May 29, 2019

Extended Relief for Non-ACA-compliant Small Group and Individual Policies and Plans

Expand/collapse »

March 19, 2019

IRS Provides Tax Relief for Victims of Severe Storms, Tornados and Straight-Line Winds

Expand/collapse »

June 12, 2018

Alabama Enacts Data Breach Notification Law

Expand/collapse »

June 13, 2017

Law on Group Health Coverage for Autism Spectrum Disorder Amended

Expand/collapse »

March 7, 2017

Extension of Non-PPACA-compliant Small Group and Individual Policies and Plans

Expand/collapse »

October 20, 2015

On Oct. 1, 2015, Insurance Commissioner Ridling issued Bulletin No. 2015-06. The bulletin encourages insurers and vision care providers to review their plan form filings and provider contracts to ensure compliance with the terms of recently adopted Ala. Act No. 2015-481 (SB 270, 2015 Regular Session).

As background, on June 11, 2015, Gov. Bentley signed SB 270 into law. The law prohibits insurers of vision care services from limiting a vision care provider's ability to set fees for services and materials, to participate in specific vision care plans and to choose sources of suppliers in certain circumstances. The law also prohibits vision care providers from charging more to an insurer than the customary rates of those vision care providers and requires reasonable reimbursements for vision care services and materials to vision care providers. The Alabama Department of Insurance may adopt rules to implement this law.

The law became effective June 11, 2015.

Bulletin No. 2015-06 »

July 14, 2015

On June 11, 2015, Gov. Bentley signed SB 296 into law. The law places restrictions on the terms of certain health insurance policies, health maintenance organization plans and other health benefit plans with respect to dental services. The new law prohibits a policy or plan from setting fees for services that are not covered by the plan or policy and provides certain exceptions. Specifically, an insurance policy, plan or contract providing for third-party payment or prepayment of health or medical expenses issued after Jan. 1, 2016 may not require a dental care provider to provide service to a covered person at a fee set by the policy or plan unless the services are covered by the policy or plan. The law becomes effective Sept. 1, 2015.

Senate Bill 296 – Act No. 2015-483 »

On June 11, 2015, Gov. Bentley signed SB 270 into law. The law prohibits insurers of vision care services from limiting a vision care provider's ability to set fees for services and materials, to participate in specific vision care plans and to choose sources of suppliers in certain circumstances. The law also prohibits vision care providers from charging more to an insurer than the customary rates of those vision care providers and requires reasonable reimbursements for vision care services and materials to vision care providers. The Department of Insurance may adopt rules to implement this law. The law is effective immediately.

Senate Bill 270 – Act No. 2015-481 »

February 10, 2015

On Jan. 26, 2015, a federal district court ruled that Alabama's prohibitions against permitting same-sex marriage are unconstitutional. Previously, the court ruled that Alabama's prohibitions against recognizing out-of-state same-sex marriages are unconstitutional. The court blocked the state from enforcing these prohibitions, but stayed both rulings until Feb. 9, 2015 (Strawser v. Strange, S.D. Ala., No. 1:14-cv-00424, 1/26/15; Searcy v. Strange, S.D. Ala., No. 1:14-cv-00208, 1/23/15). On Feb. 9, 2015, the U.S. Supreme Court denied the application for a continued stay. Therefore, it appears that same-sex marriage is legal in Alabama.

The rapid changes in state marriage laws have important effects for individuals in Alabama and for employers administering state tax rules. They are less significant for purposes of administering federal tax and benefit rules due to the Supreme Court's Windsor decision and subsequent agency guidance recognizing all same-sex spouses regardless of state of residence. Employers in Alabama should work closely with their attorneys and tax advisors to ensure plan design compliance in light of the ongoing developments in this area.

This will most likely mean that group health insurance policies issued in Alabama will need to amend their plan documents to offer coverage to same-sex spouses. We are expecting further guidance from the state and will report such in future editions of Compliance Corner.

Strawser v. Strange »
Searcy v. Strange »
Feb. 9, 2015, U.S. Supreme Court Order »

October 7, 2014

On Oct. 2, 2014, the U.S. DOL’s Wage and Hour Division and the Alabama Department of Labor signed a memorandum of understanding to work together to identify misclassification of employees as independent contractors. Alabama joins other states which already have such an agreement in place, including California, Colorado, Connecticut, Hawaii, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Minnesota, Missouri, Montana, New York, Utah and Washington. The issue of misclassification of workers has been emphasized over the last few years due to the potential for these workers to be denied access to health insurance, benefits, family and medical leave, overtime compensation, minimum wage and unemployment insurance. Due to health care reform, there is even greater focus on employers properly identifying workers who must be offered employer-sponsored health insurance if they are working at least 30 hours per week, or the employer may be at risk for a penalty under the employer mandate.

Press release »
DOL misclassification homepage »

August 12, 2014

On July 28, 2014, the Alabama Department of Insurance issued Bulletin No. 2014-03. The bulletin provides guidance regarding calculation of composite rates for Alabama-issued policies for policy years beginning on or after Jan. 1, 2015. As background, final rules issued by HHS March 11, 2014, provided for a two-tiered federal calculation method for composite rates (one tier for each covered adult age 21 or older and a second tier for each covered child under age 21). However, the same final rule permitted states to substitute their own alternative to the federal methodology by seeking approval from HHS. This bulletin issued by the state of Alabama is confirmation that the state has sought such alternative certification and it was approved. In this case, the state requested to use a four-tiered calculation: employee, employee + spouse, employee + children and employee + family.

This means that while health insurance carriers issuing small group market plans in the state will continue to provide per-member billing, they may choose to provide family composite premiums on an optional basis. If they do so, the carrier must follow the state's four-tiered approved alternative method. If a carrier offers the family composite methodology, it must make it available for each small employer in the market.

The bulletin provides definitions for each rating tier, as well as the factors to be used when determining the final premium charged for each employee. Importantly, the bulletin does not apply directly to small employers, although this information is important for all employers to understand. Small employers in Alabama may use composite rates rather than per member rates to determine the percentage of the premium paid by the employer versus employee contribution levels for policies issued in 2015 if the carrier has opted to follow this alternative calculation method. The bulletin is effective immediately.

Bulletin No. 2014-03 »
Federal Chart of Approved States with Rating Variations »

May 20, 2014

On April 2, 2014, Gov. Bentley signed SB 123 into law, creating Act 2014-219. The law suspends the Alabama Health Insurance Plan (AHIP), which is the state's high-risk pool. The law includes an exception that would allow the AHIP to reopen if federal law ever requires the state of Alabama to offer guaranteed-issue health coverage to eligible individuals.

Act 2014-219 »

January 20, 2021

COVID-19 Insurance Update

Expand/collapse »

November 10, 2020

State Insurance Update

Expand/collapse »

April 28, 2020

COVID-19 Insurance Updates

Expand/collapse »

April 14, 2020

COVID-19 Insurance Updates

Expand/collapse »

March 31, 2020

COVID-19 Insurance Updates

Expand/collapse »

March 17, 2020

Insurance Updates Regarding COVID-19

Expand/collapse »

March 3, 2020

Grandmothered Plans Extended

Expand/collapse »

April 2, 2019

One-Year Extension for Grandmothered Plans

Expand/collapse »

February 5, 2019

Information on AHPs

Expand/collapse »

May 1, 2018

Extension of Non-ACA-Compliant Plans

Expand/collapse »

July 25, 2017

HHS Approves Alaska's Section 1332 Waiver from Several ACA Requirements

Expand/collapse »

August 23, 2016

Updates to Coverage for Primary Care Provider, Pediatrician and OB-GYN Services

On July 20, 2016, Gov. Walker signed HB 372 into law, which provides updates to coverage requirements for services provided by primary care providers (PCPs), obstetricians and gynecologists (OB-GYNs) and pediatricians. On PCPs and pediatricians, plans that provide coverage through networks of providers must allow plan participants to access out-of-network providers. Such plans may require higher copayments, deductibles or premiums for out-of-network providers. Also, if a plan requires participants to designate a PCP, participants may choose any available PCP (which, effective Oct. 16, 2016, includes a pediatrician) to receive appropriate specialty care. On OB-GYNs, effective Oct. 16, 2016, plans that provide coverage for OB-GYN services and require participants to select a PCP must allow female participants to receive OB-GYN care from participating providers that specialize in OB-GYN services without requiring prior authorization or referrals. Employers with fully insured plans in Alaska should be aware of the new law and requirements.

HB 372 »

August 9, 2016

On July 11, 2016, Gov. Walker signed SB 53 into law. The new law contains two separate requirements for fully insured plans in Alaska. The first requirement relates to coverage for autism spectrum disorder. Under current law, coverage must include treatment prescribed by a licensed physician or psychologist. Under the new law, that list includes treatment prescribed by an advanced practice registered nurse practitioner. The second requirement relates to coverage of services provided by midwives. Specifically, under the new law, plans that provide coverage for services performed for women during pregnancy and childbirth (and for a period of time following childbirth) must provide coverage for the same services performed by advanced practice registered nurses, so long as the services performed are within the practice scope of certified midwives (also sometimes referred to as ‘certified nurse midwives’). The law is effective July 7, 2016. Overall, the law adds no new employer compliance obligations, but employers with fully insured plans in Alaska should be aware of the changes.

SB 53 »

On July 11, 2016, Gov. Walker signed SB 142 into law. The new law relates to coverage for certain anti-cancer treatment for fully insured plans in Alaska. Under the new law, plans that provide coverage for anti-cancer medications that are injected or administered intravenously by a health care provider and such medications administered directly by the plan participant (such as orally administered or self-injected medications) cannot apply higher cost-sharing (including co-insurance, co-payments or deductibles) than the plan applies to injected or intravenously anti-cancer medications. This is the case regardless of the plan’s formulations or benefit category design or determination. For purposes of the new law, “anti-cancer medications” include drugs or biologics used to kill, slow or prevent the growth of cancerous cells or to treat related side effects. The new law is effective for plans beginning (or renewed) on or after Jan. 1, 2017. The law includes no new employer compliance obligations, but employers with fully insured plans in Alaska should be aware of it.

SB 142 »

July 12, 2016

On June 14, 2016, Gov. Walker signed HB 234 into law, creating Chapter 17. Under the new law, plans that provide coverage for mental health benefits must provide coverage for those benefits delivered through telehealth services by Alaska-licensed health care providers. The law applies to plans offered, issued, delivered or renewed in Alaska on or after Sept. 11, 2016. The new law does not add new employer obligations, but fully insured Alaska employers should be aware of the coverage requirements.

Chapter 17 »

May 3, 2016

On March 24, 2016, the Alaska Division of Insurance published Bulletin 16-04. The bulletin relates to an extension of non-PPACA-compliant small group policies and plans. As background, the federal government previously announced a transition policy that allows insurers (if allowed by the state) to renew non-grandfathered non-PPACA-compliant plans, so long as the transitional coverage does not extend beyond Dec. 31, 2017.

Bulletin 16-04 states that the Division will allow insurers the option to renew non-PPACA-compliant policies if coverage has been continuously in effect since Dec. 31, 2013. Those policies may continue to be renewed on or before Oct. 1, 2017, provided the policy will terminate by Dec. 31, 2017. Insurers may early renew or issue coverage for periods less than one year if a policy terminates prior to Dec. 31, 2017 and the employer wants coverage through the end of the calendar year.

The bulletin presents two options for insurers that elect to extend non-PPACA-policies. Under the first option, an insurer may permit employer-sponsored groups currently enrolled in the insurer’s non-PPACA-compliant plan to continue to renew their coverage. Under the second option, the insurer may provide an additional opportunity to renew coverage in its non-PPACA-compliant plan to an employer-sponsored group that is currently enrolled in the insurer’s non-PPACA-compliant plan but has indicated its intent to non-renew at the end of the plan year.

Alaska small employers that are interested in renewing a non-PPACA-compliant plan should work with their advisors and insurers.

Bulletin 16-04 »

August 25, 2015

On Aug. 13, 2015, the Alaska Department of Labor and Workforce Development signed a memorandum of understanding (MOU) with the DOL. The MOU is meant to announce that the state and the DOL will work together to prevent the improper classification of employees as independent contractors or other non-employee workers. The MOU states that the two entities will share information and coordinate enforcement in an effort to protect employee/worker rights under both federal and state law. The MOU arose as a result of the DOL’s Misclassification Initiative. According to the press release, Alaska is one of 25 states to sign such an MOU with the DOL.

Alaskan employers should review their employment practices to ensure that individuals are properly classified as either employees or independent contractors. The proper classification is important for purposes of PPACA’s employer mandate, as well as many other federal and state laws and calculation of employment taxes. Because the classification analysis is based on the specific facts and circumstances surrounding an employer’s situation, employers should work with outside counsel to resolve any questions.

Misclassification MOU »
DOL News Brief »
Alaska Press Release »
DOL Misclassification Initiative Web Page »

March 24, 2015

On Feb. 23, 2015, the Alaska Division of Insurance issued a press release relating to a special enrollment period (SEP) for the Alaska health insurance exchange. As background, on Feb. 20, 2015, the federal government announced it would allow a SEP related to the federal tax penalty for consumers in states with health exchanges run by the federal government. The press release states that Alaskans who "first became aware of, or understood the implications of, the shared responsibility payment in connection when preparing their 2014" federal income taxes will have the opportunity to avoid the penalty in 2015 by signing up for coverage during a SEP between March 15 and April 30. To qualify for the SEP, Alaskans must certify that they filed their tax returns and paid the penalty for not having coverage in 2014.

The news release does not require any new compliance obligations or otherwise affect employers in Alaska. However, employers will want to be aware of the news release should employees have questions relating to SEP opportunities in the exchange.

Press Release  »

On Feb. 18, 2015, the Alaska Division of Insurance published Bulletin B 15-05. The bulletin applies to insurers and relates to coverage of services relating to behavior analysis and other autism service providers, as required by Alaska law. According to the bulletin, denying a claim solely on the basis that a behavioral analyst is not licensed in Alaska is a violation of Alaska law. An insurer’s failure to promptly pay such claims may also result in late payment interest penalties.

