Group Health Plans: Federal Mandates Other Than COBRA & HIPAA

Mental Health Parity

• Under the MHPA/MHPAEA, cost-exemption notices notifying participants and beneficiaries of the plan’s reliance on the increased cost exemption, including among other things, a statement regarding the availability upon request of a summary of the information on which the exemption was based (required only if plan claims exemption) Triggered only if plan claims the exemption from MHPAEA Provide upon event (must provide a 30 days advance notice to participants, beneficiaries and DOL) or on request

• Opt-out notices notifying enrollees of opt-out by selffunded non-federal governmental plan, annually and upon enrollment

• Employer Health Plans must provide a comparative analysis of the application of Non-Quantitative Treatment Limits (NQTLs) to Mental Health/Substance Use benefits in comparison to Medical/Surgical benefits to ensure parity exists.

Women’s Health and Cancer Rights Act (WHCRA)

• Enrollment notices notifying participants of WHCRA rights included upon initial enrollment, if not included in an SPD that is distributed upon initial enrollment

• Annual notices notifying participants of WHCRA rights, if not included in an SPD that is distributed annually

• Opt-out notices notifying enrollees of opt-out by selffunded non-federal governmental plan, annually and upon enrollment Plans

Newborns’ and Mothers’ Health Protection Act (NMHPA)

• Include in the SPD – Must describe, with respect to childbirth hospital stay for mother and newborn the applicable State or Federal requirements and the plan’s coverage – use DOL model language

• Opt-out notices notifying enrollees of opt-out by selffunded non-federal governmental plan, annually and upon enrollment

Patient Protections Under Health Care Reform

• Written notice of the right to designate a primary care provider or pediatrician and to obtain obstetrical or gynecological care without preauthorization or referral must be provided not later than the first day of the first plan year beginning on or after September 23, 2010, and with SPD

Surprise Billing

• Employer Health Plans must provide to participants, in plain language, information regarding balance billing protections in both emergency and certain nonemergency situations. The information must be listed on the plan’s website and on all EOBs.

Cost Transparency Rules

• Employer Health Plans must make available to members price comparison information. The information must be accessible in an internet-based self-service tool (or paper upon request). By January 1, 2023, plans must have price comparison information for 500 items and services as described in regulation. By January 1, 2024, all other items and services must be accessible through the internet tool.