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Mandated Benefits and Coverage

Mandated benefits are benefits that are legally required to be covered by either state law, federal law, or in some cases both.  Some mandated benefits require treatment of specific health conditions, provide guidelines around the cost-sharing that can be passed off to participants, or restricts how benefits can and cannot be covered. 


Provided below is a short description of each subtopic. 


Annual and Lifetime Dollar Limits on Essential Health Benefits Prohibited - Plans may not impose annual and lifetime dollar limits on Essential Health Benefits if offered.


Clinical Trial Requirement - Group health plans and health insurance issuers offering group or individual health insurance coverage may not: 1) deny "qualified individuals" participation in certain "approved clinical trials;" 2) deny the coverage of "routine patient costs" furnished in connection with the clinical trial; or 3) discriminate against the individual on the basis of the individual's participation in such trial. 


Coverage of Dependent Children to Age 26 - Plans must make dependent coverage available for any child (regardless of marital status) of an employee who is deemed to be the employee’s biological, step, foster or adopted child (including a child placed for adoption) until such child reaches age 26.


Discrimination Concerns - Plans must be aware of 105(h) discrimination concerns as well as HIPAA discrimination concerns when operating their plans. 


Mental Health Parity - The law requires group health plans that choose to cover mental health and substance abuse services cover those services in parity with medical and surgical services also offered.


Michelle's Law - Michelle’s Law prohibits group health plans from terminating the coverage of a dependent child enrolled in a post secondary school educational institution on a medically necessary leave of absence which results in the loss of student status.


Newborns' and Mothers' Health Protection Act - The Newborns' and Mothers' Health Protection Act requires all health plans that offer maternity coverage to provide coverage for at least 48 hours following traditional childbirth or 96 hours following birth by caesarian section.


Out of Pocket Maximums (In-Network) - The out-of-pocket maximum is the annual limit on cost sharing that can be imposed on participants for their health coverage. Once a participant has paid cost sharing (deductibles, copays, and coinsurance) equal to the out-of-pocket maximum, the plan must pay 100% of that participant’s covered health expenses for the remainder of the benefit year.


Patient Protections -The Patient Protections provided three new requirements that plans must follow. They are: (1) allowing participants the choice of in-network Primary Care Providers (PCPs), (2) allowing direct access for female participant to seek coverage for in-network obstetrical (OB) or gynecological (GYN) care and (3) providing for emergency services, whether provided by in-network or out-of-network providers.


Pre-Existing Conditions - Plans may not impose any pre-existing condition exclusions or limitations regardless of age.


Preventive Services Mandate -  A non-grandfathered plan must comply with the following under the preventive services mandate: Plans must provide coverage at no cost (no copays, deductibles or coinsurance can be imposed) for certain in-network "recommended preventive services", including preventive immunizations; if a service is identified as being a recommended preventive service, the plan must provide coverage of that service; and a plan may impose cost-sharing requirements on coverage of recommended preventive services delivered by an out-of-network provider.


Qualified Medical Child Support Orders (QMCSO) - A QMCSO is a judgment, decree, or order issued by a court or through a state administrative process which requires a health plan to provide coverage to a participant's child or alternate recipient.


Rescission of Coverage - Affordable Care Act regulations prohibit a group health plan, regardless of grandfathered status, from rescinding coverage for any individual covered under the plan with a few limited exceptions.


Waiting Period Limited to 90 days or less - Prohibits all plans regardless of grandfathered status from imposing waiting periods in excess of 90 days.


Internal and External Appeal Requirements - All non-grandfathered health plans must adhere to internal claims and appeals and external review requirements.


The Women's Health and Cancer Rights Act (WHCRA) - Requires group health plans to provide certain benefits regarding a mastectomy and to provide their plan participants notice of their rights with regard to mastectomies.


HIPAA Wellness Programs -  Increases the maximum permissible reward under a health-contingent wellness program offered in connection with a group health plan from 20% to 30% of the cost of coverage or up to 50% if tobacco is included in the wellness program.


Employment Laws


Americans with Disabilities Act (ADA) - The Americans with Disabilities Act (ADA) is a broad federal law protecting persons with disabilities from discrimination in employment, government and commercial activities, transportation, and telecommunications


FMLA - The Family Medical Leave Act (FMLA) allows an employee to take unpaid, job-protected leaves of absence for family and medical reasons while maintaining health coverage as if the employee had never taken time off.


Genetic Information Nondiscrimination Act (GINA) - The Genetic Information Nondiscrimination Act of 2008 (GINA), prohibits group health plans from increasing the group premium or contribution amounts based on the genetic information of one or more individuals in the group.


The Pregnancy Discrimination Act - Prohibits the discrimination on the basis of pregnancy, childbirth, or related medical conditions constitutes unlawful sex discrimination under


USERRA - Requires a health plan to allow a uniformed service member who is called to active duty to elect to continue health coverage under the employer's group medical plan during their military leave.


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This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.