Although the bulletin applies to insurers, employers in Alaska should be aware of the bulletin and the coverage requirements relating to behavior analysis and autism service providers, particularly those that may not be licensed in Alaska.

Bulletin B 15-05 »

November 4, 2014

On Oct 17, 2014, the U.S. Supreme Court denied Alaska’s request for a stay in a case, Parnell v. Hamby, Case No. 3:14-cv-00089-TMB (D. Alaska Oct. 12, 2014) challenging Alaska’s ban on same-sex marriage. As background, in 1998 Alaska voters passed a constitutional amendment that defines “marriage” as between one man and one woman. That constitutional amendment has been the subject of recent litigation. Earlier this month, a federal district court in Alaska ruled that the amendment is unconstitutional. That decision paved the way for same-sex couples to begin marrying in Alaska. However, the state requested a stay on the decision and over the course of a few days, that request made its way to the U.S. Supreme Court. As a result of the stay’s denial, same-sex marriage is now legal in Alaska. Although no specific guidance has been released, the ruling most likely means that group health insurance policies issued in Alaska will be required to cover same-sex spouses. NFP Benefits Compliance will continue to monitor the issue and report on any additional guidance in future editions of Compliance Corner.

Supreme Court Denial  »

September 9, 2014

On July 2, 2014, the Alaska Division of Insurance updated a document titled “2015 Alaska ACA Form and Rate Guidance.” The update relates to Alaska’s approach for composite rating requirements in the small group market. As background, final rules issued by HHS March 11, 2014, provided for a two-tiered federal calculation method for composite rates (one tier for each covered adult age 21 or older and a second tier for each covered child under age 21). However, the same final rule permitted states to substitute their own alternative to the federal methodology by seeking approval from HHS.

The Alaska document states that Alaska has been approved for and will implement a four-tiered rating structure, including employee, employee plus spouse, employee plus children, and employee plus family. This means that while insurers issuing small group market plans in the state will continue to provide per-member billing, they may choose to provide family composite premiums on an optional basis. If so, the insurer must follow the state’s four-tiered alternative method. If an insurer offers the family composite methodology, it must make it available for each small employer in the market, regardless of size. Tiered composite premium rates must be set at the beginning of the plan year and do not change through the year, even if the distribution of employees among the tier levels changes.

The tiered-composite methodology applies to Alaska small employer premium rates for plans offered outside of the federally facilitated exchange in Alaska beginning Jan. 1, 2015. Those offered on the exchange must use per-member premium ratings.

The document provides definitions for each rating tier, as well as the factors and methodology to be used when determining the final premium charged for each employee. Importantly, the bulletin does not apply directly to small employers, although this information is important for all employers to understand. If the insurer has opted to follow the four-tiered alternative calculation method, small employers in Alaska may use composite rates rather than per-member rates to determine the percentage of premium paid by the employer versus the employee.

2015 Alaska ACA Form and Rate Guidance »
Federal Chart of Approved States with Rating Variations »

April 8, 2014

On March 28, 2014, the Alaska Division of Insurance issued Bulletin B14-03. The bulletin relates to the March 5, 2014, CMS announcement of a two-year extension to the transitional policy for non-PPACA-compliant health benefit plans (as covered in the March 11, 2014, edition of Compliance Corner). The bulletin states that Alaska will allow insurers to renew non-grandfathered plans according to the extended CMS transitional policy in both the individual and small group markets. Alaska employers that have had their plans cancelled should consult with insurers on whether those plans can be continued in light of the CMS announcement and the department’s directive.
Bulletin B14-03 »

April 28, 2020

COVID-19 Insurance Updates

Expand/collapse »

April 14, 2020

Executive Order on Prescription Drug Coverage During COVID-19

Expand/collapse »

FAQ Regarding the Fair Wages and Healthy Families Act

Expand/collapse »

March 31, 2020

Insurance Updates Regarding COVID-19

Expand/collapse »

January 24, 2017

State Disability Rates Revised for 2017

Expand/collapse »

San Francisco HCSO Health Care Expenditure Rates Increased for 2017

Expand/collapse »

January 10, 2017

New Law Mandates Paid Sick Leave for Santa Monica Employees

Expand/collapse »

October 4, 2016

Out-Of-Network Coverage and Cost-Sharing

On Sept. 23, 2016, Gov. Brown signed AB 72 into law. This new legislation amends the California Health & Safety Code to address reimbursement for out of network (OON) providers who provide services at in-network facilities. California joins several other states, including New York, Connecticut and Florida, which offer consumers protections against surprise OON bills, as well as a process for providers and insurers to resolve payment disputes for OON care.

The legislation provides that if an insured receives services covered by his/her health plan by an OON provider at an in-network facility, the insured is only obligated to pay the OON provider the cost sharing amount that he/she would otherwise be obligated to pay had the same covered service been provided by an in-network provider. In addition, the OON provider is prohibited from billing or collecting any amount beyond the insured’s cost sharing obligation, unless the insured has a plan that includes an OON benefit and the insured consents in writing to receive services from the OON provider at least 24 hours in advance of the episode of care. At the time consent is provided, the OON provider must give the insured a written estimate of his/her total out-of-pocket cost of care.

A health plan must pay an OON provider who provides covered services to an insured at an in-network facility the greater of the average contracted rate or 125 percent of the amount Medicare reimburses for the same or similar service. Payment made by the plan to the OON provider will constitute payment in full unless either party uses the independent dispute resolution process or other means to resolve the dispute. The Department of Managed Health Care will establish a new independent dispute resolution process for resolving payment disputes between OON providers and payers.

AB 72 is effective July 1, 2017.

AB 72 »

Contraceptives: Annual Supply

On Sept. 23, 2016, Gov. Brown signed SB 999 into law. This law enables doctors and other health-care providers to prescribe up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives such as birth control pills, the ring and the patch. In addition, it authorizes pharmacists to dispense, at a patient’s request, up to a 12-month supply of FDA-approved contraceptives at one time and it requires health care service plans and health insurance policies to cover the costs of a 12-month prescription. Currently, women are allowed to fill at most a 90-day prescription of birth control at one time.

SB 999 becomes effective Jan. 1, 2017.

SB 999 »

Premium Rate Change Notice

On Sept. 23, 2016, Gov. Brown signed SB 908 into law. This law is meant to help alert consumers whenever state regulators consider increases to their health insurance premiums to be too high. Under current law, the California Department of Managed Health Care and the California Department of Insurance review premium rate increases proposed by insurers and health plans that each agency regulates. When the agencies conclude that an increase is unjustified, they can ask the insurer to rescind the increase, but the company is not legally obligated to comply. The agencies’ only recourse is to post the information on their websites.

Under this new legislation, insurers are required to send written notices to policyholders advising them that regulators found their small group premium rate increases to be unreasonable or unjustified. The notices must be sent at least 60 before the policy renewal date, or 10 days before the start of the next health insurance open enrollment period, thereby giving consumers time to shop for a new plan.

SB 908 is effective Jan. 1, 2017.

SB 908 »

Autism and Pervasive Developmental Disorders

On Sept. 23, 2016, Gov. Brown signed AB 796 into law, which amends California’s Lanterman Developmental Disabilities Services Act. Under that law, every health care service plan contract and health insurance policy issued in California must provide coverage for behavioral health treatment for pervasive developmental disorder or autism until Jan. 1, 2017. This new legislation simply deletes the sunset date in the Lanterman Act and extends the operation of these provisions indefinitely, thereby creating a new state-mandated program that will provide services for people with developmental disabilities, including autism.

AB 796 is effective Jan. 1, 2017.

AB 796 »

Notice of Timely Access to Care

On Sept. 23, 2016, Gov. Brown signed SB 1135 into law. The new legislation requires health plans and insurers in California to notify consumers and health care providers about a patient’s right to timely care and language assistance. Under current law, consumers have the right to timely access to care and care in their preferred language. However, very few people know these consumer protections exist. Therefore, this new law requires health plans and insurers to communicate these rights through existing documents and communication channels, such as:

• Evidence of coverage documents;
• Wherever information on language assistance is provided, as required by existing law;
• Provider directories;
• Health plan and insurer websites; and
• Annual enrollment or renewal notices.

In addition, SB 1135 requires health plans and insurers in California to provide doctors, hospitals and other health providers with information about timely access requirements.

SB 1135 is effective July 1, 2017.

SB 1135 »

Cost-sharing Changes

On Aug. 25, 2016, Gov. signed SB 923 into law. This law prohibits health plans and insurers in the individual and small group markets from changing the cost-sharing design during the plan year except when required by state or federal law. Under current law, health plans and insurers are prohibited from changing the premium rates in a given “rate year.” This new law extends that protection to a plan’s cost-sharing design as well. For purposes of this legislation, cost-sharing refers to what the copays or coinsurance are for a specific benefit: For example, the copay for a generic drug is $10 or $25; the copay for the brand name drug is $20 or $50 while the coinsurance for a hospital stay is 20 percent of the cost.

SB 923 is effective on Jan. 1, 2017.

SB 923 »

Immigration Status

Earlier this year, Gov. Brown signed SB 10 into law. SB 10 expands health care coverage to all Californians, regardless of immigration status, by permitting the state to apply for a federal waiver that would allow undocumented immigrants and their non-US born children to buy coverage through Covered California, the state’s health insurance marketplace, by using their own money. PPACA explicitly excludes undocumented immigrants from receiving health coverage through federally-funded programs, including Covered California. This law removes that barrier by directing the state to apply for a waiver under PPACA Section 1332. If granted, the waiver would make it possible for undocumented adults to review and purchase plans from Covered California. These individuals will remain ineligible to receive subsidies.

While the law is effective immediately, the requirement to offer qualified health plans to undocumented individuals on the state’s exchange does not become operative until Jan. 1, 2018, for coverage beginning Jan. 1, 2019. This allows the state time to apply for and receive a Section 1332 waiver.

SB 10 »

June 1, 2016

On Oct. 8, 2015, California Gov. Jerry Brown signed AB 1305 into law. This law imposes a maximum out-of-pocket (OOP) limit for an in individual participant enrolled in family coverage that is no greater than the maximum OOP limit for self-only coverage for that insurance product. Essentially, this means that for all fully-insured plans sitused in California, an individual enrolled in family coverage will not be required to pay more than what he/she would pay in OOP expenses if he/she were enrolled in self-only coverage under the same insurance product. In other words, the self-only OOP maximum is “embedded” in the family coverage. This OOP maximum requirement went into effect on Jan. 1, 2016.

Additionally, AB 1305 requires embedded deductibles. This means that if a family plan includes a deductible, the plan may not impose a greater deductible on an individual participant in family coverage than the deductible for self-only coverage. For individual and small group plans, the embedded deductible requirement became effective Jan. 1, 2016, and for large group plans, this requirement becomes effective Jan. 1, 2017.

AB 1305 does pose a compliance concern for employers offering fully-insured HSA-compatible HDHP coverage in California if that coverage offers a self-only deductible or OOP maximum amount that is below the minimum federal deductible required for family HDHP coverage.

As background, PPACA imposes OOP maximums on individual and group health plans. For 2016, those maximum limits are $6,850 for self-only coverage, and $13,700 for family coverage. Furthermore, to be eligible to contribute to an HSA, federal law requires that an individual be covered under an HDHP that meets certain deductible thresholds (and those are indexed each year). For 2016, an HDHP must have a minimum deductible of $1,300 for self-only coverage and $2,600 for family coverage.

However, in light of this new law, let’s consider a fully-insured HSA-compatible plan with a deductible and OOP maximum of $1,500 for individual coverage and $3,000 for family coverage. AB 1305 requires that the family HSA benefit have an embedded OOP maximum of $1,500 for individuals since the OOP maximum is $1,500 for individuals; despite the fact that federal law requires that in order to be considered as a qualified HDHP for HSA purposes, the family deductible has to be no lower than $2,600. This contradicts federal rules. Therefore, in order to satisfy AB 1305 requirements and at the same time comply with federal HSA-HDHP rules, fully-insured HSA-compatible HDHP plans in California have increased their self-only OOP maximums to meet the family $2,600 deductible threshold.

Changes may be forthcoming to resolve this potential problem, and NFP Benefits Compliance will provide an update if the legislation is revised. Also, it’s worth noting that AB 1305 does not apply to grandfathered plans; rather it applies to non-grandfathered individual and group health care service plan contracts that provide for essential health benefits.

AB 1305 »

April 19, 2016

As a reminder, employers covered by San Francisco's Health Care Security Ordinance (HCSO) are required to submit the 2015 Employer Annual Reporting Form to the Office of Labor Standards Enforcement (OLSE) by April 30, 2016. Failure to submit the form may result in penalties of $500 per quarter. If you were not covered by the HCSO in any quarter of 2015, you do not need to submit the form, and no further action is required.

Employers can check whether they are required to complete the form by completing a short survey on the first page of the Annual Reporting Form. Employers that were not covered by the HCSO in 2015 will be directed to a web page indicating that they do not need to complete the remainder of the 2015 Employer Annual Reporting Form.

Annual Reporting Form »
Additional Information »

On April 11, 2016, Gov. Jerry Brown signed AB 908 into law. The law will bolster the Paid Family Leave (PFL) program for all California workers by increasing the PFL wages available to workers who take time off to care for ill family members or bond with a new child.

Under the current California PFL law, California workers may receive 55 percent of their wages for up to six weeks. However, starting Jan. 1, 2018, those wages will increase as follows:

• If an employee earns up to 33 percent of the state's average weekly wage ($1,120.67), the employee’s PFL wage replacement will go from 55 to 70 percent of normal earnings;
• If an employee earns more than 33 percent of the state's average weekly wage ($1,120.67), that employee’s PFL wage replacement will go from 55 to 60 percent of normal earnings.

In addition to PFL wage increases, the new law eliminates the one-week waiting period for PFL claims. The 6-week period for PFL benefits will not change.

AB 908 »

January 12, 2016

The California Employment Development Department (EDD) recently announced that the 2016 employee contribution rate for State Disability Insurance will remain at 0.9 percent. The taxable wage base from which the contributions will be taken will increase from $104,378 to $106,742 for calendar year 2016 and the maximum cost to an employee will be $960.68.

