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Opt-Out Filings

With the passing of many laws such as the Newborns' and Mothers' Health Protection Act of 1996, the Mental Health Parity Act of 1996, the Women's Health and Cancer Rights Act of 1998, the Genetic Information Nondiscrimination Act of 2008 (GINA), the Mental Health Parity and Addiction Equity Act of 2008, and (in 2008 also) Michelle's Law, self-funded health plans were granted to right to opt-out of the requirements of several of these laws.


Any group electing to exempt itself, must understand that the HIPAA opt-out is valid for one specified plan year only and must be renewed with each subsequent plan year. If the HIPAA opt-out is granted, the plan must communicate the opt-out to its plan members.


For plans beginning before September 23, 2010, the seven categories of coverage which may be exempt are as follows:


1.  Limitations on preexisting condition exclusion periods;

2.  Special enrollment periods;

3.  Prohibitions against discriminating against individual participants and beneficiaries based on health status;

4.  Standards relating to benefits for mothers and newborns;

5.  Parity in the application of certain limits to mental health benefits;

6.  Required coverage for reconstructive surgery following mastectomies; and

7.  Coverage of dependent students on medically necessary leave of absence.


If a self-funded plan sponsor wishes to exempt its plan from one or more of the requirements, the plan sponsor is permitted to file for an exemption by notifying the Centers for Medicare & Medicaid Services (CMS). As of December 31, 2014, notification to CMS must be made using the Non-Fed Module.


Annual Notice Requirement

Under an opt-out election, the plan must provide an annual notice to plan enrollees as well as notice upon enrollment in the plan.


This opt-out election is not available to private plans, nor is it available to governmental plans that are not self-funded.


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.