July 11, 2017
Fire Departments Must Provide Cancer Insurance
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On May 4, 2017, Gov. Deal signed HB 146 into law, amending section 25-3-23 of
the Georgia Code relating to general requirements for legally organized fire
departments. The law was passed to mandate insurance coverage for the 19 types
of cancer firefighters contract the most.
Specifically, this law requires such fire departments in Georgia to purchase
and maintain certain cancer insurance coverage for firefighters (including
volunteer firefighters), and the law also requires such departments to provide
income protection for up to three years.
Coverage will need to be provided for firefighters who have served 12
consecutive months. Insurance benefits will include a lump-sum benefit of
$25,000 or $6,250 depending on the cancer’s severity. In addition, for those
unable to perform job duties due to the diagnosis, a monthly benefit equal to
60 percent of the firefighter’s monthly salary, or a monthly benefit of $5,000,
whichever is less, will begin six months after the firefighter’s diagnosis and
continue for 36 months. The monthly benefit for volunteer firefighters unable
to perform their job duties will be $1,500, payable in the same manner as that
for paid firefighters.
This law is effective for legally organized fire departments in Georgia as of
Jan. 1, 2018.
HB
146 »
June 13, 2017
Plans Must Provide Hearing Aids for Children
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On May 8, 2017, Gov. Deal signed SB 206 into law, amending section 33-24 of
the Georgia Code. This law requires health plans to provide coverage for
hearing aids to plan participants age 18 or younger, outlines the frequency
with which such hearing aids must be replaced, addresses covered services
and supplies and allows for the option of higher-priced devices.
This law is effective for health plans issued, delivered, executed or
renewed in Georgia on or after Jan. 1, 2018.
SB
206 »
Synchronization of Prescription Drug Refills
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On May 9, 2017, Gov. Deal signed SB 200 into law, amending section 33-24 of
the Georgia code. This law requires plans that provide prescription drug
benefits to permit and apply prorated daily cost-sharing rates for
prescriptions dispensed by pharmacies for less than a 30-day supply, if for
the purpose of synchronizing plan participants' medications.
Synchronization involves coordinating the medication refills of a patient
that is taking two or more medications such that the medications are
refilled on the same schedule. While plans may prorate daily cost-sharing
rates for synchronized medications, they may not prorate dispensing fees,
which must be based on the number of prescriptions filled.
This law is effective for plans providing prescription drug coverage that
are issued, delivered, executed or renewed in Georgia on or after July 1,
2017.
SB
200 »
May 31, 2017
Available Paid Sick Leave Must be Usable to Care for Immediate Family
Members
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On May 8, 2017, Gov. Deal signed SB 201 into law, creating Section 34-1-10
of the Georgia code. This law does not require the provision of paid sick
leave, but allows use of existing or future paid sick leave in order to
care for immediate family members. Specifically, the new law requires
employers that offer paid sick leave to allow employees to use up to five
days of said leave in each calendar year to care for immediate family
members.
The law applies to employers, public and private, that have 25 or more
eligible employees, although an employer that offers an employee stock
ownership plan is exempt from the requirement. An eligible employee is
defined as an employee that works at least 30 hours per week.
An immediate family member is defined as an employee’s child, spouse,
grandchild, grandparent or parent, or any dependents shown on the
employee’s most recent tax return. Leave must be earned before taken and
employees taking leave under this law must comply with the terms of the
employer’s sick leave policy.
The new law is effective July 1, 2017.
SB
201 »
February 7, 2017
IRS Provides Tax Relief for Victims of January Severe Weather in
Georgia
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On Jan. 26, 2017, the IRS announced, in ATL-2017-03, tax filing relief for
taxpayers who reside or have a business in Dougherty County, Georgia.
Dougherty County was declared a federal disaster area following the severe
storms, tornados, and straight-line winds that took place beginning on Jan.
2, 2017. Victim taxpayers in Dougherty County (those who reside or have a
business there) are eligible for postponement of time to file returns, pay
taxes and perform other time-sensitive acts.