For claims beginning on or after Jan. 1, 2016, weekly benefits range from $50 to a maximum of $1,129. To qualify for the maximum weekly benefit amount ($1,129) an individual must earn at least $26,070.92 in a calendar quarter during the base period.

Finally, effective Jan. 1, 2016, the tax rate for employers, partners and self-employed individuals who choose coverage in California's temporary disability insurance program is 4.67 percent.

Disability Insurance and Paid Family Leave Benefit Amounts »

Rates, Withholding Schedules and Meals and Lodging Values »

The San Francisco Health Care Security Ordinance (HCSO) requires covered employers to satisfy an employer spending requirement by making health care expenditures for their covered employees, among other reporting and notice requirements. For more information on what constitutes covered employers/covered employees, please visit the San Francisco HCSO website, linked below.

The health care expenditure rate varies depending on the size of the employer and increases slightly each year. As of Jan. 1, 2016, the health care expenditure rate for employers with 100 or more employees will be $2.53 per hour payable (up from $2.48 per hour payable in 2015). For employers with 20 to 99 employees, the expenditure rate will increase to $1.68 per hour payable (up from $1.65 per hour payable in 2015).

The San Francisco Office of Labor Standards Enforcement (OLSE) is responsible for enforcing the employer requirements of the HCSO.

San Francisco HCSO Website »

Beginning Jan. 1, 2016, the city of San Francisco requires that at least 80 percent of the required amount of health care expenditures for each covered employee must be made as irrevocable expenditures. An irrevocable health care expenditure is a health care expenditure that has not been retained by and cannot at any time be recovered by or returned to the employer. For more information on what constitutes a revocable and irrevocable expenditure, please visit the HCSO website.

San Francisco HCSO Website »

All covered employers are required by the HCSO to post an official notice regarding the HCSO in a conspicuous place at any workplace or job site where any covered employee works. The HCSO has released a new 2016 Official OLSE Notice (note: the Notice is 8.5” x 14”). Covered employers should ensure the new version of the notice is displayed at applicable job sites. A copy of the new 2016 Notice can be found here.

November 3, 2015

On Sept. 28, 2015, Gov. Brown signed AB 1515, which clarifies and corrects sections in the insurance code and restores the requirement that interest be applied to claim payments under non-health disability policies when a payment is made more than 30 days after receipt of the claim. In addition, the law updates the California Department of Insurance’s contact information on notices and disclosures for consumers by requiring these disclosures to include the Department of Insurance’s website address. In addition, the law aims to increase the department’s efficiency in processing and approving administrative settlements by allowing the commissioner to delegate settlement authority for minor non-insurer cases to a deputy commissioner. Finally, AB 1515 makes several other changes that include increasing conformity to the National Association of Insurance Commissioner’s Model Laws.

AB 1515 is effective January 1, 2017.

AB 1515 »

On Oct. 9, 2015, Gov. Brown signed AB 387 into law. The new law is intended to improve the department's ability to approve draft disability policies by extending the period of time allowed for the department to review the policy forms and any associated risks and premium rates from 30 to 120 calendar days. Moreover, it authorizes the commissioner to develop new guidelines to streamline the file review process for life and disability insurance forms and then to publish these procedures on the department’s website for public review. The legislature hopes that by providing clearer guidelines for insurers to follow when submitting policies for approval, and increasing time allowed to review and approve policies, the new law will improve the overall process and reduce confusion for consumers and the industry.

AB 387 »

On Oct. 6, 2015, Gov. Brown signed SB 575 into law, giving consumers new protections concerning non-forfeiture benefits under their long-term care contracts. The new law protects consumers, specifically the elderly and their caregivers, by requiring long-term care insurers to provide annual notification of the availability of non-forfeiture benefits and contingent benefits to the insured and the insured's designated backup contact. The notification must include the availability of the non-forfeiture benefit, the dollar amount of the non-forfeiture benefit and the name, address and telephone number of the insurer for questions about the benefit. Insurers must send the first annual revised notice to affected policyholders by July 1, 2016.

SB 575 »

October 6, 2015

On July 16, 2015, Gov. Brown signed into law AB 987, which amends the Fair Employment and Housing Act (FEHA) to provide protection for employees who make a request for an accommodation of a disability or religious beliefs. Existing law requires an employer to provide reasonable accommodation for, among other things, a person’s disability and religious beliefs and prohibits discrimination against any person who has either opposed any practices forbidden under the act or filed a complaint. This bill would also prohibit an employer from retaliating or otherwise discriminating against a person for requesting accommodation of his or her disability or religious beliefs, regardless of whether the accommodation request was granted.

AB 987 was initiated in reaction to Rope v. Auto-Chlor System of Washington, Inc., a 2013 decision from a California appellate panel. In that case the employee requested a leave of absence to donate a kidney to his sister five months prior to the surgery. Two months before the surgery the employee was terminated. He sued for associational disability discrimination under FEHA, but the appellate panel affirmed dismissal of his suit, holding that "a mere request—or even repeated requests—for an accommodation, without more" does not constitute protected activity sufficient to support a claim for retaliation in violation of FEHA. AB 987 amends the statute to establish that "[a] request for reasonable accommodation based on religion or disability constitutes protected activity … such that when a person makes such a request, he or she is protected against retaliation for making the request."

The changes to FEHA take effect Jan. 1, 2016.

AB 987 »

August 25, 2015

On July 14, 2015, Gov. Brown signed AB 1541 into law. The new law amends Section 1798.81.5 of the California Civil Code that requires employers to protect employees' and applicants' personal information for accessing online accounts. Existing law requires employers to implement and maintain reasonable security procedures and practices to protect state residents' personal information from unauthorized access, destruction, use, modification and disclosure. Current law defines ‘personal information’ as first name/initial and last name in combination with data such as a Social Security number, where the name or data are unencrypted. AB 1541 expands the definition of personal information to include username or e-mail address in combination with a password or security question and answer that permits access to online accounts. Personal information will not include information lawfully made available to the public from government records.

The new law takes effect Jan. 1, 2016.

AB 1541 »

On July 27, 2015, California’s Office of Administrative Law voted to approve an emergency regulation submitted by the California Department of Insurance. The regulation amends Title 10 of the California Code of Regulations that requires health insurers to maintain adequate medical provider networks that meet the needs of their policyholders, maintain accurate provider directories and requires disclosure of out-of-network providers who may participate in a patient’s planned care.

The amended provisions include:

• Insurers must ensure their networks have an adequate number of primary care physicians accepting new patients.
• The network must include providers of the following services: Behavioral health therapy, substance use disorder, psychiatric inpatient hospitalization, detoxification, psychological testing and outpatient retail pharmacies.
• Participants must be able to access information about mental health and substance use disorder services, such as benefits and providers, by calling a customer service representative during normal business hours.
• The network must include an adequate number of providers with admitting and practice privileges at network hospitals.
• If medically appropriate care cannot be obtained from a network provider, then the insurer shall arrange for care from a non-network provider with the patient only responsible for in-network cost sharing.
• The network should have adequate capacity and availability of licensed health care providers to allow for appropriate appointment waiting times. For example, a participant should not have to wait more than 48 hours for an urgent care appointment that does not require prior authorization; 10 business days for a non-urgent primary care physician or mental health provider appointment; 15 days for a non-urgent specialist appointment.
• The network must ensure triage or screening services are available by telephone, and that the waiting time for these services does not exceed 30 minutes.
• Insurers shall also ensure that during normal business hours, the waiting time for a person to speak with a customer service representative does not exceed 10 minutes.
• Policies that cover pediatric dental and/or vision essential health benefits must assure that there are adequate oral and vision providers, including general and specialists, to accommodate anticipated enrollment growth.
• Online network provider directories must include specific information about each provider and be made available to both covered persons and consumers. The network provider directory must be updated weekly.

While the new regulations apply to insurers, employers should understand the new safeguards and provisions that will be included under their group insurance policy.

The emergency regulation is effective from July 27, 2015, to Oct. 27, 2015, with the expectation of further legislative action.

Title 10 CCR Section 2240 »

June 30, 2015

On June 17, 2015, Gov. Brown signed SB 125 into law. The law provides that for plan years starting on or after Jan. 1, 2016, employer size will be determined using the federal method of calculating full-time equivalent employees for employer mandate purposes. When determining whether an employer is eligible for a small or large group policy, the employer will need to calculate the number of full-time employees working 30 hours or more per week. They will then need to total the number of hours by all non-full-time employees and divide by 120. The sum of the two calculations will yield the employer’s number of full-time equivalents. If an employer has 100 or fewer full-time equivalent employees, they will be considered a small employer. Finally, it is important to note that when determining size, the employer must include employees of all related employers.

SB 125 »

May 5, 2015

On March 5, 2015, the California Fair Employment and Housing Council amended the California Family Rights Act, which is the state’s version of FMLA.

Existing California law is already similar to FMLA in that it provides up to 12 weeks of unpaid job protected leave for employees who have worked for the employer for at least 12 months and at least 1,250 hours in the last 12 month period. Under both laws, the employee must have a qualifying reason for leave. Qualifying reasons include birth, adoption, foster care or serious health condition of an employee or family member.

The amendments more closely align the state’s regulations with FMLA. The amended provisions include:

• An employer may deny reinstatement to a key employee if certain requirements are met.
• A covered employer includes a successor employer.
• Joint employers may share responsibility for an eligible employee. A joint employment relationship occurs when two or more businesses control the work conditions of the employee (such as a PEO or staffing agency and recipient organization).
• When determining whether the employee has met the 12-month service requirement, the employer must include employment records for the last seven years.
• When determining whether the employer has at least 50 employees within a 75-mile radius, employees with no fixed worksite (for example, working from home) would be included in the count for the worksite from which they receive assignments or to which they report.
• The term 'serious health condition' includes inpatient care or continuing treatment, which may include substance abuse.
• The employee has the right be reinstated to the same or comparable position. Comparable is clarified to mean that the position is equivalent in terms of pay, benefits, shift, schedule, geographic location, working conditions, privileges, perquisites, status, duties, responsibilities, skill, effort and authority.
• The employer must respond to a request for leave within five business days. (The deadline under CFRA was previously 10 calendar days.)
• If the employee’s leave is unpaid, the employee may agree to prepayment of any required premiums or the employer may require payment during the leave.

The regulations include a revised certification form. There is a new posting requirement; however, the revised poster is not yet available. The amendments are effective July 1, 2015.

Regulations »

The California Division of Labor Standards Enforcement recently posted guidance related to the state’s new paid sick leave law on its website in the form of frequently asked questions. The guidance provides clarification on rehired employees. If an employee is rehired within one year by the same employer, the employee’s previously accrued hours are restored. Additionally, the rehired employee’s 90 day waiting period is waived if they met the requirement during their previous employment period.

The guidance also states that employers are required to provide individualized notice to new employees hired after Jan. 1, 2015. Existing employees must receive a notice by July 8, 2015.

Paid Sick Leave FAQs »

Employee Notice »

January 13, 2015

As discussed in the Sept. 23, 2014 edition of Compliance Corner, eligible employees must accrue at least one hour of paid sick leave for every 30 hours worked beginning July 1, 2015. Effective Jan. 1, 2015, employers must notify employees of the new law effective by posting the new employment poster.

Paid Sick Leave Poster »

On Sept. 30, 2014, Gov. Brown signed AB 1710 into law. Existing law requires businesses that maintain computerized personal information to notify affected individuals of a security breach in which their information was accessed by an unauthorized person. The new law, which took effect Jan. 1, 2015, requires the business to provide the affected individuals with 12 months of appropriate identify theft prevention and mitigation services.

AB 1710 »

December 2, 2014

The California Office of Labor Standards Enforcement (OLSE) has released the 2015 Health Care Security Ordinance (HCSO) expenditure rates. Effective Jan. 1, 2015, employers with 100 or more employees will be required to spend $2.48 per hour, which is an increase from the 2014 rate of $2.44 per hour. For-profit employers with 20 to 99 employees, as well as nonprofit employers with 50 to 99 employees, will be required to spend $1.65 per hour, which is an increase from the 2014 rate of $1.63. For-profit employers with one to 19 employees and nonprofit employers with one to 49 employees continue to be exempt from the HCSO requirement.

The OLSE has also implemented new rules regarding expenditure methods. Effective Jan. 1, 2015, at least 60 percent of the employer’s HCSO expenditures must be irrevocable expenditures, meaning the amount paid by the employer cannot be recovered or returned to the employer. Examples of irrevocable expenditures are insurance premiums, contributions to the City Option and HSA contributions. An example of a revocable expenditure is a contribution to an HRA in which the employer allocates the funds as a debit in its accounting, but does not actually pay the funds into a separate account on the employee’s behalf.

Effective Jan. 1, 2016, at least 80 percent of the employer’s expenditures must be irrevocable with that amount increasing to 100 percent Jan. 1, 2017.

2015 HCSO Rate Announcement »
Irrevocable Expenditures FAQs »

The California Employment Development Department has released the 2015 withholding rates for the State Disability Insurance (SDI) program. The withholding rate is 0.9 percent, which is a decrease from the 2014 rate of 1.0 percent. The maximum wage limit is $104,378, which is an increase from the 2014 limit of $101,636. The maximum annual contribution for an employee is $939.40, which is a decrease from the 2014 limit of $1,008.80.

SDI Rate Announcement »

October 21, 2014

On Sept. 25, 2014, Gov. Brown signed SB 1182 into law, which requires insurers to provide large group clients deidentified claims data annually upon request. For this purpose, a large group client is defined as an employer who has at least 1,000 covered lives, of which at least 500 are covered by that insurer; or a multiemployer trust with at least 500 covered lives, of which at least 250 are covered by that insurer.

