIPAA certificate of
creditable coverage
(§ 701(e); 29 CFR 2590.701-5)
See Checklist questions
10-15 |
All group health plans. |
Each certificate must
include:
-
Date issued;
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Name of plan;
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Individual’s name and
ID;
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Plan administrator
name, address, and
phone number;
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Phone number for
further information;
and
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Individual’s creditable
coverage information.
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When the certificate is provided
upon request, as soon as
possible.
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When the certificate is provided
automatically upon loss of coverage
and a COBRA qualifying
event, not later than the end of
the period for providing COBRA
notice (generally 44 days).
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When the certificate is provided
automatically upon loss of coverage
and not a COBRA qualifying
event, within a reasonable
time after coverage ceases (as
soon as possible).
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General notice of preexisting
condition
exclusion
(29 CFR 2590.701-3(c))
See Checklist question 8 |
Any group health plan
that contains a preexisting
condition exclusion. |
The plan must disclose the
existence and terms of any
preexisting condition
exclusion under the plan
and the rights of individuals
to demonstrate creditable
coverage. This
includes a description of
the right of the individual
to request a certificate
from a prior plan or issuer
and a Statement that the
current plan will assist in
obtaining a certificate from
any prior plan or issuer, if
necessary. |
Must be provided before a preexisting
condition exclusion may be
applied to any individual. |
Individual notice of
preexisting condition
exclusion
(29 CFR 2590.701-5(d))
See Checklist question 9 |
Group health plans that
contain a preexisting
condition exclusion, but
only after receiving creditable
coverage information
from an individual
that is not enough to offset
the preexisting condition
exclusion period. |
This notice must include:
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The plan’s determination
of the period of
creditable coverage
(note: the plan must
allow the individual a
reasonable opportunity
to submit additional
evidence of creditable
coverage);
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The remaining preexisting
condition exclusion
period that will
apply to the individual;
and
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A description of any
appeal procedures
established by the plan
or issuer.
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Within a reasonable time of the
presentation of creditable coverage
by the individual. |
Notice of special
enrollment rights
(29 CFR 2590.701-6(c))
See Checklist question
18 |
All group health plans. |
A description of the plan’s
special enrollment rules. |
On or before the time an
employee is offered an opportunity
to enroll in the plan. |
Description of rights
with respect to hospital
stays in connection
with childbirth
(§ 711(d); 29 CFR 2520.102-3(u))
See Checklist question
36 |
Group health plans that
provide maternity or
newborn infant coverage. |
The plan’s SPD must include
a Statement describing any
requirements under Federal or State law applicable to the
plan, and any health insurance
coverage offered under
the plan, relating to any hospital
length of stay in connection
with childbirth for a
mother or newborn child. If
the Federal law applies in
some areas in which the plan
operates and State law applies
in other areas, the SPD should
describe the different areas
and the Federal or State requirements applicable in
each. |
In the SPD (or SMM). |
WHCRA enrollment
notice
(§ 713(a))
See Checklist question
39 |
Group health plans that
provide coverage for
mastectomy benefits. |
The benefits that WHCRA
requires the group health plan
to cover and any deductibles
and coinsurance limitations
applicable to such coverage.
(Under WHCRA, coverage of
breast reconstruction benefits
may be subject only to
deductibles and coinsurance
limitations consistent with
those established for other
benefits under the plan or
coverage.) |
Upon enrollment in the plan. |
WHCRA annual
notice
(§ 713(a))
See Checklist question
38 |
Group health plans that
provide coverage for
mastectomy benefits. |
Information on the availability
of benefits for the treatment of
mastectomy-related services,
including reconstructive surgery, prostheses, and physical complications,
including lymphedemas
under the plan; and
information on how to obtain
a detailed description of the
mastectomy-related benefits
available under the plan. |
Once each year after enrollment
in the plan. |
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Important - This certificate provides evidence of your prior health
coverage.