Of particular interest as it relates to benefits, the IRS gives victim
taxpayers until May 31, 2017 to perform certain time-sensitive actions
described in the regulations (like filing Forms 5500). Specifically, if an
affected employer has a Form 5500 filing that would have become due between
Jan. 2, 2017 and May 31, 2017, then the due date of that filing is extended
to May 31, 2017.
The IRS automatically identifies taxpayers located in Dougherty County and
applies automatic filing and payment relief. However, affected employers
that have a business located outside the covered disaster area, but were
impacted by the disaster, must call the IRS disaster hotline at
866-562-5227 to request this tax relief.
ATL-2017-03 »
November 15, 2016
Insurance Directive Reinforces No Cost Sharing Related to Preventive
Colonoscopy
On Nov. 2, 2016, Commissioner of Insurance Hudgens issued Directive 16-EX-6 to
all Georgia insurers related to in-network preventive colorectal screenings.
CMS and other federal agencies have provided sufficient guidance to establish
that all services directly related to a preventive colonoscopy are to be
provided without cost sharing. The actual findings of the screening have no
bearing on the cost sharing. Yet, it has come to the Commissioner’s attention
that issues continue to occur as to the breadth of coverage including improper
cost sharing, denials of claims, or improper balance billing.
This directive clarifies that it is the insurer’s responsibility to adjust the
claim promptly, fairly and accurately once it is determined that the claim is
related to the preventive colonoscopy screening. Failure of insurers to make
proper adjustments in a timely manner will be viewed as unfair claims
settlement practices.
Insurers are also tasked with developing educational materials for insureds
highlighting different concepts that include (but are not limited to) the
differences between diagnostic and preventive, cost sharing and no cost
sharing, in or out-of-network, and providing helpful guidance regarding
referrals for preventive colorectal screenings.
Although this directive is aimed at insurers, it is important for employers to
be aware of what insurers may be doing and what they are now directed to do.
Directive 16-EX-6 »
June 1, 2016
On April 27, 2016, Gov. Deal signed HB 965 into law, amending Chapter 24 of
Title 33 of the Official Code of Georgia Annotated. This makes a change to plan
requirements regarding drug treatment for those suffering from stage four
advanced, metastatic cancer.
The amendment provides that health benefit plans issued, delivered or renewed
in Georgia cannot limit or exclude coverage for drugs that are approved by the
federal Food and Drug Administration to treat stage four advanced, metastatic
cancer by requiring that plan participants first fail to respond successfully
to a different drug or drugs or prove a history of failure of such drug or
drugs. “Stage four advanced, metastatic cancer” means cancer that has spread
from the cancer's original or primary sites to nearby tissues, lymph nodes or
other areas or parts of the body.
This law applies to fully-insured plans issued, delivered or renewed on or
after July 1, 2016.
HB
965 »
November 17, 2015
On Nov. 6, 2015, Commissioner of Insurance Hudgens issued Bulletin 15-EX-3
related to the Georgia definition of small group in light of passage of the
PACE act. As background, the PACE act was signed into federal law Oct. 7, 2015,
and repealed PPACA’s mandated small-group expansion. As a result of the PACE
act, the federal government will continue to define small groups as those with
1-50 employees. As Georgia is no longer required to expand the definition of
small group to 1-100 employees, this bulletin confirms that the small employer
definition in Georgia is 1-50 employees and the counting methodology for
grouping purposes is limited to full time equivalent employees (which, while
not entirely clear, would appear to include part-time hours, similar to the
counting procedures that apply under PPACA’s employer mandate). The bulletin
also confirms that insurers will continue to utilize eligible employees for
participation rate purposes.
Bulletin 15-EX-3 »
September 8, 2015
On July 14, 2015, the Georgia Department of Revenue (DOR) issued guidance for
same-sex couples regarding filing tax returns. Effective June 26, 2015, the
state of Georgia authorizes and recognizes same-sex marriages due to the U.S.