The new law also requires the Department of Managed Health Care and the Department of Insurance to post the following information on its website for at least 60 days prior to the implementation of an insurer’s significant rate increase:

• Justifications for an unreasonable rate increase
• The plan’s overall medical trend factor assumptions
• The plan’s actual costs by category, including hospital inpatient, hospital outpatient, physician services, prescription drugs, laboratory and radiology
• The amount of the projected trend attributable to price inflation, fees and policy trends

SB 1182 »

On Sept. 25, 2014, Gov. Brown signed AB 1962 into law, which will apply the federal medical loss ratio rebate requirements to dental policies issued in California. The law is effective Jan. 1, 2018.

AB 1962 »

On Sept. 25, 2014, Gov. Brown signed SB 1052 into law. The new law requires insurers that provide prescription drug benefits with one or more drug formularies to post the formularies on the insurer’s website. Any changes to the formularies must be updated on at least a monthly basis. The Department of Managed Health Care and the Department of Insurance will develop a template for this purpose prior to Jan. 1, 2017.

SB 1052 »

On Sept. 25, 2014, Gov. Brown signed SB 1053 into law, which mandates certain coverage related to contraceptive services and devices. As background, PPACA requires non-grandfathered group health plans to provide coverage for contraception with no cost-sharing for participants. The new law requires all group health plans (both grandfathered and non-grandfathered) that provide coverage for hospital, medical and surgical expenses to provide coverage for:

• All FDA-approved contraceptive drugs, devices and other products for women, including those available over the counter, as prescribed by the insured’s provider.
• Voluntary sterilization procedures.
• Patient education and counseling on contraception.
• Follow-up services related to the covered drugs, devices, products and procedures, including but not limited to the management of side effects, counseling for continued adherence and device insertion and removal.

As required by PPACA, non-grandfathered plans may not impose any cost-sharing for these services and devices. The same coverage shall be provided to spouses and dependents as is provided to employees. There is an exemption for religious employers. The law is effective for policies issued or renewed on or after Jan. 1, 2016.

SB 1053 »

October 7, 2014

On Sept. 25, 2014, Gov. Brown signed SB 1053 into law. Effective for plan years starting on or after Jan. 1, 2016, group health insurance policies must provide coverage for all FDA-approved contraceptive methods for women. Covered contraceptive methods include drugs, devices and products available over the counter as prescribed by the participant’s health care provider; voluntary sterilization procedures; and patient education and counseling related to contraception. Additionally, health insurance policies must provide coverage for follow-up services related to covered drugs, devices, products and procedures including management of side effects, counseling for continued adherence and device insertion and removal. Non-grandfathered plans may not impose any cost-sharing amounts on these covered services.

An exemption is available for plans sponsored by a religious employer. For this purpose, “religious employer” is defined as an entity for which the inculcation of religious value is the purpose of the entity, the entity primarily serves and employs persons who share the religious tenets of the entity, and the entity is a nonprofit organization under IRC Section 6033(a)(3)(A).

SB 1053 »

On Sept. 25, 2014, Gov. Brown signed SB 1182 into law. Under the new law, health insurers will be required to provide large group policyholders with aggregate de-identified claims information on an annual basis. The information shall be available upon request and at no charge to the policyholder.

SB 1182 »

September 23, 2014

On Sept. 10, 2014, Gov. Brown signed AB 1522 into law. The new law requires employers to provide certain employees with paid sick leave. Employees are eligible if they work 30 days or more in the first year of employment. Eligible employees will accrue at least one hour of paid sick leave for every 30 hours worked. The paid sick leave accrues from the date of hire, but an employee may not be able to use the accrued hours until the 90th day of employment. Accrued hours carry over to subsequent years. An employer may limit an employee’s use of paid sick leave to 24 hours, or three days, per year. Employees may use paid sick leave for the purpose of diagnosis, care or treatment of an existing health condition; preventive care for an employee or family member; or leave related to the fact that the employee is a victim of domestic violence, sexual assault or stalking. The law is effective July 1, 2015.

AB 1522 »

August 26, 2014

On Aug. 15, 2015, Gov. Brown signed SB 1034 into law. The new law will bring the state’s mandated 60-day maximum waiting period in line with federal requirements by increasing the maximum waiting period to 90 days for policies issued in California. Effective Jan. 1, 2015, group health plans subject to California insurance mandates may impose a maximum waiting period of 90 days. The change creates some confusion for both employer plan sponsors and insurance carriers who have adjusted plan designs to accommodate the previous 60-day maximum requirement. It is not yet known how carriers will respond to the law. They may choose to leave the 60-day maximum waiting period as is in their group product offerings.

SB 1034 »

July 29, 2014

The DOL and the California Department of Insurance will present a free two-day compliance seminar for employer plan sponsors on Sept. 9 and 10, 2014. The seminar will be held in Los Angeles and cover a number of topics, including the employer mandate, other health care reform requirements, the California marketplace, FMLA, COBRA, California insurance mandates and fiduciary responsibility.

Additional Information and Registration »

On July 14, 2014, the San Diego City Council approved a sick pay ordinance that will apply to employers who have an employee performing work within the San Diego city limits. Employees must accrue one hour of paid sick leave for every 30 hours worked within the city, up to a maximum accrual of 40 hours per year. Unused hours will carry over to the next year, but are not required to be paid out upon termination of employment. Employees may use the paid sick leave hours for their own health care appointments or illness, to care for an ill family member or an absence related to domestic violence. The law is effective April 1, 2015. Employers will be required to post a notice informing employees of the new benefit, as well as provide a notice to new employees hired after April 1, 2015.

Ordinance »

July 15, 2014

On June 16, 2014, Gov. Brown signed SB 20 into law. The new law provides that policies sold in the individual market on or after Jan. 1, 2014, shall limit enrollment to an annual enrollment period and special enrollment periods. The annual enrollment period for coverage effective Jan. 1, 2015, will be Nov. 15, 2014, to Feb. 15, 2015. The annual enrollment period for subsequent years will be Oct. 15 to Dec. 7 of the preceding calendar year. While the law only applies to individual policies, employers may be interested in what options are available for employees.

SB 20 »

On July 7, 2014, Gov. Brown signed SB 1446 into law. The new law relates to the March 5, 2014, CMS announcement of a two-year extension to the transitional policy for non-PPACA-compliant health benefit plans (as covered in the March 11, 2014, edition of Compliance Corner). The California Department of Insurance and the Department of Managed Health Care will permit insurers to renew noncompliant policies, but on a more restrictive basis than was provided by CMS. The law allows insurers to renew non-grandfathered small employer policies that were in effect on Dec. 31, 2013, and that are still in effect on July 7, 2014, to be renewed until Jan. 1, 2015, and to continue to be in force until Dec. 31, 2015. Such policies would not be subject to the federal and state requirements related to community rating, the prohibition of pre-existing condition exclusions and coverage of essential health benefits.

SB 1446 »

June 17, 2014

On June 10, 2014, the California Court of Appeals, Second Appellate District issued a ruling in Rea v. Blue Shield of California, B244314, 2014 WL 2584433 (Cal. Ct. App. June 10, 2014). At issue was the fact that the Blue Shield policy excluded residential treatment for anorexia nervosa. The court reversed an earlier decision by a trial court and ruled that anorexia nervosa was a mental condition and, as such, was covered by the California Mental Health Parity Act. The act requires medically necessary treatment for mental conditions. Thus, the court ordered Blue Shield to provide coverage for residential treatment for anorexia nervosa when it was determined to be medically necessary for the insured.

In California, HMO's and managed care organizations (including Blue Shield) are governed by the Department of Managed Health Care, while all other insurers are governed by the Department of Insurance. On June 11, 2014, Insurance Commissioner Dave Jones issued a press release announcing that the ruling will apply to all insurance policies issued in California. Employers sponsoring group health insurance policies in California should review the exclusions of their plan and work with the carrier to make any necessary amendments regarding coverage of residential treatment for anorexia nervosa.

Rea v. Blue Shield of California »
Insurance Commissioner's Press Release »

June 3, 2014

On May 16, 2014, the California Department of Insurance issued a notice summarizing the state's security breach notification requirements. The law applies to entities that conduct business in California and own or license computerized data that contains personal information, including employers. A state resident must be notified if it is reasonably believed that his/her unencrypted personal information was acquired by an unauthorized person (i.e., security breach). If more than 500 residents are affected, the entity must also submit a copy of the breach notification to the California attorney general.

Notice »

April 22, 2014

On March 26, 2014, the California Metropolitan Transportation Commission approved the launch of the Bay Area Commuter Benefits Program. The program implements SB 1339, which was signed into law in September 2012. Bay Area employers with 50 or more full-time employees (those working 30 hours or more per week) will be required to provide commuter benefits to covered employees (those working 20 hours or more per week). It applies to employers in the following counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo and Santa Clara, as well as the southern portion of Sonoma County and the southwestern portion of Solano County.

Employers must register via the program website and offer one of four commuter benefit options, listed below, by Sept. 30, 2014.

• Option 1: Pretax Benefit – Allow employees to exclude up to $130 of their transit or vanpooling expenses each month from taxable income.
• Option 2: Employer-provided Subsidy – Provide a subsidy to reduce or cover employees’ monthly transit or vanpool costs, up to $75 per month.
• Option 3: Employer-provided Transit – Provide a free or low-cost transit service for employees, such as a bus, shuttle or vanpool service.
• Option 4: Alternative Commuter Benefit – Provide an alternative commuter benefit that is as effective in reducing single-occupancy commute trips as Options 1, 2 or 3.

Announcement »
Program Registration and Details »

January 28, 2014

On Dec. 4, 2013, Section 2274.53 was added to Title 10 of the California Administrative Code. The new regulations provide additional information on the grace period that insurers must provide employer policyholders for payment of group health policies. Under existing rules, employers have a 30-day grace period in which to submit payment. The new rules clarify that the 30-day period begins the day following the last day of coverage for which the insurer has received payment. If payment is made on or before the last day of the grace period, the insurer shall continue coverage beyond the grace period without interruption. This is an important clarification for employers because nonpayment of premium is one of the few reasons that an insurer may refuse to renew a group policy. Section 2274.53 is effective Jan. 1, 2014.
Regulations »

The maximum benefit under the state-mandated disability insurance program has increased from $1,067 to $1,075 per week. The change is effective for claims beginning on or after Jan. 1, 2014. As background, California is one of a handful of states that require disability insurance coverage for employees performing work in the state.
Announcement »

On Dec. 20, 2013, the City and County of San Francisco Office of Labor Standards Enforcement posted new frequently asked questions related to the Health Care Security Ordinance. The new guidance clarifies that employer contributions toward excepted benefits constitute valid health care expenditures to satisfy the employer's spending requirement under the ordinance — including contributions for dental insurance, vision insurance, medical indemnity insurance, long-term, nursing home, home health or community-based care insurance, and insurance limited to a specific disease or illness. Contributions to a stand-alone dental or vision HRA would also count as valid health care expenditures.

FAQs »

March 2, 2021

Emergency Regulation Establishes SEP for State Exchange

Expand/collapse »

Emergency COVID-19 Regulation Extended

Expand/collapse »

February 2, 2021

Marketplace Special Enrollment Period

Expand/collapse »

January 20, 2021

Emergency COVID-19 Regulation Adopted

Expand/collapse »

Utilization Review Regulations Adopted

Expand/collapse »

December 22, 2020

Telehealth Services Required during COVID-19 Crisis

Expand/collapse »

December 8, 2020

New Regulations Aim to Make Plans More Affordable

Expand/collapse »

November 10, 2020

Voters Pass Statewide Family and Medical Leave Statute

Expand/collapse »

October 13, 2020

Statute Imposes Fee on Insurers

Expand/collapse »

September 29, 2020

Statute Reduces Burdens on Telehealth

Expand/collapse »

September 1, 2020

Paid Sick Leave Update

Expand/collapse »

August 4, 2020

COVID-19 Insurance Update

Expand/collapse »

July 21, 2020

Legislature Passes New Paid Leave Legislation

Expand/collapse »

May 12, 2020

COVID-19 Insurance Updates

Expand/collapse »

April 28, 2020

COVID-19 Insurance Updates

Expand/collapse »

April 14, 2020

Emergency Rule Regarding Telehealth

Expand/collapse »

Special Enrollment Period on Exchange Extended

Expand/collapse »

COVID-19 Insurance Updates

Expand/collapse »

March 31, 2020

COVID-19 Insurance Updates

Expand/collapse »

Special Enrollment Period on Exchange

Expand/collapse »

Emergency Rules Granting Paid Sick Leave for Eligible Workers Amended

Expand/collapse »

March 17, 2020

Insurance Updates Regarding COVID-19

Expand/collapse »

Emergency Rules Grant Paid Sick Leave for Eligible Workers

Expand/collapse »

January 22, 2020

Surprise Billing Law Effective January 1, 2020

Expand/collapse »

Cost of Prescription Insulin Drugs Capped

Expand/collapse »

November 26, 2019

Task Force Formed to Study Implementation of Family Medical Leave Insurance Program

Expand/collapse »

October 15, 2019

State Coverage Option for Individuals

Expand/collapse »

September 4, 2019

Special Enrollment Period Available for Consumers Enrolled in Trinity Healthshare

Expand/collapse »

August 7, 2018

Data Privacy Requirements for Employers

Expand/collapse »

July 24, 2018

Coverage of Drugs to Treat Opioid Addiction Required

Expand/collapse »

May 15, 2018

Pharmacist Health Care Services Coverage

Expand/collapse »

Step Therapy Prohibited for Stage Four Metastatic Cancer Drugs

Expand/collapse »

April 4, 2017

Division Releases Bulletin on Telehealth and Telemedicine

Expand/collapse »

May 5, 2015

On April 24, 2015, the Colorado Division of Insurance published Bulletin No. B-4.83. The new bulletin is directed toward insurers and relates to preventive services that must be covered at zero cost-sharing by health benefit plans in Colorado.

As background, PPACA requires certain preventive care to be covered with no cost-sharing requirements (e.g., copayments, deductible, coinsurance, etc.) if provided by an in-network provider. The U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the Health Resources Services Administration (HRSA)) provide recommendations as to which preventive services are included under the PPACA requirement. The recommendations are ongoing and generally become applicable no later than the plan year that begins on or after the one-year anniversary of the recommendation. In addition to federal law, Colorado also requires certain preventive services to be covered at zero cost-sharing.