You may need to furnish this certificate if you become eligible under a
group health plan that excludes coverage for certain medical conditions that
you have before you enroll. This certificate may need to be provided if
medical
advice, diagnosis, care, or treatment was recommended or received for the
condition within the 6-month period prior to your enrollment in the new plan.
If you become covered under another group health plan, check with the plan
administrator to see if you need to provide this certificate. You may also
need
this certificate to buy, for yourself or your family, an insurance policy
that does
not exclude coverage for medical conditions that are present before you
enroll.
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Date of this certificate:
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Name of group health plan:
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Name of participant:
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Identification number of participant:
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Name of any dependents to whom this certificate applies:
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Name, address, and telephone number of plan administrator or issuer
responsible for providing this certificate:
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For further information, call:
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If the individual(s) identified in line 3 and line 5 has at least 18
months of
creditable coverage (disregarding periods of coverage before a 63-day
break), check here ____ and skip lines 9 and 10.
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Date waiting period or affiliation period (if any) began:
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Date coverage began:
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Date coverage ended:________(or check if coverage is continuing as of the
date of this certificate: _______).
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Note: separate certificates will be furnished if information is not
identical for
the participant and each beneficiary. |
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If you are declining enrollment for yourself or your dependents (including
your spouse) because of other health insurance coverage, you may in the
future be able to enroll yourself or your dependents in this plan, provided
that
you request enrollment within 30 days after your other coverage ends. In
addition, if you have a new dependent as a result of marriage, birth,
adoption,
or placement for adoption, you may be able to enroll yourself and your
dependents, provided that you request enrollment within 30 days after the
marriage, birth, adoption, or placement for adoption. |
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A group health plan (or issuer) may not impose a preexisting condition
exclusion
with respect to a participant or dependent before notifying the participant,
in writing, of —
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The existence and terms of any preexisting condition exclusion under the
plan;
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The rights of individuals to demonstrate creditable coverage (and any
applicable waiting periods);
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The right of the individual to request a certificate from a prior plan or
issuer, if necessary; and
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That the current plan (or issuer) will assist in obtaining a certificate
from
any prior plan or issuer, if necessary.
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A group health plan (or issuer) seeking to impose a preexisting condition
exclusion is required to disclose to the individual, in writing —
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Its determination of the period of creditable coverage, including the
source
and substance of any information on which the plan or issuer relied (note:
the plan must allow a reasonable opportunity to submit additional evidence
of creditable coverage);
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The remaining preexisting condition exclusion period that will apply to
the
individual; and
-
Any appeal procedures established by the plan or
issuer.
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The following is sample language that group health plans subject to the
Newborns’ Act may use in their SPDs to describe the Federal requirements
relating to hospital lengths of stay in connection with childbirth: |
“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 mother’s or newborn’s
attending
provider, after consulting with the mother, from discharging the mother or
her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans
and issuers may not, under Federal law, require that a provider obtain
authorization
from the plan or the insurance issuer for prescribing a length of stay not
in excess of 48 hours (or 96 hours).” |
Plans subject to State law requirements will need to prepare SPD
Statements
describing any applicable State law. |
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Do you know that your plan, as required by the Women’s Health and Cancer
Rights Act of 1998, provides benefits for mastectomy-related services
including
all stages of reconstruction and surgery to achieve symmetry between the
breasts, prostheses, and complications resulting from a mastectomy, including
lymphedemas? Call your Plan Administrator [insert telephone number] for more
information. |
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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 the patient, for:
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All stages of reconstruction of the breast on which the mastectomy was
performed;
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Surgery and reconstruction of the other breast to produce a symmetrical
appearance;
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Prostheses; and
-
Treatment of physical complications of the mastectomy, including
lymphedemas.
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These benefits will be provided subject to the same deductibles and coinsurance
applicable to other medical and surgical benefits provided under this
plan. Therefore, the following deductibles and coinsurance apply: [insert
deductibles and coinsurance applicable to these benefits]. |
If you would like more information on WHCRA benefits, call your Plan
Administrator [insert telephone number]. |
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