Supreme Court decision in Obergefell v. Hodges. Therefore, same-sex
marriages that were previously recognized for federal income tax purposes are
now recognized by Georgia for state income tax purposes. For employers, this
means the cost to cover same-sex partners under employer-provided benefit plans
is not taxable for state purposes.
The guidance states that improper tax treatment will be corrected through the
tax return process and the filing of amended returns. Therefore, while
employers should no longer withhold income tax from amounts that would now be
subject to pre-tax treatment, employers should not have to adjust for
over-withholding of state taxes related to employer-provided benefits provided
to same-sex couples.
GA DOR Guidance »
August 25, 2015
On Aug. 11, 2015, Commissioner of Insurance Hudgens issued Directive 15-EX-3
related to patient access to eye care. The directive reinforces that insurers
must allow covered persons to obtain eye services from providers who are
otherwise licensed to provide such services. Some insurers have been limiting
coverage to services performed or products sold by certain providers only. The
directive points to the recent Georgia Supreme Court case of Spectera, Inc.
v. Wilson (749 S.E.2d 704 (2013)). Based on that case, a provider may
provide all the services for which he or she is licensed and may receive
provider panel reimbursement from an insurer as long as the service is
otherwise covered by the insurance policy. Although this directive is aimed at
insurers, it is important for employers to be aware that insurers cannot
restrict the access to eye care in this manner.
Directive 15-EX-3 »
June 30, 2015
On June 17, 2015, Insurance and Safety Fire Commissioner Hudgens issued
Bulletin 15-EX-2 related to the new autism spectrum disorder coverage
requirement under HB 429, as previously reported in the May 19, 2015 edition of
Compliance Corner. In the Bulletin, Commissioner Hudgens clarifies
that insurers may impose a cap of $30,000 on claims paid for applied behavior
analysis for the purpose of treating a person with autism spectrum disorder.
This cap only applies to applied behavior analysis and does not apply to other
treatments which may be required by HB 429 (such as therapy services or
counseling).
The autism spectrum disorder requirements are effective for fully insured plans
issued or renewed on or after July 1, 2015.
Bulletin 15-EX-2 »
May 19, 2015
On April 29, 2015, Gov. Deal signed HB 429 into law, amending Chapter 24 of
Title 33 of the Official Code of Georgia Annotated. The new law makes two
significant changes relating to health insurance coverage.
First, plans cannot restrict coverage for prescribed, medically appropriate
treatments for participants who are diagnosed with a terminal condition.
‘Terminal condition’ is defined as any physician-diagnosed illness, health
condition or disease that is expected to result in death in two years or less.
The health benefit plan shall not refuse to pay/reimburse for the treatment
(including for any drug or device) as long as such end-of-life care is
consistent with best practices for treatment of the terminal condition and such
treatment is supported by peer-reviewed medical literature.
In addition, plans must provide coverage related to autism spectrum disorders
for any plan participants who are six years of age or younger. Specifically,
plans must provide coverage for any assessments, evaluations or tests by a
licensed physician or psychologist for diagnosis and any treatment for any such
disorders diagnosed. This includes counseling, habilitative, rehabilitative and
therapy services. Coverage for prescription drugs to treat autism spectrum
disorders must be determined in the same manner as coverage for prescription
drugs to treat other illnesses or conditions covered by plans. This provision
does not apply to employers that have 10 or fewer employees. Therefore,
fully-insured Georgia employers with more than 10 employees should be aware of
the new terminal condition and autism spectrum disorder coverage requirements,
and should work with insurers if any issues arise.
These two changes are effective July 1, 2015.
HB
429 »
February 10, 2015
On Jan. 29, 2015, Insurance and Safety Fire Commissioner Hudgens issued
Executive Directive 15-EX-2 related to hospital and other fixed indemnity
insurance products. The state has implemented new procedures and enforcement to
align with federal requirements for such policies. As background, in May 2014,
CMS issued final regulations related to fixed indemnity insurance products. An
individual fixed indemnity policy would be exempt from PPACA's coverage
mandates (regarding, for example, essential health benefits, annual dollar
limits and maximum out-of-pocket limits) if it qualified as a HIPAA-excepted
benefit. To qualify as an excepted benefit:
To qualify as an excepted benefit:
- The policy must only cover individuals who have other coverage considered
minimum essential coverage (MEC).