The bulletin provides insurers with the most recent recommendations and Colorado preventive service coverage mandates, including recommendations issued in 2013 and 2014. The bulletin has three attachments with charts listing the preventive services. Attachment A contains the USPSTF recommendations which take effect April 24, 2015. These include alcohol misuse and counseling, breast cancer preventive medications and lung cancer screenings. Attachment B contains the preventive services mandated by Colorado law (not included in the USPSTF’s recommendations). These include chicken pox vaccinations, colorectal screening and cervical cancer vaccine. Attachment C contains the HRSA women’s’ preventive services guidelines, which includes gestational diabetes screening, human papillomavirus testing and breastfeeding supplies.

Although the bulletin applies only to insurers, Colorado employers should review the bulletin to better understand which services and benefits under their group health plans will be considered preventive care that should be provided with zero cost-sharing to covered employees.

Bulletin No. B-4.83

On April 16, 2015, Gov. Hickenlooper signed SB 15-015 into law. The new law relates to health benefit plan coverage for autism spectrum disorder (ASD). Under the new law, group health plans offered in Colorado must provide coverage for ASD that is substantially equivalent to benefits for a physical illness and must not contain any limits on the number of services or visits. ASD is defined by reference to “The Diagnostic and Statistical Manual of Mental Disorders” and generally includes autistic and Asperger’s disorders.

Although the new law does not create any additional obligations for employers, Colorado employers with fully insured plans should reach out to insurers to discuss the new coverage requirements. The new law is effective for plans issued, delivered or renewed on or after Jan. 1, 2017 (although the law encourages insurers to comply as soon as possible).

SB 15-015

April 7, 2015

On March 20, 2015, Gov. Hickenlooper signed HB 15-1029 into law. The new law relates to telehealth coverage of health benefit services. According to the new law, insurers cannot require plan participants to have in-person contact with health care providers if services can be provided appropriately through telehealth. ’Telehealth’ is defined as the delivery of health care services through telecommunication systems, including information, electronic and communication technologies to facilitate the assessment, diagnosis, treatment, education or self-management of a person’s health care. Importantly, ’telehealth’ does not include communications via health care services via telephone, facsimile or email systems. The new law is effective for plans and policies issued or renewed on or after Jan. 1, 2017. While the new law applies only to insurers, employers will want to be aware of the law to assist employees that may have questions with respect to coverage of telehealth services.

HB 15-1029  »

March 24, 2015

On March 13, 2015, the Colorado Division of Insurance (DOI) issued a press release and FAQ related to phasing out non-PPACA-compliant group health plans in Colorado. Specifically, health insurance plans for small employers that do not meet PPACA requirements will not continue into 2016. Previously, the DOI allowed insurers in Colorado to continue non-PPACA-compliant plans for small groups (employers with two to 50 employees) through Dec. 31, 2015. The allowance was intended to permit time for transition to PPACA-compliant plans. The bulletin states that insurers will notify small employers that hold non-PPACA-compliant plans of the discontinuation of the plans, as well as information about available options (including whether the insurer will offer PPACA-compliant plans). The notices must be provided no later than 90 days in advance of the expiration date of the policy (180 days if the insurer is leaving the Colorado insurance market). Importantly, according to the bulletin, insurers may not automatically enroll a current policyholder into a new plan from that insurer. The DOI FAQs provide additional clarification on both the phase-out process and the insurer notices. Employers with non-PPACA-compliant plans should be aware of the press release and FAQs, and should work with insurers on identifying their options going forward.

Press Release  »
FAQs  »

On March 10, 2015, the Colorado Division of Insurance (DOI) issued a news release related to exchange special enrollment periods (SEPs) and federal income tax penalties. As background, on Feb. 20, 2015, the federal government announced it would allow a special enrollment period related to the federal tax penalty for consumers in states with health exchanges run by the federal government. According to the news release, Colorado’s exchange is not run by the federal government, and therefore Colorado may make its own decisions related to SEPs. The bulletin states that DOI will not allow a SEP for 2015 health insurance coverage for individuals who will have to pay a tax penalty for not having health insurance in 2014. The press release describes the various factors weighed in coming to that conclusion.

The SEP generally relates to individual coverage, and does not directly affect employers. However, employers should be aware of the press release, should employees have questions related to federal tax penalties or exchange enrollment. The press release includes phone numbers individuals who have questions relating to special enrollments may call for information.

News Release »

February 10, 2015

On Jan. 28, 2015, The Colorado Division of Insurance published Bulletin No. B-4.82. The new bulletin is meant to clarify the Division's position regarding consumer cost-sharing variations for prescription drug benefits. The bulletin states that certain cost-sharing structures for prescription drug benefits may constitute discrimination that would violate Colorado insurance law. As an example, the Division will view the placement of most or all drugs used to treat a specific condition on the highest cost tiers as discrimination against those individuals who have chronic conditions that require treatment with such drugs. The bulletin also describes other prescription drug plan cost-sharing arrangements that may be problematic under Colorado law. The bulletin does not apply to grandfathered plans, transitional plans, large group plans and HSA-qualified HDHPs, and is intended to apply for plan years beginning on or after Jan. 1, 2016.

The bulletin does not affect Colorado employers' compliance obligations, but is a good resource for understanding how prescription drug plans must be structured in Colorado both on and off the state health insurance exchange.

Bulletin No. B-4.82  »

January 13, 2015

On Nov. 25, 2014, the State of Colorado Civil Rights Commission adopted revisions to its rules and regulations relating to employment discrimination. Specifically, 3 CCR Sec. 708-1 was revised to include new rules relating to the prohibition on employment discrimination against qualified employees and applicants based on sex. The rules also include pregnancy discrimination. While most of the revisions relate to employment law (such as hiring or firing, selection and promotion and retirement), some relate to fringe benefits. Under the revisions, employer contributions for fringe benefits cannot discriminate based on sex. “Fringe benefits” include insurance, pension and retirement, welfare programs, profit-sharing, bonus plans and leave. In addition, employers cannot condition fringe benefits on employees’ status as “head of household” or “principal wage earner” for their family if this condition adversely affects employees based on sex. The revisions are effective Dec. 15, 2014.

Revised 3 CCR Sec. 708-1  »

September 23, 2014

On Sept. 9, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.78. The bulletin clarifies that employers with grandfathered small group health plans that no longer qualify as small employers under Colorado’s current law may be allowed to continue such plans until Dec. 31, 2015. The choice to continue the plans is up to the insurer — they are under no obligation but may choose to do so. Colorado employers with small group plans should consult with their insurer in determining whether the plan will be continued pursuant to the bulletin.

Bulletin No. B-4.78 »

September 9, 2014

On Aug. 21, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.77, a new bulletin relating to health benefit plan premium payment grace period considerations for consumers, providers and insurers. As background, Colorado law provides for a 31-day grace period for consumers with individual or small group health benefit plans who are not receiving the advance payment tax credit (APTC) and who have missed a premium payment, and a 90-day grace period for individuals receiving the APTC. Grace periods do not apply to the payment of the first month’s premium. During the 90-day grace period, carriers must cover claims incurred during the first month and may pend claims incurred during the second and third months. Insurers must also give notice to consumers that the claims may be denied if no further premium payments are received, and issue a 30-day advance notice before terminating the policy due to nonpayment of premiums.

The bulletin clarifies that insurers must always honor and pay claims incurred during the first month of the grace period, regardless of whether the consumer is receiving the APTC or not. Consumers are liable for the premium until the policy has been terminated in compliance with the 30-day advance notice requirement. The bulletin also clarifies notice requirements between the insurer, provider and consumer with respect to the second and third months of the grace period, in which the insurer may pend claims. If a provider receives a notice that a consumer is in those second or third months, the provider may make arrangements with the consumer – prior to delivering services – to ensure that the provider receives payment for services during those months (including collection of full or partial payment from the consumer). If the provider requires full or partial payment, and the consumer pays all past-due premiums and the insurer pays the pended claims, the provider must refund all payments received from the consumer to the extent the payments exceed the consumer’s responsibility.

Although the new bulletin does not add compliance requirements for employers or plans, employers should be aware of the bulletin in case issues arise with respect to grace periods and claim payments.

Bulletin No. B-4.77 »

August 26, 2014

On June 9, 2014, Colorado’s health insurance exchange, “Connect for Health Colorado,” announced in a press release that it has approved its budget for the 2014–15 fiscal year. To help fund the state’s exchange in future years, the budget includes transitional funding authorized by 2013 Colorado legislation, allowing the exchange to set a $1.80 per member per month health insurance carrier assessment. Other states have implemented similar assessments or user fees as a way to fund state exchanges going forward. The approved budget reduced the assessment to $1.25 per member per month. The assessment appears to apply to all health insurance policies issued in Colorado from July 1, 2014, through June 30, 2015. Thus, all health insurance policies – individual and small and large group – issued on or off the exchange in Colorado will be subject to the $1.25 per member per month assessment. While the press release and assessment relate to insurers, the assessment may be passed on to employers and individuals via increased premium rates.

Press Release »

The Colorado Division of Insurance recently promulgated regulations that require the inclusion of a two- to three-page supplement to the PPACA-required SBC for each plan provided to state residents. The SBC supplements must be distributed with SBCs and contain additional information about deductibles, covered cancer screenings, pre-existing condition rules, balanced billing and binding arbitration clauses. The regulations require insurance carriers to produce and distribute the SBC supplement for fully insured plans. Self-insured plans are exempt from the requirement. While Colorado employers have no obligation to produce or distribute the SBC, they should be aware of the additional requirement.

SBC Supplement Regulations and Sample »

August 12, 2014

On July 25, 2014, the U.S. District Court for the District of Colorado, in Burns v. Hickenlooper, No. 1:14-cv-01817-RM-KLM (D. Colo. 2014), ruled that Colorado's constitutional and statutory prohibitions against same-sex marriage are unconstitutional. The court blocked the state from enforcing the prohibitions, but stayed its ruling until Aug. 25, 2014, thereby allowing time for the state to appeal the decision. Previously, on July 9, 2014, (as reported in the July 15, 2014, edition of Compliance Corner) a Colorado state court also ruled that the state's same-sex marriage ban is unconstitutional (but also stayed its ruling). So for now, the same-sex marriage prohibitions in Colorado remain in effect, pending the outcome of the appeals.

Burns v. Hickenlooper »

July 15, 2014

On July 9, 2014, the Colorado District Court for Adams County, in Brinkman v. Long, struck down Colorado's ban on same-sex marriage. The Colorado law passed by voters in 2006 defines "marriage" as only between a man and a woman. The court struck down the law as an unconstitutional violation of due process and equal protection. The court stayed the ruling, meaning that same-sex marriages cannot take place in Colorado while the case is appealed. The issue of same-sex marriage appears to be headed to the U.S. Supreme Court, as other similar cases have already made their way further up in the appellate process. NFP Benefits Compliance will continue to monitor developments on this case, as same-sex marriage has significant implications for employers and their health benefit plan offerings.

Brinkman v. Long »

On June 30, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.76, which relates to short-term, limited duration health benefit plans and special enrollment periods. The purpose of the bulletin is to inform carriers and consumers that short-term, limited duration health benefit plans do not qualify as minimum essential coverage (MEC) under PPACA's individual mandate and that loss or termination of a short-term health plan does not trigger a special enrollment period that would allow a consumer to purchase a PPACA-compliant health benefit plan outside of an open enrollment period. The bulletin states that all carriers that sell or issue short-term health plans must include on all marketing materials and the policy's face page a statement that the plan does not qualify as MEC and that a termination or other loss of a short-term plan does not constitute a special enrollment right for other coverage.

Bulletin No. B-4.76 »

June 3, 2014

On May 19, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.75. The bulletin is directed toward insurers, and contains the notices that must be delivered to consumers (i.e., employers) with non-PPACA-compliant health benefit plans that an insurer has elected to continue into 2015. Previously, the division announced, in Bulletin No. B-4.73, that it will allow insurers to continue such non-PPACA-compliant plans through 2015, as allowed by a March 4, 2014, CMS announcement of a two-year extension to their transitional policy on the issue.

The new bulletin clarifies that insurers do not have to continue non-PPACA-compliant plans, but that if they choose to do so, they must use the notices attached to the bulletin. The notices must be distributed to policyholders no later than 30 days prior to the start of any limited or special enrollment period. The bulletin contains no employer requirements, but employers should be aware of the bulletin, particularly if they have previously had their plans cancelled. Employers in this situation should reach out to insurers to determine if their plans can be continued in light of the division's position.

Bulletin No. B-4.75 »

May 20, 2014

On May 5, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.73, which relates to the March 4, 2014, CMS announcement of a two-year extension to the transitional policy for non-PPACA-compliant health benefit plans (as covered in the March 11, 2014, edition of Compliance Corner). The bulletin formalizes a May 2, 2014, division press release on the same topic. According to the bulletin, the division will allow insurance carriers to continue non-PPACA-compliant health plans through 2015. Since continuation of cancelled plans is optional, Colorado employers that had their plans cancelled should consult with their carriers on whether those plans can be continued in light of the bulletin.

Bulletin B-4.73 »

On May 5, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.74, which relates to the definition of "renewed" as it applies to health insurance. According to the bulletin, carriers and consumers (e.g., employers) should refer to the policy contract language first whenever any questions concerning the term "renewed" arises. Absent a specific definition in the contract, though, "renewed" means a policy renewed upon the occurrence of the earliest of:

• The annual anniversary date of issue
• The date on which premium rates can be or are changed according to the terms of the plan
• The date on which benefits can be or are changed according to the terms of the plan

The bulletin further expounds on the definition. Colorado employers should be aware of the definition, since it applies in several different contexts with respect to plan offerings, including the renewal date upon which federal and state regulations may take effect. Employers should review their policy contract and familiarize themselves with the appropriate definition of "renewed."

