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Compliance

The following is a list of some common compliance areas that impact our clients on a regular basis.

Please note that there are many laws that affect employee benefits plans and these are not the only laws you need to be informed about. This list is intended to be a quick overview of a number of basic reporting and disclosure requirements that group health plans and/or employers must provide to participants, beneficiaries and other individuals under Title I of ERISA and other miscellaneous federal laws.

  • COBRA – Consolidated Omnibus Budget Reconciliation Act of 1985 – Allows certain former employees, retirees, spouses, and dependent children the right to continue health coverage for a limited amount of time.

  • ERISA – Employee Retirement Income Security Act of 1974 – Laws regulating the establishment and administration of employee health and welfare plans. Also imposes reporting and disclosure requirements, including Summary Plan Descriptions.

  • HIPAA – Health Insurance Portability and Accountability Act of 1996 – Limits a group health plan's ability to impose pre-existing condition exclusions, provides special enrollment rights for eligible persons; prohibits group plans from individual discrimination based on health conditions. Creates national standards for handling individuals' protected health information.

  • FMLA – Family and Medical Leave Act of 1993 - Provides eligible employees with up to 12 work weeks of unpaid leave a year for certain medical or family reasons. Requires group health benefits to be maintained during the leave.

  • Medicare Part D – Plans that offer prescription drug coverage on a group basis to active and retired employees and to Medicare Part D eligible individuals must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D eligible individuals who are covered by, or who apply for, prescription drug coverage under the entity’s plan. This creditable coverage notice alerts the individuals as to whether or not their prescription drug coverage is at least as good as the Medicare Part D coverage.

  • MHPA– Mental Health Parity Act of 1996 – Provides parity of annual and lifetime dollar limits on mental health benefits with those of medical/surgical benefits.

  • MSP Laws – Medicare Secondary Payer – Laws that govern which coverage pays first when a Medicare beneficiary also has coverage through a group health plan. Rules are based on the number of employees, the reason for Medicare eligibility and the work status of the health plan enrollee.

  • Newborns’ and Mothers’ Health Protection Act – The plan’s SPD must include a statement describing any requirements under federal or state law applicable to the plan, and any health insurance coverage offered under the plan, relating to any hospital length of stay in connection with childbirth for a mother or newborn child. If the federal law applies in some areas in which the plan operates and state law applies in other areas, the SPD should describe the different areas and the federal or state requirements applicable in each.

  • Qualified Medical Child Support Orders – This is a notification from the plan administrator regarding receipt and qualification determination on a medical child support order directing the plan to provide health insurance coverage to a participant’s noncustodial children.

  • USERRA – Uniformed Services Employment and Reemployment Rights Act of 1994. – Protects the employment rights and benefits of those who serve our country voluntarily or involuntarily in the armed forces.

  • WHCRA – Women's Health and Cancer Rights Act 1998 – Also know as "Janet's Law" – Requires health plans that cover mastectomies to pay for reconstructive surgery and other services associated with a mastectomy.


Please note that the information presented on this page is intended to provide general information on common compliance issues. Every effort has been made to ensure the accuracy of the information; however, the law and regulations may change over time. The information presented on this website does not constitute legal advice. You should consult an attorney or other professional with specific questions regarding your compliance obligations.


For more information on how we can serve your insurance needs, please call A.E. Mourad Agency at (248) 336-1600.
 
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