- There is no coordination of benefits with another health plan.
- The benefits are paid as a fixed-dollar amount per day or service
regardless of the amount incurred.
- The participant is provided with a written notice explaining that the
policy would not qualify as MEC for individual mandate purposes.
For new policies issued with an effective date beginning on or after Jan. 1,
2015, the Georgia Department of Insurance requires that the participant certify
that they have other coverage that qualifies as MEC. There is a safe harbor
extension until no later than May 1, 2015 for issuers that filed policy form
amendments by Oct. 1, 2014 (to allow previously approved amendments to be
finish the their use for the year). For coverage that is already in force or
that will take effect later in 2015, the notice and attestation requirements
would apply to the first renewal application with an effective date on or after
Oct. 1, 2016.
An employer offering fixed indemnity products to employees should review them
carefully for compliance.
Executive Directive 15-EX-2 »
August 12, 2014
On Aug. 1, 2014, Insurance and Safety Fire Commissioner Hudgens issued Bulletin
14-L&H-1 outlining Georgia's small group health composite rating for use in
preparing 2015 small group health rates. As background, in March HHS
established the federal composite rating methodology, a two-tier rating system.
At that time, HHS also authorized states to utilize a different composite
rating strategy, provided they are submitted to and approved by HHS. Georgia
has exercised this option by introducing a four-tier small group rating
methodology. A carrier is not required to provide family composite rates, but
if it does, it must make it available to each small employer in
the market.
The methodology for developing small group premiums in Georgia and allocating
them to participants is as follows:
-
Development of Aggregate Small Group
Premiums — For
each employee and dependent, the premium must be determined
as follows:
- For each covered adult 21 and over, multiply the base rate by the
applicable age and geographic factors without applying any tobacco
factor.
- For each covered child age 0-20, calculate the rate for the three
oldest children by multiplying the base rate by the applicable age
and geographic factors without applying any tobacco factor.
Age and geographic area are determined at the time the coverage is quoted.
-
Allocation of Premium to Small Group
Members — Once
the small group's aggregate premium has been calculated, it must be
allocated back to covered employees based on their tier factor. Georgia has
adopted the following four-tier approach and corresponding factors:
- Employee only = 1
- Employee + spouse = 2
- Employee + children (including all covered children up to age 26) =
1.85
- Employee + family = 2.85
- Final Employee Premium — Final employee
premium = [group aggregate premium] / [weighted employee count] x
[employee's tier factor]
- Recalculation of Average Monthly
Premiums —
The methodology above determines an employee's monthly premium based on a
census of employees (and covered dependents) at the time the policy was
issued. The average monthly premium for each tier must remain the same for
the entire policy period despite changes to the census. The average monthly
premium must be recalculated annually, based on the census at the time the
policy is rated.
- Application of Tobacco Use Factors — The
family composite premiums do not include a tobacco use factor. Any tobacco
use factor must be applied to the specific individual's premium contributed
to the aggregate premium. The additional premium is then added to the
monthly premium for that individual based upon the tier allocation.
Note that the federally facilitated SHOP will not use composite premium methods
for the 2015 plan year. The federally facilitated SHOP plans to use the federal
composite premium method for the 2016 plan year.
Bulletin 14-L&H-1 »
Hawaii
February 5, 2019
Revised Disability Compensation Notice
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The Department of Labor and Industrial Relations has issued a revised
version of the “Disability Compensation Law Notice to Employees,” which
must be posted in the workplace. The poster advises employees of their
right to temporary disability insurance, prepaid health care and workers
compensation benefits.