Bulletin B-4.74 »

May 6, 2014

On May 2, 2014, the Colorado Division of Insurance issued a press release relating to the March 4, 2014, CMS announcement of a two-year extension to the transitional policy for non-PPACA-compliant health benefit plans (as covered in the March 11, 2014, edition of Compliance Corner). According to the press release, the Division of Insurance will allow insurance carriers to continue non-PPACA-compliant health plans through 2015. Since continuation of cancelled plans is optional, Colorado employers that had their plans cancelled should consult with their carriers on whether those plans can be continued in light of the press release.
Bulletin No. B-4.71 »

April 22, 2014

On April 3, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.71. The new bulletin relates to the minimum benefit for applied behavioral analysis (ABA) treatment for autism spectrum disorder for children, and is meant to clarify the minimum amount of such treatment that carriers must provide. Specifically, all group health insurance policies must provide, at a minimum, $34,000 annually in ABA therapy benefits for children through age 8, and $12,000 for children age 9 to age 19, regardless of the number of visits required to reach those benefit amounts. If the minimum ABA therapy benefits of $34,000 or $12,000, as applicable, have not been provided when the minimum number of visits has been reached, additional visits must be authorized until the $34,000 or $12,000 minimums have been provided. The current number of visits established by rule is 550 visits for a child through age 8 and 185 visits for a child aged 9 to 19. Although the bulletin is directed toward insurers, employers with fully insured plans in Colorado should be aware of the coverage requirements.
Bulletin No. B-4.71 »

On April 3, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.72. The new bulletin is meant to clarify that limited benefit plans, hospital indemnity or other fixed indemnity plans should not be marketed or represented as substitutes for health benefit plans, and that such plans do not provide sufficient coverage to qualify as minimum essential coverage for purposes of PPACA. The bulletin reminds insurers that such plans are not major medical insurance or comprehensive policies and do not provide the necessary PPACA-compliant coverage, and therefore may leave a consumer or individual liable for the individual mandate penalty under PPACA. Insurers selling these limited benefit or indemnity plans that are marketed as a substitute for or equivalent to a PPACA-compliant plan may be inviting liability under Colorado’s misleading and deceptive practice laws. In addition, insurers who sell limited benefit plans must provide notice that the plan does not provide minimum essential coverage as mandated by PPACA. The bulletin provides required language that must be included on the policy’s front page. Although the bulletin is directed toward insurers, employers will want to be aware of the bulletin and the appropriate types of coverage that will be considered sufficient for purposes of PPACA.
Bulletin No. B-4.72 »

January 28, 2014

On Jan. 14, 2014, the Colorado Division of Insurance issued Bulletin No. B-4.69. The bulletin is directed toward insurers, and is meant to help clarify the meaning of "reasonable assurance" for purposes of ensuring an individual's (in the individual market) or employer's (in the small group market) possession of pediatric dental coverage as an essential health benefit (EHB) under PPACA. As background, individual and small group policies sold both inside and outside of the exchange now must cover EHBs, which includes pediatric dental coverage. Carriers offering health benefit plans inside the exchange do not have to provide pediatric dental coverage as long as a certified stand-alone pediatric dental plan is available for purchase on the exchange.

On the other hand, carriers offering plans outside the exchange must have reasonable assurance that the purchaser already has pediatric dental EHB coverage prior to issuing a plan that does not contain such coverage. According to the bulletin, the division has created two methods to ensure compliance with the reasonable assurance standard. The first is through an application developed by the division that allows an applicant to certify that pediatric dental coverage has been obtained under another plan (and the carrier may require the applicant to provide proof). The second is through the sale of exchange-certified "child only" pediatric dental policies at low or no cost to individuals and families that have no children. The bulletin states that these new policies allow purchasers to obtain the required pediatric dental coverage with full knowledge that the benefit will never be needed or used. The proof of purchase of that policy meets the reasonable assurance requirement.

Small employers in Colorado should review the bulletin to better understand the reasons for the pediatric dental coverage requirement, and the reasons why a carrier may be asked to provide reasonable assurances if purchasing a small group plan outside the exchange.
Bulletin No. B-4.69 »

November 10, 2020

Website Offers PFMLA Resources for Employers

Expand/collapse »

April 14, 2020

Premium Grace Period Required

Expand/collapse »

Financial Protections for Health Care Providers and Consumers

Expand/collapse »

March 31, 2020

Access Health Announces Special Enrollment Period Due to Coronavirus Emergency

Expand/collapse »

Governor Issues Coronavirus Public Health Emergency Response Order

Expand/collapse »

Insurance Department Calls for Premium Grace Period

Expand/collapse »

March 17, 2020

Coronavirus Outbreak and Testing Bulletin

Expand/collapse »

February 4, 2020

Guidance Regarding Health Insurance Tax Repeal

Expand/collapse »

July 9, 2019

Paid Family Leave Law Enacted

Expand/collapse »

June 11, 2019

Guidance on Stop-Loss Insurance Policies

Expand/collapse »

April 2, 2019

Clarification of Infertility Treatment Mandates

Expand/collapse »

October 30, 2018

Connecticut to use AV Calculator

Expand/collapse »

September 5, 2018

Association Health Plan Regulation of Out-of-state Plans

Expand/collapse »

August 21, 2018

Association Health Plan Restrictions

Expand/collapse »

Requirements for Short-term, Limited-Duration Health Policies

Expand/collapse »

July 10, 2018

Telehealth Services

Expand/collapse »

Act Mandates Coverage of Essential Health Benefits and Expands Health Benefits for Women, Children and Adolescents

Expand/collapse »

March 20, 2018

Moratorium on Health Insurance Tax Impacts Carrier Rates

Expand/collapse »

August 8, 2017

Limits on Participant Payments for Prescription Drugs at the Point of Sale

Expand/collapse »

Treatment of Substance Abuse and Opioid Addiction

Expand/collapse »

Coverage and Definition of Infertility Expanded

Expand/collapse »

April 18, 2017

Coinsurance in HMO Plan Designs

Expand/collapse »

March 7, 2017

Reminders on Plan Prescription Drug Formularies

Expand/collapse »

June 28, 2016

On June 7, 2016, Gov. Malloy signed SB 262 into law, creating Public Act No. 16-195. This law expands the reasons an eligible employee may take leave under the Connecticut Family and Medical Leave Act (CTFMLA). In addition to the reasons currently listed in the CTFMLA, eligible employees may take leave due to a qualifying exigency (as defined by federal FMLA regulations) arising out of the fact that the spouse, son, daughter or parent of the employee is on active duty, or has been notified of an impending call or order to active duty, in the armed forces.

Under the law, in such circumstances private employees may take up to 16 work weeks of unpaid time off during any 24 month period. In order to qualify, a private employee must work for an employer with at least 75 employees and have been employed by the employer for at least 12 months and worked at least 1,000 hours during that time.

The law is effective immediately.

Public Act No. 16-195 »

June 14, 2016

On June 2, 2016, Gov. Malloy signed HB 5233 into law, creating Public Act No. 16-82. This law requires certain individual and fully-insured group health insurance policies to cover, at the option of the covered woman, mammograms provided by breast tomosynthesis. Breast tomosynthesis is a three-dimensional mammographic method. By law, such policies must cover baseline mammograms for women age 35 through 39, and annual mammograms for women age 40 or older. This law is effective Jan. 1, 2017.

Public Act No. 16-82 »

On May 27, 2016, Gov. Malloy signed HB 5053 into law, creating Public Act No. 16-43. The law requires insured group health plans that are delivered, issued, renewed, amended or continued on or after Jan. 1, 2017, to provide coverage for prescription drugs without prior authorization when they are in their formularies and are approved for treating drug overdoses. This law contains various provisions on opioid abuse prevention and treatment and related issues. Thus, there are various effective dates, starting as soon as upon the passage of this law.

Public Act No. 16-43 »

On May 27, 2016, Gov. Malloy signed HB 5591 into law, creating Public Act No. 16-29. This law establishes the Connecticut Retirement Security Program to improve the retirement security of workers in the state who do not have access to an employer-sponsored retirement plan or payroll deduction individual retirement account (IRA).

The law's requirements apply to all “qualified employers,” defined as private sector employers that employ at least five people each of whom was paid at least $5,000 in wages in the preceding calendar year. “Covered employees” are those who have worked for a qualified employer for a minimum of 120 days and are at least age 19 years old.

The law creates the Connecticut Retirement Security Authority (“the Authority”), which has been given the task of establishing the program, which will consist of Roth IRAs for eligible private-sector employees. The individual Roth IRAs will be established and maintained through the Authority's program or a third-party entity in the business of establishing and maintaining IRAs.

Under the program, qualified employers must automatically enroll each covered employee within 60 days after the employer provides the employee with the informational material on the program the bill requires. If the employee does not affirmatively opt in (contribution options are provided) the employer must enroll the employee with a contribution of at least 3 percent but not more than 6 percent of the employee's taxable wages (up to normal IRS limits). A covered employee may opt out of the program by electing a contribution level of zero. Employers will not be required to match contributions.

Finally, the law contains penalties for employers that fail to remit contributions or that fail to enroll employees.

The program is expected to be implemented by Jan. 1, 2018. Some sections of this law are effective immediately and others are effective July 1, 2016.

Public Act No. 16-29 »

March 8, 2016

On March 2, 2016, the Connecticut Insurance Department published Bulletin HC-111 regarding health insurance coverage for preventative services and the repeal and replacement of Bulletin HC-100 issued on Nov. 3, 2014. The bulletin is directed toward insurers and health care centers operating in Connecticut.

The revised bulletin still addresses health insurance coverage for preventative services. The bulletin clarifies requirements under the federal health care reform law and reconciles these requirements with Connecticut mandates for fully insured non-grandfathered group health plans, effective Jan. 1, 2015. A discussion of the interaction between federal and state mandates follows:

• Clarifying that the term “reasonable medical management” under federal law should be based upon the statutory definition of “medical necessity” found in the Connecticut General Statutes Section 38a-482a.
• Clarifying that “breastfeeding support” as required under federal law should take into account Connecticut mandates found under Connecticut General Statutes Section 38a-530c(d) and 38a-503c(d) which requires two follow up lactation support visits occur when a mother is discharged early from the hospital. The first visit must occur within 48 hours of discharge and the second follow up visit must occur within seven days of discharge.
• Clarifying that contraceptive coverage must include any prescription contraceptive method approved by the Food and Drug Administration (FDA). This means that sterilization procedures for men may not be covered under federal law but may be covered by an insurance company separately, subject to state law.
• Clarifying that maternity coverage, including prenatal care, is covered without cost sharing under federal law. However, services related to maternity that are not preventative may be subject to cost-sharing, although any preventative service with no direct guidance may be subject to medical necessity.

Bulletin HC-111 »

February 23, 2016

On Feb. 16, 2016, the Connecticut Insurance Department published Bulletin HC-110 regarding the one-year moratorium on the fee on health insurance providers (called “covered entities”). The bulletin is directed toward insurers, and states that they must suspend the collection of the fee for the 2017 calendar year.

As background, PPACA instituted the fee to help fund the cost of PPACA implementation and exchanges. This fee applies to any "covered entity" engaged in the business of providing health insurance to U.S. citizens, residents and certain other persons present in the U.S. Put simply, this fee only applies to insurers, and the regulations specifically exclude self-insured plans (although it does apply to fully insured limited-scope dental, vision and retiree-only plans, which are exempt from most PPACA requirements). On Dec. 18, 2015, President Obama signed the Consolidated Appropriations Act, 2016 into law, which includes a one-year moratorium on the fee from Jan. 1, 2017, through Dec. 31, 2017.

The bulletin informs carriers that if they have approved group rates for plan years beginning in 2016 that they are directed to refile such rates for second, third and fourth quarter of 2016 to remove the fee for the portion of the plan year in 2017. For groups with plan years beginning Feb. 1, 2016, and Mar. 1, 2016, carriers are directed to provide a credit or refund of the 2017 fee to the employer group in the 2016 plan year. Filings should be submitted no later than Mar. 1, 2016.

While the suspension of this tax does not require any employer action, employers may see a decrease in costs since most insurers passed the fee onto the plan through rate increases.

Bulletin HC-110 »

On Feb. 5, 2016, the Connecticut Insurance Department published Bulletin HC-109 to provide guidance as to the maximum copayment amounts for health insurance plans. The bulletin rescinds Bulletin HC-94, Maximum Copays and Filing Issues, that was issued on Mar. 10, 2014.

As background, in December 2015, the Insurance Department conducted a data call to determine reasonable levels of copayment amounts regarding specified categories of benefits. The maximum copays are set to not exceed 50 percent of the 90 percentile of claims for the category. For the home health care category, 25 percent was used in lieu of 50 percent to reflect the statutory requirement in Conn. Gen. Stat. Section 38a-493 and Section 38a-520 that coinsurance cover at least 75 percent of the charges. The maximum copay for routine radiology does not apply to advance radiology services that are subject to the limits set forth in Conn. Gen. Stat. Section 38a-511 and Section 38a-550.

The following indicates the revised maximum copays and the copays will be effective for all policies issued or renewed on or after Jan. 1, 2017.

• Durable Medical Equipment $25
• Home Health Care $25
• Ambulance $225
• Laboratory $10
• Routine radiology services $40

The maximum copays for the following categories of benefits were not part of the most recent data call and will remain at the current allowable levels.

• PCP Office Visit $40
• Specialist Office Visit $50
• Urgent Care $75
• Emergency Room $200
• Inpatient Admission $500/day up to $2000
• Outpatient Surgery/Services $500
• Generic Drug $5
• Brand Drug $60

Plans that use coinsurance may not impose an enrollee cost sharing amount that exceeds 50 percent. This applies both for in and out of network benefits. There is no restriction on the differential of the coinsurance level between in and out of network benefits. The level of coinsurance must be consistent for all services within a service category except for plans utilizing tiered networks.

Bulletin HC-109 »

October 20, 2015

On Oct. 9, 2015, the Connecticut Insurance Department published Bulletin HC-106 regarding rate filings for small employer plans. The bulletin is directed toward insurers, and states that the change to the definition of small group in CGS 38a-564, as amended by Section 17 of Public Act No. 15-247, will be postponed.

