Individual C is covered under the plan and has an adverse health condition. Same facts as Example 4, except the disease management program provides an enhanced benefit in the form of a lower annual deductible to individuals under the program; the lower deductible applies with respect to all medical expenses incurred by the individual. (i) Facts. (2) Conclusion. In this Example 10, the plan violates the rules of this paragraph (c)(4). When reference is made in this paragraph (c) to a type of financial requirement or treatment limitation, the reference to type means its nature. (For example, if a participant develops asthma or depression, requires surgery and convalescence, or some other medical condition or consideration makes completion of the original action plan inadvisable or unreasonably difficult, the physician may modify the original action plan.) Other people may become eligible for the disease management program based solely on their answers to questions about their individual medical history. (ii) Conclusion. If you would like to learn more, there is additional information on our "Special Enrollment Period" page. [69 FR 78797, Dec. 30, 2004; 70 FR 21147, Apr. To compensate for this reality, some health insurance plans attempt to steer employee behavior based on costs. Group. A current employee is described in this paragraph (b)(2)(i) if a person becomes a dependent of the individual through marriage, birth, adoption, or placement for adoption. (D) Any request for, or receipt of, genetic services (as defined in paragraph (a)(4) of this section), or participation in clinical research which includes genetic services, by the individual or any family member of the individual. (iii) Specific rule relating to source-of-injury exclusions . (ii) Conclusion. Plan Sponsor F offers its full-time employees hired on or after January 1, 2022, an HRA on the same terms and it continues to offer its full-time employees hired before that date a traditional group health plan. (E) If reasonable under the circumstances, a plan or issuer may seek verification, such as a statement from an individual's personal physician, that a health factor makes it unreasonably difficult for the individual to satisfy, or medically inadvisable for the individual to attempt to satisfy, the otherwise applicable standard of an activity-only wellness program. developer resources. Benefits provided under an HRA or other account-based group health plan, other than a health FSA, are excepted if they satisfy all of the requirements of this paragraph (b)(3)(viii). (4) If an individual's personal physician states that a plan standard (including, if applicable, the recommendations of the plan's medical professional) is not medically appropriate for that individual, the plan or issuer must provide a reasonable alternative standard that accommodates the recommendations of the individual's personal physician with regard to medical appropriateness. Published on May 10, 2023. If you complete this program, you will qualify for a reward. (2) For purposes of paragraph (f)(1)(ii) of this section, modifications made uniformly and solely pursuant to applicable Federal or State requirements are considered a uniform modification of coverage if: (i) The modification is made within a reasonable time period after the imposition or modification of the Federal or State requirement; and. (In addition, the plan also violates the similar rule in paragraph (b)(2) of this section.). (2) No traditional group health plan may be offered to same participants. The program also satisfies the requirements of paragraph (f)(4)(iv) of this section because it makes available to all individuals who do not satisfy the BMI standard a reasonable alternative standard to qualify for the reward (in this case, a walking program that is not unreasonably burdensome or impractical for individuals to comply with and that is otherwise reasonably designed based on all the relevant facts and circumstances). Faculty and staff are treated differently with respect to other employee benefits such as retirement benefits and leaves of absence. (ii) Conclusion. (C) Similar supplemental coverage provided to coverage under a group health plan. In this Example 2, the requirement to provide evidence of good health in order to be eligible for late enrollment in the HMO option is a rule for eligibility that discriminates based on one or more health factors and thus violates this paragraph (b)(1). See special rules for office visits in paragraph (c)(3)(iii) of this section. (4) The finding by the Secretary is made after submission of a written recommendation by the applicable state authority of such state, in a form and manner specified by HHS. For the purpose of this paragraph (d)(6) and paragraph (f)(1) of this section, a student premium reduction arrangement is defined as any program offered by an institution of higher education under which the cost of insured or self-insured student health coverage is reduced for certain students through a credit, offset, reimbursement, stipend or similar arrangement. (ii) The written report