Revised Disability Compensation Law Notice to Employees
»
August 21, 2018
Medication Synchronization
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On July 11, 2018, Gov. Ige signed HB 2145 into law. The new law allows for
medication synchronization for participants who are taking two or
medications for chronic conditions. The synchronization allows for the
multiple medications to be filled at the same time by the same network
pharmacy, which the new law states increases medication adherence. The new
law specifically requires group health insurance policies to provide
coverage for partial supplies of such medication (less than a 30 day
supply) with prorated cost sharing applied. The law was effective July 1,
2018.
HB 2145 »
Restrictions on Short-Term, Limited-Duration Policies
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On July 10, 2018, Gov. Ige signed HB 1520 into law. The new law prohibits
an insurer from issuing or renewing a short-term, limited-duration health
insurance policy for an individual who was eligible to purchase individual
health insurance through the marketplace during open enrollment or a
special enrollment period in the previous calendar year. Further, insurers
are prohibited from issuing such a policy with a coverage period longer
than 90 days. This law is more restrictive than the recently issued federal
regulations related to short-term, limited-duration health insurance
policies, which permits renewals for up to 36 months.
HB 1520 »
August 7, 2018
Transitional Policies Extended
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Insurance Commissioner Ito announced in Memorandum 2018-2H that insurers
will be allowed to renew noncompliant individual and small group
non-grandfathered plans with policy years beginning on or before Oct. 1,
2019. This is related to the CMS announcement on April 9, 2018 of an
extension to the transitional policy for non-PPACA-compliant health benefit
plans. Such plans must have existed before Oct. 1, 2013 and aren’t required
to be in compliance with certain PPACA mandates, including community
rating, coverage of essential health benefits, prohibition on pre-existing
condition exclusions and the annual out-of-pocket maximum limit. Employers
with non-PPACA-compliant plans should work with their carrier and advisor
in determining whether their plan can be extended.
Memorandum 2018-2H »
July 24, 2018
Adoption of ACA Mandates
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On July 5, 2018, Gov. Ige signed SB 2340 into law. The new law amends
Hawaii’s Revised Statutes to impose the following requirements on group
health insurance policies issued in the state:
- Provide coverage to children until age 26 (if the policy already
provides coverage for children)
- Prohibition on pre-existing health conditions exclusions
- Prohibition on using a participant’s gender to determine premiums or
contributions
This doesn’t currently impact group health insurance policies, as they’re
already required to be in compliance with these provisions under the ACA.
The purpose of this new law is to protect these provisions in case they’re
repealed at the federal level. If that were to happen, policies issued in
Hawaii would still be required to be in compliance with these three
requirements.
The law was effective upon the governor’s signature.
S.B. 2340 »
September 19, 2017
Family Leave Expansion
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On July 10, 2017, Gov. Ige signed HB 213 into law. The new law expands the
state’s existing family leave law. As background, employers who have 100 or
more employees working in Hawaii must provide up to four weeks of unpaid
leave in a 12-month period to eligible employees. Employees are eligible if
they have worked for the employer for at least six months and have a
qualifying reason.
Qualifying reasons include birth, adoption and to care for a family member
(employee’s child, spouse, reciprocal beneficiary or parent) with a serious
health condition. The new law adds a sibling to the list of family members
for whom the employee may take leave. Additionally, the death of the
employee’s child, spouse, reciprocal beneficiary, parent or spouse has been
added as the fourth qualifying reason for leave.
The employer may require certification, such as a statement from a health
care provider when leave is to care for a seriously ill family member or a
death certificate following the death of a family member. The law was
effective July 10, 2017.
HB 213 »
August 8, 2017
Network Access and Adequacy
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On July 12, 2017, Gov. Ige signed SB 387 into law. The new law requires
insurers that offer network plans to maintain a network that is sufficient
in numbers and appropriate in types of providers, including those that
serve predominantly low-income, medically underserved individuals. This is
to ensure that all covered benefits will be accessible without unreasonable
travel or delay. Covered participants must have access to emergency
services 24 hours per day, seven days per week.
