Health and Benefit Plan Compliance Requirements
This page designed to provide a general overview of the regulatory acts it describes. The information included on this page is not a substitute for legal or professional opinions. Additional information can be found at www.dol.gov.
Affordable Care Act 2010 (PPACA) – PPACA is a federal law requiring most U.S. citizens and legal residents to have health insurance. Under PPACA state-based American Health Benefit Exchanges will be so individuals can purchase coverage, with premium and cost-sharing credits available to individuals and families. Small businesses can also purchase coverage through the Exchange available in their state. PPACA requires employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers. This law imposes new regulations on health plans in the Exchanges and in the individual and small group markets.
Americans with Disabilities Act of 1990 (ADA) – The ADA is a federal law that prohibits employers from discriminating against a qualified individual with a disability. The ADA applies to all employers with 15 or more employees.
Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) – CHIPRA is a federal law in which group health plans and group health insurance issuers must offer new special enrollment opportunities. Plans and issuers must permit employees and dependents that are eligible for, but not enrolled in, a group health plan to enroll in the plan upon; losing eligibility for coverage under a State Medicaid or CHIP program, or becoming eligible for State premium assistance under Medicaid or CHIP. The employee or dependent must request coverage within 60 days of being terminated from Medicaid or CHIP coverage or within 60 days of being determined to be eligible for premium assistance.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – COBRA is a federal law that provides rights to temporary continuation of group health plan coverage for certain employees, retirees, and family members at group rates when coverage is lost due to certain qualifying events. Generally, COBRA applies to employers who employed 20 or more employees in the prior calendar year.
Employee Retirement Income Security Act of 1974 (ERISA) – ERISA is a federal law that regulated employee benefit plans, such as group health plans, that private sector employers, employee organizations (such as a union), or both, offer to employees and their families.
Family Medical Leave Act of 1993 (FMLA) – FMLA is a federal law that provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires group health benefits be maintained during the leave. FMLA pertains to employers who employ 50 or more employees for each working day in 20 or more calendar weeks of the current or preceding calendar year are deemed to be engaged in commerce or in an industry or activity affecting commerce.
Medicare Modernization Act – The MMA provides a prescription drug benefit (Medicare Part D) for Medicare eligibles. There are requirements to notify employees, as well CMS, of creditable coverage standards. It also includes provisions for employers offering retiree prescription drug benefits to take advantage of a retiree drug subsidy, if eligible.
Medicare Secondary Payer Laws (MSP) – The MSP laws define when Medicare will be the primary payer for services covered under a group health plan. The size of the group will affect whether the group or Medicare is the primary payer. MSP laws prohibit a group from offering Medicare Supplemental coverage to a person eligible for group health coverage that should be primary to Medicare.
Mental Health Parity Act (MHPA) – MHPA is a federal law that requires that annual or lifetime dollar limits on mental health benefits provided by a group health plan be no lower than the annual or lifetime dollar limits for medical and surgical benefits offered by that plan. MHPA applies to employers with more than 50 employees.
Newborns’ and Mothers’ Health Protection Act (Newborns’ Act) – The Newborns’ Act is a federal law that prohibits health plans and insurance companies (including Health Maintenance Organizations) that cover hospitalization in connection with childbirth from restricting a mothers’ or newborns’ benefits for such hospital stays to less than 48 hours for a vaginal delivery or 96 hours for delivery by cesarean section, unless the attending doctor or nurse midwife, or other licensed health care provider, in consultation with the mother, discharges earlier.
The Genetic Information Nondiscrimination Act of 2008 (GINA) – GINA is a federal law that is designed to prohibit the use of genetic information in health insurance and employment. The Act prohibits group health plans and health insurers from denying coverage to a healthy individual or charging that person higher premiums based solely on a genetic predisposition to developing a disease in the future. The legislation also bars employers from using individuals’ genetic information when making hiring, firing, job placement, or promotion decisions.
The Health Insurance Portability and Accountability Act (HIPAA) – HIPAA is a federal law that limits pre-existing condition exclusion, permits special enrollment when certain life or work events occur, prohibits discrimination against employees and dependents based on their health status, and guarantees availability and renewability of health coverage to certain employees and individuals.
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) – USERRA is a federal law that protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service. It also prohibits employers from discriminating against past and present members of uniformed services, and applicants to the uniformed services.
Women’s Health and Cancer Rights Act (WHCRA) – WHCRA is a federal law that provides important new protections for individuals who have undergone a mastectomy.