described in paragraph (g)(3)(i) of this section shall be maintained by the group health plan or health insurance issuer, along with all supporting documentation relied upon by the actuary, for a period of six years following the notification made under paragraph (g)(6) of this section. There is no evidence to suggest that the classification is directed at individual participants or beneficiaries. (a) In general. Next, its important to know where to go to explore your options for both individual and group health plans. The same terms requirement of paragraph (c)(3) of this section is satisfied in this paragraph (f)(1)(iv) (Example 4) because employees who have completed a waiting period and employees who have not completed a waiting period may be treated as different classes and Plan Sponsor D offers an HRA on the same terms to all participants who have not completed the waiting period. 2. (B) Conclusion. (iii) The rules of this paragraph (b)(1) are illustrated by the following examples: (i) Facts. A group health plan applies a $2 million lifetime limit on all benefits. If you do choose to offer coverage, there are regulations you will have to followthe most important of which we explain on this site. Limited-scope dental benefits, limited-scope vision benefits, or long-term care benefits are excepted if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of a group health plan as described in paragraph (b)(3)(ii) of this section. In this Example 1, the plan violates the rules of this paragraph (c)(3) because coinsurance for the second 24-hour period of the 48-hour stay is greater than that for the preceding portion of the stay. (g) Requirements not subject to exemption . Plan Sponsor E is a staffing firm that places certain of its employees on temporary assignments with customers that are not the common law employers of Plan Sponsor E's employees or treated as a single employer with Plan Sponsor E under section 414(b), (c), (m), or (o) of the Code (unrelated entities); other employees work in Plan Sponsor E's office managing the staffing business (non-temporary employees). Employers with 20 or more employees are required by law to offer current workers and their spouses who are age 65 (or older) the same GHP health benefits that are provided to younger employees. Members who take up the insurance are generally eligible to renew coverage while they continue to be members of the group, subject to certain conditions. (ix) Example 9: New full-time employees and part-time employees offered HRA . For 2020 and again for 2021, Plan Sponsor A offers all employees $7,000 each in an HRA, and the HRA provides that amounts that are unused at the end of a plan year may be carried over to the next plan year, with no restrictions on the use of the carryover amounts compared to the use of newly available amounts. See special rules for office visits and plans with multiple network tiers in paragraph (c)(3)(iii) of this section. For example, most employees dont know that an advanced scan, such as an MRI, can be thousands of dollars less if performed at a free-standing clinic rather than in the hospital setting. A plan may require an employee declining coverage (for the employee or any dependent of the employee) to state in writing whether the coverage is being declined due to other health coverage only if, at or before the time the employee declines coverage, the employee is provided with notice of the requirement to provide the statement (and the consequences of the employee's failure to provide the statement). (2) Hospital stay benefits not mandated. (e) Integration of Individual Coverage HRAs with Medicare . (iii) Part A or B of Title XVIII of the Social Security Act (Medicare). (ii) Conclusion. 2. If the plan combines the highest levels of copayment, the combined projected payments for the two highest copayment levels, the $50 copayment and the $20 copayment, are not more than one-half of the outpatient, in-network medical/surgical benefits subject to a copayment because they are exactly one-half ($300x + $100x = $400x; $400x/$800x = 50%). (5) Research exception. (ii) Conclusion. In states, and for products where applicable, the premium may include a $1 administrative fee. Based on the information about A and A's dependents, the issuer excludes A and A's dependents from the group policy it offers to the employer. Most of the time consumers shop around for the best price. For all medical/surgical benefits, the plan imposes a coinsurance requirement. The participant's personal physician is permitted to change or adjust the treatment plan at any time and the option of following the participant's personal physician's recommendations is clearly disclosed. (1) The HRA or other account-based group health plan is offered by a small employer (as defined in PHS Act section 2791(e)(4)). Subject to paragraph (c)(3)(i)(D) of this section, any reasonable method may be used to determine the dollar amount expected to be paid under a plan for medical/surgical benefits subject to a financial requirement or quantitative treatment limitation (or subject to any