If the network doesn’t include a type of participating provider or has an
insufficient number or type of providers to provide a specific covered
benefit to a participant without unreasonable travel or delay, the benefit
must be paid at in-network levels.
Insurers must electronically post a current and accurate provider
directory, which must be updated at least monthly. The general public must
be able to view the directory without creating or accessing an account or
entering a policy number.
The law is generally effective for policy years beginning on or after Jan.
1, 2019.
SB 387 »
April 18, 2017
Transitional Policies Extended
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On March 1, 2017, Hawaii Insurance Commissioner Ito announced in Memorandum
2017-3H that insurers will be allowed to renew noncompliant individual and
small group non-grandfathered plans with policy years beginning on or
before Oct. 1, 2018. This is related to the Feb. 23, 2017, CMS announcement
of an extension to the transitional policy for non-PPACA-compliant health
benefit plans. Such plans must have existed before Oct. 1, 2013 and are not
required to be in compliance with certain PPACA mandates including
community rating, coverage of essential health benefits, prohibition on
pre-existing condition exclusions and the annual out-of-pocket maximum
limit. Employers with non-PPACA-compliant plans should work with their
carrier in determining whether their plan can be extended.
Memorandum
2017-3H »
January 24, 2017
Section 1332 State Innovation Waiver Approved
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On Dec. 30, 2016, CMS approved part of Hawaii’s Section 1332 request for a
waiver of SHOP requirements. The approval is in effect for five years- Jan.
1, 2017 through Dec. 31, 2021. As a result, the following provisions are
waived in Hawaii:
- State/federal establishment of a SHOP
- Employee choice of QHPs at a single level of coverage through the SHOP
- Continuation of participation in the SHOP for growing employers
- CO-OPs and multi-state plans be recognized as QHPs in the SHOP
CMS denied Hawaii’s request for state agencies other than Medicaid to
participate in the exchange. The individual exchange in Hawaii will
continue to be operated as a federally-facilitated exchange through www.healthcare.gov.
CMS approved Hawaii’s waiver request based upon Hawaii’s unique Prepaid
Health Care Act, which requires employers to provide certain coverage to
employees working 20 hours or more per week. The employer must pay at least
50 percent of the premium and the employee’s contribution for self-only
coverage cannot exceed one and a half percent of the employee’s wages.
There is assistance available for employers who are experiencing bankruptcy
or employers who have under eight employees and who may be having financial
difficulty complying. The waiver is conditioned upon the continuance of
these programs and ongoing reporting.
CMS Memorandum of Approval »
January 10, 2017
2017 TDI Rates
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The Hawaii Department of Labor and Industrial Relations, Disability
Compensation Division, announced its 2017 rates for state temporary
disability insurance (TDI). Effective Jan. 1, 2017, the maximum weekly
benefit amount is $594, a $24 increase from 2016. The maximum employee
contribution rate remains 0.5 percent. However, the maximum weekly wage
base increases to $1,023.31 (up from $982.36 in 2016), which means a
maximum weekly deduction of $5.12 (up from $4.91 in 2016).
Announcement
»
October 18, 2016
Mandated Coverage for 12-Month Contraceptive Supplies
On July 5, 2016, Gov. Ige signed SB 2319 into law. Effective for policies
issued or renewed on or after Jan. 1, 2017, group health plans must provide
coverage for contraceptive supplies for up to a 12-month period.
SB 2319
»
Mental Health Coverage to Include Dietician Services
On June 29, 2016, Gov. Ige signed SB 2854 into law. Effective July 1, 2016,
group health insurance policies must provide coverage for mental health
services provided by licensed dietitians treating eating disorders.
SB
2854 »
August 9, 2016
On July 5, 2016, Gov. Ige signed HB1897 into law. Effective for plan years
beginning on or after Jan. 1, 2018, group health insurance policies must
provide coverage for sexually transmitted disease screenings, including
screening for human immunodeficiency virus and acquired immunodeficiency
syndrome.