Conn. Gen. Stat. §38a-564 defines ‘small employer’ as up to 100 employees, but provides the Commissioner the ability to postpone implementation of that definition. In order to be consistent with federal law as a result of passage of the PACE Act, the Department has decided that the small group definition will remain 1-50 employees.

The bulletin informs carriers that they may modify previously approved small group rates for 2016 to the extent the revised rates would be more favorable to the marketplace. The bulletin is effective immediately.

Bulletin No. HC-106 »

August 25, 2015

On Aug. 13, 2015, Insurance Commissioner Wade issued Bulletin HC-104. The bulletin repeals and replaces Bulletin HC-64 (dated Jan. 20, 2006) and clarifies Connecticut’s mandated coverage for infertility treatment under Conn. Gen. Stat. § 38a-509 and § 38a-536 to reflect changes brought about under PPACA.

Specifically, the bulletin removes the age limit for the infertility treatment coverage mandate. This means health insurance plans sold in Connecticut will no longer be allowed to limit coverage of medically necessary infertility treatment to individuals under age 40.

The bulletin also addresses the general use of age-based benefit restrictions and refers to HHS guidance on what is considered a potentially discriminatory benefit design. Based on HHS guidance stating that age limits are discriminatory when applied to services that have been found clinically effective for all ages, Connecticut has determined infertility treatment may be clinically effective for all ages and is therefore requiring carriers to remove age limits on infertility benefits for policies issued or renewed on or after Jan. 1, 2016.

Bulletin HC-104 »

July 28, 2015

On June 30, 2015, Gov. Malloy signed SB 1085 into law. The law amends Section 38a-514 to expand services for mental or nervous conditions that certain health plans must cover. The law mandates that each group health plan cover the diagnosis and treatment of mental or nervous conditions on the same basis as medical, surgical or other physical conditions. Among other things, the law also requires plans to cover:

• Medically necessary acute treatment and clinical stabilization services
• General inpatient hospitalization, including at state-operated facilities
• Services provided by advanced practice registered nurses for mental or nervous conditions
• Programs to improve health outcomes for mothers, children and families

Moreover, a group policy may not prohibit an insured from receiving, or a provider from being reimbursed for, multiple screening services as part of a single-day visit to a health care provider or multicare institution (e.g., hospital, psychiatric outpatient clinic, or free standing facility for substance use treatment).

Finally, the law amends Section 38a-514 to substitute the term “benefits payable” for “covered expenses” as it pertains to the mental or nervous conditions coverage provisions. Under this law, these are the usual, customary, and reasonable charges for medically necessary treatment or, in the case of a managed care plan, the contracted rates.

The law applies to fully insured group health plans issued or renewed on or after Jan. 1, 2016.

Senate Bill 1085 »

On June 30, 2015, Gov. Malloy signed SB 949 into law. The law updates Connecticut’s data security laws and adds stringent new requirements to protect an individual’s confidential information.

The law creates the requirement for a comprehensive information security program. By October 1, 2017, health insurers, HMOs, and certain entities regulated by the Connecticut Insurance Department (e.g. pharmacy benefits managers and TPAs), must implement and maintain a comprehensive information security program to safeguard an insured’s and enrollee’s personal information. It specifies program requirements including encryption of personal information and disciplinary procedures for employees who violate the security policies, requires the program to be updated at least annually and requires the entities to offer at least one year of free identity theft prevention and mitigation services if there is an actual or suspected breach.

The law also adds a 90-day deadline for data breach reporting, which is applicable to anyone who conducts business in Connecticut. Generally, it requires the person to notify impacted state residents of a breach within 90 days after discovering it and offer at least one year of free identity theft prevention and mitigation services.

Both of these updates are effective Oct. 1, 2015.

Senate Bill 949 »

On June 23, 2015, Gov. Malloy signed SB 467 into law, requiring group health plans to cover telehealth services to the extent that they cover the services through in-person visits between an insured person and a health care provider. Telehealth services shall only be provided through real-time, interactive, two-way communication technology. It does not include the use of a fax machine, audio-only telephone texting or e-mail. The law also requires that a telehealth provider obtain a patient’s informed consent at the first telehealth interaction to provide services and inform the patient about the treatment methods and limitations of treating a person through telehealth.

The law applies to fully insured group health plans issued or renewed on or after Jan. 1, 2016.

Senate Bill 467 »

On July 2, 2015, Gov. Malloy signed HB 6772 into law, which amends Section 52-321a. The amendments exempt from creditors’ claims interests in or amounts payable to participants and beneficiaries of certain allocated or unallocated group annuity contracts purchased by an ERISA-covered plan.

To qualify for the exemption, a group annuity contract must be issued to an employer or pension plan to provide employees or retirees with defined retirement benefits. In addition, the original retirement benefits must be protected under ERISA or Pension Benefit Guaranty Corporation and the group annuity contract must not be protected by ERISA or the PBGC on or after the effective date of the group annuity contract.

As background, under Section 52-321a, creditors cannot claim interests in and payments from certain accounts, including certain retirement accounts, simplified employee pension plans and medical savings accounts.

The law is effective Oct. 1, 2015.

House Bill 6772 »

On June 30, 2015, Gov. Malloy signed SB 1502 into law, which provides in Section 413 that the labor commissioner must establish the procedures needed to implement a paid family and medical leave (FML) program.

By Oct. 1, 2015, the labor commissioner must contract with a consultant to create an implementation plan for the FML program and to perform an actuarial analysis and report on the employee contribution level needed to ensure a sustainable FML program.

Senate Bill 1502 »

July 14, 2015

On June 15, 2015, Insurance Commissioner Wade issued Bulletin HC-102. The bulletin clarifies Connecticut's mandated coverage for hearing aids under Conn. Gen. Stat. § 38a-490b and § 38a-516b in relation to changes brought about under PPACA. Specifically, the bulletin addresses the general use of age-based benefit restrictions and refers to HHS guidance on what is considered a potentially discriminatory benefit design. Based on HHS guidance stating that age limits are discriminatory when applied to services that have been found clinically effective for all ages, the state has determined hearing aids may be clinically effective for all ages and is therefore requiring carriers to remove the age limits on hearing aid benefits for policies issued or renewed on or after Jan. 1, 2016.

Bulletin No. HC-102 »

On July 8, 2015, Insurance Commissioner Wade issued Bulletin HC-103 to be read in conjunction with Bulletin HC-95 dated Mar. 17, 2014. The bulletin provides guidance on provisions that will not be approved in a stop-loss policy issued by an accident and health insurer, which insures the employer or its group health plan and not the enrollees covered by the plan. Policies issued or renewed on or after Jan. 1, 2016 may not contain the following provisions:

• Mid-term rate increases at the discretion of the carrier
• Early termination at the discretion of the carrier other than in accordance with the cancellation and nonrenewal laws
• Rescissions for reasons other than fraud or intentional misrepresentation
• Annual dollar limitations in coverage
• Requirements that enrollees be actively at work
• Mandated provider networks
• Case management requirements
• Differences in attachment points based on the health status of the insured

Employers who sponsor a self-insured plan with stop-loss coverage should review their stop-loss contract and work with their attorney and carrier to remove such provisions.

Bulletin No. HC-103 »

June 30, 2015

On June 22, 2015, Gov. Malloy signed Substitute SB No. 428 into law, creating Public Act 15-56. The law extends workplace harassment, discrimination and retaliation protection already available to employees covered by the Connecticut Fair Employment Practices Act to unpaid interns.

The law defines “intern” as “an individual who performs work for an employer for the purpose of training,” and imposes specific conditions that must be satisfied before the position qualifies as an internship covered by the new law. Those requirements are:

• The employer is not committed to hire the individual performing the work at the conclusion of the training period;
• The employer and the individual performing the work agree that the individual performing the work is not entitled to wages for the work performed; and,
• The work performed
  • supplements training given in an educational environment that may enhance the employability of the individual,
  • provides experience for the benefit of the individual,
  • does not displace any employee of the employer,
  • is performed under the supervision of the employer or an employee of the employer, and
  • provides no immediate advantage to the employer providing the training and may occasionally impede the operations of the employer

If any of these criteria is not met, the individual is not an “intern” under the new statute.

While the new law does not require benefit coverage for an unpaid intern, it requires employers to review their practices relating to interns. Since the law also implicates non-benefits laws, such as employment and labor law, employers should work with outside counsel in ensuring compliance. The law is effective Oct. 1, 2015.

Public Act 15-56 »

June 2, 2015

On May 26, 2015, Gov. Malloy signed SB 1029 into law, creating Public Act No. 15-7. The law makes minor changes to the state statute concerning uncontested dissolutions of marriage. While employers are not directly impacted by the changes, it is worth noting that changes in the law provide for an expedited divorce or legal separation if certain factors are met. The law permits a couple to file a joint petition in the judicial district in which one of the party resides for a dissolution of marriage or legal separation and waives certain time periods if agreement on all terms of the dissolution of marriage or legal separation is reached.

Connecticut is one of the few states which recognize legal separation. Employers sponsoring group health plans, especially those subject to COBRA, should be familiar with whether their plan allows an employee to drop a spouse’s coverage due to legal separation and whether COBRA is triggered at that time. Further, employers should ensure they have communicated the proper timeframes (typically 60 days) for the employee to notify the employer that a divorce or legal separation has occurred. Employers accomplish this by distributing a COBRA Initial Notice within 90 days of the coverage effective date to both the covered employee and covered spouse. This becomes even more important for those employees entering into a uncontested legal separation or dissolution of marriage where the timeline for the proceedings occurs on an expedited basis and failure to notify the employer on a timely basis can result in a denial of COBRA coverage. The law is effective Oct. 1, 2015.

Public Act No. 15-7 »

On May 19, 2015, Gov. Malloy signed SB 426 into law, creating Public Act No. 15-6. The law limits employer access to employee social media, email and other online accounts. The law prohibits employers from requesting or requiring an employee or job applicant to 1) provide the employer with a user name, password or other way to access the employee's or applicant's personal online account 2) authenticate or access such an account in front of the employer; or 3) invite, or accept an invitation from, the employer to join a group affiliated with such an account. Employers are prohibited from firing, disciplining or otherwise retaliating against an employee who 1) refuses to provide this access or b) files a complaint with a public or private body or court about the employer's request for access or retaliation for refusing such access. Employers may not refuse to hire an applicant because the applicant would not provide access to his or her personal online account. ‘Personal online account’ is defined as any online account an employee or applicant uses solely for personal purposes, including, but not limited to email, social media and retail-based web sites.

Employees and applicants are permitted to file a complaint with the Connecticut Labor Commissioner, who can impose civil penalties of up to $25 for initial violations against job applicants and $500 for initial violations against employees. Penalties for subsequent violations can be up to $500 for violations against applicants and up to $1,000 for violations against employees.

The new law is effective Oct. 1, 2015.

Public Act No. 15-6 »

February 24, 2015

On Feb. 18, 2015, the State of Connecticut Insurance Department released Bulletin HC-90-15, which primarily affects carriers issuing health insurance policies in the state for individual and small group plans. A couple of points may interest employers, however. Specifically, the bulletin clarified that the state benchmark plan used for 2014 and 2015 will be extended for use during 2016. All non-grandfathered small employer plans both inside and outside the state exchange are required to provide coverage for essential health benefits as outlined in the state benchmark plan. Further, for small group plans offered beginning Jan. 1, 2016, the state will conform to the federal rating requirements with the exception of geographic rating areas. Connecticut was approved to establish eight rating areas by county for the small group market. As a reminder, gender differences, industry and group size, tobacco use, administrative expense differentials and network cost differentials will no longer be permitted in the Connecticut small group market for rating purposes. Finally, rating for family members will be performed in accordance with the final rule, which states that the family rate is the sum of the rates for the employee, spouse, children aged 21 or older and the rates for the three oldest children under age 21.

Bulletin No. HC-101  »

January 13, 2015

On Dec. 1, 2014, the Connecticut Insurance Department issued Bulletin No. HC-101 in order to clarify the Department’s policy on insurance benefits payable for work-related injuries or sicknesses and for policies providing for disability income protection, accident only benefits or travel health policies. The following provisions must be followed for such policies:

• Benefits payable as a result of work-related illness or injury under these policies must be payable on a lump sum or a fixed dollar (indemnity) basis. For example: $75 per/day while hospital confined, $10 per doctor office visit, $50 per day while out of work due to an accident or sickness and $1,000 death benefit payable to an employee’s family.
• A policy cannot provide benefits for work-related illness or injury based on the difference between what an employee was earning prior to a work-related accident or sickness and what the employee is entitled to receive from workers’ compensation following the accident or sickness.
• A disability income policy may only provide benefits for work related injuries and/or sickness on an indemnity or lump sum basis.
• A policy may not provide benefits for work-related illness or injury based on a percentage of pre-disability income.
• Work-related accident and sickness benefits must be payable in addition to any workers’ compensation benefits policy approved by the Insurance Commissioner under § 31-345 of the Connecticut General Statutes. A statement needs to be included in the policy to the effect that “This policy does not replace or otherwise effect any statutorily required workers’ compensation insurance required to be provided to you by law.”

Bulletin No. HC-101  »

November 18, 2014

On Nov. 3, 2014, the State of Connecticut Insurance Department issued Bulletin No. HC-100, which addresses health insurance coverage for preventative services. The bulletin clarifies requirements under the federal health care reform law and reconciles these requirements with Connecticut mandates for fully insured non-grandfathered group health plans, effective Jan. 1, 2015. A discussion of the interaction between federal and state mandates follows:

• Clarifying that the term “reasonable medical management” under federal law should be based upon the statutory definition of “medical necessity” found in the Connecticut General Statutes Section 38a-482a.
• Clarifying that “breastfeeding support” as required under federal law should take into account Connecticut mandates found under Connecticut General Statutes Section 38a-530c(d) and 38a-503c(d) which requires two follow up lactation support visits occur when a mother is discharged early from the hospital. The first visit must occur within 48 hours of discharge and the second follow up visit must occur within seven days of discharge.
• Clarifying that contraceptive coverage must include any prescription contraceptive method approved by the Food and Drug Administration (FDA). This means that sterilization procedures for men may not be covered under federal law but may be covered by an insurance company separately, subject to state law.
• Clarifying that maternity coverage, including prenatal care and ultrasounds, are covered without cost sharing under federal law. However, services related to maternity that are not preventative may be subject to cost-sharing, although any preventative service with no direct guidance may be subject to medical necessity.

