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Federal law gives you and your family members some valuable - though limited - protections when you need to buy, change, or continue your health insurance. These important laws can affect the health benefits of millions of Americans and their families. Understanding these protections, as well as laws in your State, can help you make a more informed choice if you need to make a change in health coverage. It also can help you better understand the health coverage protections you have under the law.


The purpose of this on-line information is to give you an overview of how you may be affected by health insurance coverage changes that may apply to four different types of coverage:


1)   Self-funded group health plans (CMS has jurisdiction over self-funded public sector (non federal governmental) plans while the Department of Labor (866-444-3272) has jurisdiction over private sector self-funded group health plans.);

2)  Fully insured group health plans;

3)  Individual (non-employment based) health insurance policies; and

4)  Comparable coverage through State high risk pools, if applicable in your State.


Contact your state's insurance department to find out about whether additional protections apply to your coverage if you are in a fully insured group health plan or have individual market (non-employment based) health coverage.


Medicare and Medicaid are not issuers of health insurance.  They are public health plans through which individuals obtain health coverage.  Contact your specific Medicare or Medicaid contractor to discuss your level of benefits.


Employment related group health plans that provide benefits through insurance are known as fully insured group health plans. Employment related group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-funded group health plans.  Contact your plan administrator to find out if your group coverage is fully insured or self-funded.  Non-employment related individual health insurance policies are sold to individual policy holders.  If applicable, your State of residence may offer comparable coverage through a State high risk pool.


If you have coverage in one of the four categories listed above, you may have some protections in the following Federal laws:


  • 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 (NMHPA); and
  • The Women's Health and Cancer Rights Act of 1998 (WHCRA).

This on-line information does not cover all the details of these laws. But it does give you and your family information about your rights and protections. As you read this information, it also is important to remember that health insurance coverage is a complex issue. Your coverage and protections will depend on your specific situation. For example, you may have access to different health coverage protections depending on whether you work and get insurance through your workplace (also known as employment based coverage), or whether you have individual (non-employment based) coverage. To help you better understand this and other issues, this on-line information includes general information about these four federal laws.


In 2008, Congress enacted three important laws that provided additional protection for consumers:  The Genetic Information Nondiscrimination Act (GINA); The Mental Health Parity and Addiction Equity Act (MHPAEA) (see The Mental Health Parity Act Web page located in the left hand column); and Michelle's Law.  These new laws will take effect in 2009 and are now posted for your review.


The HIPAA certificate of creditable coverage indicates how long an individual had a group market, individual market or other health coverage.  Retain this document for your records.  This document or a copy of this document should not be sent to CMS.


For additional information, you may e-mail us at phig@cms.hhs.gov.


Note:  A non federal government employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan (opt-out) from most requirements of title XXVII of the Public Health Service (PHS) Act, with the exception of requirements of the Genetic Information Nondiscrimination Act (GINA), requirements pertaining to the certification and disclosure of an individual's creditable coverage under the plan, and the issuance of a notice of opt out to enrollees at the time of enrollment and on an annual basis thereafter.




Michelle's Law (PDF, 120KB) *NEW*

HIPAA Helpful Tips (PDF, 123KB)

HIPAA Eligibility Criteria for Individual Coverage (PDF, 29KB)

DOI Contact Information - State Status Chart (PDF, 135KB)

Interim Rules for Health Insurance Portability for Group Health Plans [04/08/1997]

Protecting Your Health Insurance Coverage [PDF, 183K]

Related Links Inside CMS

Health Insurance Reform for Employers

Related Links Outside CMSExternal Linking Policy

Final Regulations for Health Coverage Portability for Group Health Plans and Group Health Insurance Issuers Under HIPAA Titles I & IV [12/30/2004]

Nondiscrimination and Wellness Programs in Health Coverage in the Group Market [12/13/2006]

Group Market - Evidence of Creditable Coverage, 45 CFR Section 146.115(c)(3)(ii) and (iii)

Individual Market - Evidence of Creditable Coverage, 45 CFR Section 148.124(d)(2)(ii) and (iii)

Compliance Assistance Guide - Health Benefits Coverage Under Federal Law

US Department of Labor, Employee Benefits Security Administration

Georgetown University Health Policy Institute -- state specific booklets on all kinds of health coverage

USA.gov --- Federal and state government information

Kaiser Network --- developments in the health care field

National Conference of State Legislatures


Page Last Modified: 12/03/2008 4:07:44 PM
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