HB 1897 »
On June 29, 2016, Gov. Ige signed SB 2854 into law. Health insurance policies
that provide coverage for children of participants must provide coverage for
certain child health supervision services from birth to age five years. Covered
services include developmental assessment, immunizations, lab tests and medical
examinations. Existing law provides that the services may be provided by
physicians, supervised by physicians or delivered by nurses. The new law adds
physician assistant delivered services to the list of covered benefits. The new
law is effective for plan years starting on or after Jan. 1, 2017.
SB 2854 »
On June 29, 2016, Gov. Ige signed HB 2084 into law, which prohibits insurers
from discriminating in terms of eligibility or coverage based on an
individual’s actual or perceived gender identity, Prohibited discrimination
includes denying or limiting coverage for services related to gender transition
if the plan otherwise covers the services when not related to gender
transition. Plans are also prohibited from limiting coverage for a service to a
single gender. The law is effective for plan years starting on or after Jan. 1,
2017.
HB 2084 »
May 3, 2016
On April 26, 2016, Gov. Ige signed SB 2775 into law. The new law authorizes the
state to file an application for a Section 1332 State Innovation Waiver. As
discussed in the Jan. 12, 2016, edition of Compliance Corner, states
may apply for a waiver from certain provisions of PPACA, including the health
insurance marketplace for individuals, SHOP, premium tax credits, employer
mandate and individual mandate. To be approved, the state must present an
alternative strategy that will provide coverage that is at least as
comprehensive as the existing federal provision, keep care at least as
affordable and not increase the federal deficit.
Hawaii’s proposed alternative would be to waive the SHOP, maintain the
individual marketplace and align the ACA with the state’s Prepaid Health Care
Act, which places requirements on employers related to the offer of coverage to
employees.
If approved, the waiver would be effective Jan. 1, 2017.
SB
2775 »
January 12, 2016
The Hawaii Department of Labor and Industrial Relations, Disability
Compensation Division, announced its 2016 rates for state disability insurance.
Effective Jan. 1, 2016, the maximum weekly benefit amount is $570, an $18
increase from 2015. The maximum employee contribution rate remains 0.5 percent.
However, the maximum weekly wage base increases to $982.36 (up from $951.23 in
2015), which means a maximum weekly deduction of $4.91 (up from $4.76 in 2015).
Announcement
»
November 17, 2015
On Oct. 30, 2015, Insurance Commissioner Ito issued Memorandum 2015-3H related
to the definition of “small group” under state law. Hawaii insurance statutes
define a “small group” as an employer with up to 50 employees. Since the
federal provision mandating the change of the definition of small group to 100
employees is no longer in effect as a result of the PACE Act (signed into law
on Oct. 7, 2015), Hawaii will keep its definition of small group at 1 - 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.
Memorandum 2015-3H »
October 20, 2015
On Oct. 5, 2015, the Hawaii Department of Commerce and Consumer Affairs
Insurance Division released 2016 final rates for qualified health plans in the
exchange. The premium rates for individuals vary by age, but on average
increased 34.4 percent for Kaiser as compared to 2015 rates and 27.3 percent
for HMSA. There are six insurers offering coverage through the SHOP and the
rate increases range from -18.9 percent to 22.6 percent.
The state’s exchange was previously state-based and called the Hawaii Health
Connector. Effective for 2016, the exchange will now be federally facilitated
through www.healthcare.gov.
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.
Announcement »
July 28, 2015
On July 14, 2015, Gov. Ige signed SB 791 into law. The new law requires group
health plans to provide coverage for the diagnosis and treatment of autism for
children under age 14. The coverage may be subject to a deductible, coinsurance
or copayment but cannot be less favorable than the cost sharing provisions for
medical services under the plan. Coverage for applied behavioral analysis shall
be subject to a maximum benefit of $25,000 per year. Coverage may be excluded
for services provided out of state, custodial care, care provided by a family
or household member, experimental care or clinically in appropriate services or
supplies. The insurer must distribute a notice summarizing the coverage with
2016 plan materials. The law is effective for policies issued or renewed on or
after Jan. 1, 2016.