Bulletin HC-100 »

August 26, 2014

On Aug. 20, 2014, the Connecticut Insurance Department issued Bulletin HC-99, which rescinds and replaces Bulletin HC-96 issued earlier this year. This updated bulletin clarifies that the current dollar limits provided under the state’s autism mandate are pre-empted by federal law under PPACA. As a result, the insurance commissioner is requesting that all carriers remove the limits to any applied behavioral analysis benefits.

Employers with fully insured policies issued in Connecticut should note that since this would be a material modification of plan provisions, employers should ensure that the issuer will notify plan participants of the removal of the annual dollar limits. If the issuer is not performing the notification, employers subject to ERISA should provide notification to plan participants within 210 days of the close of the plan year in order to comply with the SMM. This SMM should then be attached to the plan’s SPD and provided in tandem with the SPD going forward for any new plan participants.

Bulletin HC-99 »

July 1, 2014

On June 6, 2014, Gov. Malloy signed SB 10 into law, creating Public Act 14-97. The act prohibits insured group health policies issued in the state from imposing copayments greater than $20 for certain comprehensive ultrasound breast screenings. By law, policies must cover a comprehensive breast ultrasound screening if 1) a mammogram shows heterogeneous or dense breast tissue based on the American College of Radiology's Breast Imaging Reporting and Data System or 2) a woman is at an increased risk for breast cancer because of family history, her own breast cancer history, positive genetic testing or other indications determined by her physician or advanced practice registered nurse.

The act also prohibits insured group health policies that provide coverage for occupational or physical therapy from applying copayments greater than $30 per visit for in-network occupational or physical therapy services.

The act is effective Jan. 1, 2015, for insured policies, including HMO plans, issued in Connecticut. Due to ERISA, these state insurance benefit mandates do not apply to self-insured group health plans.

Public Act 14-97 »

November 10, 2020

Regulations Provide Additional Guidance Related to Telehealth Services

Expand/collapse »

Nondiscrimination Requirements Related to Gender Identity

Expand/collapse »

September 1, 2020

Coverage for Telehealth Expanded

Expand/collapse »

March 31, 2020

New COVID-19 Bulletin on Pre-Authorization Requirements, Telehealth, Non-Cancellation for Nonpayment of Premiums, and Catastrophic Plans

Expand/collapse »

March 17, 2020

Health Insurance Coverage for Coronavirus

Expand/collapse »

Coverage for Initial Depression Screenings

Expand/collapse »

January 22, 2020

Contraceptive Coverage Mandate

Expand/collapse »

August 6, 2019

Efforts to Improve Efficiency of Claim Submissions and Payments

Expand/collapse »

Prescription Drug Cost Sharing Limit

Expand/collapse »

Step Therapy Protocol Exceptions

Expand/collapse »

October 30, 2018

Coverage for Treatment of Back Pain

Expand/collapse »

October 16, 2018

Mandated Coverage for In Vitro Fertilization and Other Fertility Services

Expand/collapse »

Revised Regulations Related to MEWAs

Expand/collapse »

September 18, 2018

Stop-Loss Policies Extended to Small Employers

Expand/collapse »

Pharmacy Gag Clauses Prohibited

Expand/collapse »

Coverage for Pediatric Autoimmune Neuropsychiatric Disorders

Expand/collapse »

Prior Authorization Requirements Restricted for Certain Prescriptions

Expand/collapse »

August 7, 2018

Experimental Treatment Coverage

Expand/collapse »

July 24, 2018

Mandated Coverage for Certain Infertility Treatments

Expand/collapse »

October 31, 2017

Coverage of Drug and Alcohol Dependencies

Expand/collapse »

Coverage for Cancer Treatment

Expand/collapse »

January 24, 2017

2018 FFE State Partnership Exchange

Expand/collapse »

January 10, 2017

Network Disclosure and Transparency

Expand/collapse »

August 23, 2016

Pre-Authorizations

On July 13, 2016, Gov. Markell signed HB 381 into law. The new law requires utilization review entities (which include health insurers, health benefit plans and health service corporations) to detail any pre-authorization requirements and restrictions readily accessible on its website and in written/electronic form upon request for participants, health care providers, government entities and the general public. Any change in the procedures must be communicated prior to the effective date.

Utilization review entities must process clean pre-authorizations for non-emergency pharmaceuticals within two calendar days; three calendar days for those related to health care services and submitted electronically; and five calendar days for those related to health care services and not submitted electronically.

A pre-authorization shall be valid for one year from the date that the health care provider receives the authorization, dependent upon continued coverage and eligibility of the participant.

There is no requirement of employers, but it is helpful for plan sponsors to understand how their insured group health plans and participants will be impacted by the amended procedures.

The new law is effective Jan. 1, 2017.

HB 381 »

April 5, 2016

On March 23, 2016, the Delaware Department of Insurance issued Bulletin No. 86. The bulletin provides guidance regarding the Gender Identity Nondiscrimination Act of 2013, which prohibits insurers from discriminating against an individual because of gender identity. The department interprets the act along with the Unfair Trade Practices Act and the ACA to prohibit a carrier from excluding, denying or otherwise limiting coverage for medically necessary services, as determined by a medical provider, based on the individual’s gender identity if the service would be covered for another participant. Further, a carrier may not impose a general exclusion for gender dysphoria or gender identity disorder.

Carriers must provide coverage, including under a group health policy,for medically necessary surgeries or treatments related to gender transition. Importantly, the 2016 state benchmark plan includes an exclusion for “change of sex surgery,” which the department warns is a violation of the law. The bulletin and its guidance are effective immediately.

Bulletin No. 86 »

February 9, 2016

On Feb. 1, 2016, Insurance Commissioner Stewart adopted final regulations related to HB 69, which was passed July 2015. As background, HB 69, effective Jan. 1, 2016, requires group health insurance policies issued in Delaware to provide coverage for telehealth and telemedicine. For this purpose, “telehealth” is defined as the use of information and communication technologies (including telephone, remote monitoring devices and other electronic means) to support clinical health care, provider consultation and patient education. Telemedicine is defined as the delivery of health care services by real time two-way audio, visual or telecommunications (including video conferencing). The health care provider must be practicing within his or her scope of practice.

The regulations prohibit an insurer from placing additional restrictions on telehealth services, such as preauthorization, medical necessity or homebound requirements that are not placed on similar non-telehealth services. The regulations are effective Feb. 11, 2016.

Final Regulations »

January 12, 2016

On Dec. 10, 2015, the Delaware Department of Insurance amended Bulletin No. 51 regarding the state’s mini-COBRA requirements for small employers. The amended bulletin includes a revised model notice for employers to distribute to terminated employees notifying them of their right to continuation.

Bulletin No. 51 »

Model Notice »

October 20, 2015

On Oct. 15, 2015, Insurance Commissioner Stewart issued Bulletin No. 79 related to the definition of small group under state law. Delaware insurance statutes define a small group as an employer with up to 50 employees. Because the federal provision mandating the change of small group to 100 employees is no longer in effect as a result of the PACE Act, Delaware will keep the definition of small group at 50 employees. Thus, groups with 51 to 100 employees will continue to be rated as large groups and will not be required to switch to the small group market in 2016.

Bulletin No. 79 »

On Sept. 29, 2015, Insurance Commissioner Stewart announced the 2016 approved rates for qualified health plans in the state exchange. The average rate increases for individual policies range from 16.9 percent to 22.4 percent compared to 2015 rates, depending on the insurer, and -0.5 to 12.7 percent for small groups. Premium rates for small groups purchasing coverage through the SHOP will vary by age, but average from $250.48 per month for a bronze plan to $359.75 for gold. While the individual policy offerings do not affect employers, it may be helpful for employers to understand what is available through the exchange when responding to employee questions. Also, small employers with up to 50 employees have the option of purchasing group coverage through the SHOP. Please consult your advisor with any questions.

Annoucement »

September 22, 2015

On Sept. 1, 2015, the Delaware Department of Insurance issued Bulletin No. 76, which clarifies the state’s requirements related to individual hospital or other fixed indemnity policies.. For any policies issued on or after Jan. 1, 2015, the policies must meet the following criteria to be in compliance with federal and state law:

• The insurance application must include an attestation that the insured has minimum essential coverage under another policy or plan.
• The application must also include model notice language indicating that the policy is a supplement for health insurance and is not a substitute for major medical coverage. The notice must also inform the insured that the lack of minimum essential coverage may result in a tax penalty.

Employers who make such coverage available to employees should be aware of the new requirements.

Bulletin No. 76 »

August 11, 2015

On July 7, 2015, Gov. Markell signed HB 69 into law. The new law requires group health plans to provide coverage for health care services provided through telemedicine. ‘Telemedicine’ is defined as the delivery of health care services by means of real time two-way audio, visual or other telecommunications or electronic communications and includes the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care. The plan may not impose a higher deductible, copayment or coinsurance amount for telemedicine services than would apply if the same service were provided through in-person consultation. The law is effective for policies issued or renewed on or after Jan. 1, 2016.

HB 69 »

June 30, 2015

On June 15, 2015, HHS conditionally approved Delaware’s application for a state-based health insurance marketplace for individual and SHOP coverage. The state’s marketplace is currently a partnership. If the state meets the conditions outlined by HHS, the state-based marketplace would be effective for 2016.

HHS Conditional Approval Letter »

June 2, 2015

On May 21, 2015, Insurance Commissioner Stewart announced that Aetna Health, Inc. and Highmark Blue Cross Blue Shield Delaware will offer employers with 51 to 100 employees the opportunity to renew their group health insurance policies at large group rates for policy plan years beginning on or before Oct. 1, 2016. This is in response to Commissioner Stewart’s Bulletin No. 75 providing carriers with such an option. Employers with 51 to 100 employees who do not take advantage of the opportunity provided by Aetna Health, Inc. and Highmark Blue Cross Blue Shield Delaware will be switched to a small group policy for plan years beginning on or after Jan. 1, 2016. The change in the definition of ‘small group’ is mandated by PPACA and includes modified community rating and mandated coverage for the essential health benefit categories.

Announcement »
Bulletin No. 75 »

January 13, 2015

On Sept. 2, 2014, Gov. Markell signed HB 294 into law. The new law requires that an employer take all reasonable steps to destroy personal identifying information that is no longer to be retained by the employer. The term personal identifying information includes an employee’s name (or first initial and last name) in combination with his or her signature, date of birth, social security number, passport number, driver’s license number, state identification number, insurance policy number, financial services account number, bank account number, credit card number, debit card number or any other financial or confidential health information. The employer must shred, erase or otherwise destroy or modify personal identifying information to make it entirely unreadable or indecipherable through any means. The law became effective Jan. 1, 2015.

HB 294  »

October 21, 2014

On Sept. 30, 2014, the Delaware Department of Insurance issued Bulletin No. 72, which reminds insurers that they must provide certain coverage related to tobacco cessation. As part of PPACA’s preventive service mandate, insurers must provide the following coverage for non-grandfathered group health plans:

• Screening for tobacco use.
• Two quit attempts per year, consisting of four sessions of individual or group cessation counseling by telephone lasting at least 10 minutes each per quit attempt.
• All medications approved by the FDA as safe and effective for smoking cessation for 90 days per quit attempt when prescribed by a health care provider.

These services must be provided with no cost-sharing for the participant and without requiring prior authorization. While the bulletin is directed at insurers, sponsors of group health policies should be mindful of the tobacco cessation programs that are available to participants under the plan.

Bulletin No. 72 »

August 26, 2014

On July 31, 2014, Gov. Markell signed SB 185 into law. The new law will prohibit employers with four or more employees from discriminating against employees based on a disability. The law previously applied to employers with 15 or more employees, which is consistent with the federal ADA. Small employers in Delaware will want to review their employment and leave policies to ensure that they are in compliance by providing reasonable accommodations for employees who require them. Reasonable accommodations may include making facilities accessible, modifying equipment and making reasonable changes in schedules or duties. While there is a posting requirement for applicable employers, the Delaware Department of Labor, Division of Industrial Affairs, has not yet revised the poster. They are expected to do so prior to the law’s Jan. 31, 2015, effective date.

SB 185 »

July 15, 2014

On June 30, 2014, Insurance Commissioner Stewart issued Bulletin No. 71. The bulletin reminds insurers that they must pay clean claims related to emergency services submitted by non-network providers within 30 days of receipt. The 30-day requirement applies regardless of whether the insurer or the provider has petitioned for arbitration. Further, the claim must be paid at the highest allowable charge for each emergency care service permitted by the insurer for any provider (including both network and non-network providers) during the 12-month period prior to the date of service for the claim in question.

Bulletin No. 71 »

April 8, 2014

On March 13, 2014, Delaware Insurance Commissioner Karen Weldin Stewart issued a statement related to the March 5, 2014, CMS announcement of a two-year extension to the transitional policy for non-PPACA-compliant health benefit plans (as covered in the March 11, 2014, edition of Compliance Corner). Commissioner Stewart stated that Delaware state law does not allow for the extension of non-PPACA-compliant plans.

Press Release »

Declaration of Emergency Leave

Expand/collapse »

March 31, 2020

Order on COVID-19 Coverage

Expand/collapse »

Revised FAQs on Insurance Issues Related to COVID-19

Expand/collapse »

January 22, 2020

Paid Family Leave Poster and Resources Published

Expand/collapse »

December 10, 2019

Employer Reporting Responsibility Related to Individual Health Insurance Mandate

Expand/collapse »

October 15, 2019

Enforcement of Employer Commuter Benefit Requirement

Expand/collapse »

April 16, 2019

Universal Paid Leave

Expand/collapse »

February 5, 2019

Protecting Pregnant Workers Notice

Expand/collapse »

November 13, 2018

Universal Paid Leave Guidance

Expand/collapse »

May 31, 2017

Coverage of Women’s Preventive Care Services

Expand/collapse »

Florida

Georgia