level of a financial requirement or quantitative treatment limitation). Coverage and Use of Fertility Services in the U.S. | KFF (1) A health insurance issuer may deny health insurance coverage in the small group market if the issuer has demonstrated to the applicable State authority (if required by the State authority) that it, (i) Does not have the financial reserves necessary to underwrite additional coverage; and. Any participant for whom it is unreasonably difficult due to a medical condition to comply with this walking program (and any participant for whom it is medically inadvisable to attempt to comply with the walking program) during the year is given the same discount if the participant satisfies an alternative standard that is reasonable taking into consideration the participant's medical situation, is not unreasonably burdensome or impractical to comply with, and is otherwise reasonably designed based on all the relevant facts and circumstances. The issuer is ceasing to offer coverage in the market in accordance with paragraph (c) or (d) of this section and applicable State law. For purposes of this section. A group health plan provides benefits for at least a 48-hour hospital length of stay following a vaginal delivery. (i) Facts. (iv) Audits. In this Example 1, A has been diagnosed by a health care professional with appropriate training and expertise in the field of medicine involved. Under a group health plan, coverage is made available to employees, their spouses, and their children. The plan or issuer must disclose in all plan materials describing the terms of an activity-only wellness program the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard), including contact information for obtaining a reasonable alternative standard and a statement that recommendations of an individual's personal physician will be accommodated. On the first day of the 2022 plan year, Plan Sponsor B has 2 new hire, full-time employees who are offered the HRA. The plan sends out a notice to all participants that describes the diabetes disease management program and explains the terms for eligibility. (i) Facts. These conditions are intended to prevent an HRA plan sponsor from intentionally or unintentionally, directly or indirectly, steering any participants or dependents with adverse health factors away from its traditional group health plan, if any, and toward individual health insurance coverage. (A) Variation due to number of dependents. (Premiums are typically shared by the employer and employees and how thats split is determined by the employer.). To the extent a plan sponsor offers any class of employees (as defined in paragraph (d) of this section) an individual coverage HRA, the plan sponsor may not also offer a traditional group health plan to the same class of employees, except as provided in paragraph (d)(5) of this section. No genetic information collected or acquired under this paragraph (c)(5) can be used for underwriting purposes (as described in paragraph (d)(1) of this section). (The $250 reward is offered in connection with a participatory wellness program and therefore is not taken into account.) If a mother and newborn covered under the plan are discharged within 24 hours after the delivery, the plan will waive the copayment and deductible. For New Mexico residents: Insured by Humana Insurance Company. (i) A genetic test, as defined in paragraph (a)(5) of this section; (ii) Genetic counseling (including obtaining, interpreting, or assessing genetic information); or. This policy is applied uniformly to all similarly situated individuals and is not directed at individuals based on any genetic information. Former employees may also be eligible, but only if they complete a specified number of years of service, are enrolled under the plan at the time of termination of employment, and are continuously enrolled from that date. In the case of health insurance coverage that is made available by a health insurance issuer in the small or large group market to employers only through one or more associations, the reference to plan sponsor is deemed, with respect to coverage provided to an employer member of the association, to include a reference to such employer. (vii) Examples. (1) In general. Parity in mental health and substance use disorder benefits. Under the terms of the HRA, a participant who is otherwise eligible for coverage must be permitted to opt out of and waive future reimbursements on behalf of the participant and all dependents eligible for the HRA from the HRA once, and only once, with respect to each plan year. (1) Limited wraparound coverage that wraps around eligible individual insurance for persons who are not full-time employees. In this Example 1, because A satisfies the conditions for special enrollment under paragraph (a)(2)(i) of this section, A, A's spouse, and A's dependent children are eligible for special enrollment under X's plan. An HRA does not fail to be treated as provided on the same terms if the plan sponsor offers the HRA to some, but not all, former employees within a class of employees.