SB
791 »
On July 6, 2015, Gov. Ige signed HB 261 into law. The new law requires insurers
to post the plan’s drug formulary on a public website. The information must
also be available through a toll-free number. Any change in coverage, such as
an addition of a new drug or removal of an existing drug, must be posted within
72 hours of the change effective date. The law is effective for policies issued
or renewed on or after Jan. 1, 2017.
HB
261 »
On July 6, 2015, Gov. Ige signed HB 174 into law. The new law requires group
health plans to provide coverage for medically necessary orthodontic services
for the treatment of orofacial anomalies resulting from birth defects. The
maximum benefit per treatment phase is $5,500, which will be indexed for
inflation in later years. The coverage may be subject to a deductible,
coinsurance or copayment but cannot be less favorable than the cost sharing
provisions for medical services under the plan. Coverage cannot be denied on
the basis that the treatment is habilitative or non-restorative in nature. The
insurer must distribute a notice summarizing the coverage with 2016 plan
materials. The law is effective for policies issued or renewed on or after Jan.
1, 2016.
HB
174 »
June 30, 2015
On June 15, 2015, Hawaii’s state-based marketplace, known as Hawaii Health
Connector, is discontinuing its SHOP and will not accept applications. Small
employers wishing to enroll in coverage should contact a broker to apply.
SHOP
Transition »
February 10, 2015
The Hawaii Department of Labor and Industrial Relations, Disability
Compensation Division, announced its 2015 rates for state disability insurance.
Effective Jan. 1, 2015, the maximum weekly benefit amount is $552, a $6
increase from 2014. The maximum employee contribution rate remains 0.5 percent.
However, the maximum weekly wage base increases to $951.23 (up from $940.05 in
2014), which means a maximum weekly deduction of $4.76 (up from $4.70 in 2014).
Announcement »
September 9, 2014
On Sept. 2, 2014, the Hawaii Department of Commerce and Consumer Affairs
Insurance Division issued a press release announcing the publication of a new
consumer guide for small groups. Employers who sponsor a small group health
plan in Hawaii will now be able to compare rates among the state’s five
carriers: Hawaii Medical Service Association, Kaiser Permanente, University
Health Alliance, Hawaii Medical Assurance Association and Family Health. The
guide is a result of Act 66, which requires carriers to publish such rates in
an effort to promote transparency and create competition.
News Release »
Rate Comparison Guide »
July 29, 2014
On June 30, 2014, Gov. Abercrombie signed SB 1233 into law. The new law permits
employees to take an unpaid leave of absence up to seven days per calendar year
for bone marrow or peripheral blood stem cell donation and up to 30 days for
organ donation. It applies only to private employers that employ 50 or more
employees. To be eligible for the leave, the employee must be employed by the
employer for at least one year prior to the leave. An employer may require that
the employee use up to three days of earned but unused paid leave time. Upon
return, the employee must be restored to the same or equivalent position. The
law is effective June 30, 2014.
In a related action, Gov. Abercrombie signed HB 2400 into law on June 30, 2014.
The state statute related to temporary disability benefits was revised to
include organ donation under the definition of disability. This means that an
employee who is on a leave of absence and unable to perform his/her work duties
due to organ donation will be eligible for partial salary replacement through
the temporary disability benefit program. This law is effective July 1, 2014.
SB 1233 »
HB 2400 »
On July 1, 2014, Gov. Abercrombie signed SB 2820 into law. The new law revises
the state's insurance code to comply with and reflect the provisions of PPACA.
The law is effective July 1, 2014. Among the provisions are:
- A group health plan may not rescind (i.e., retroactively terminate) an
individual's coverage unless the individual has committed fraud, makes an
intentional misrepresentation of material fact or fails to timely pay
required premiums or contributions toward the cost of coverage. The plan
must provide at least 30 days' advance written notice to the affected
individual prior to a rescission.
- Group health plans may not impose any financial requirements or treatment
limitations on mental health or substance use disorder benefits that are
more restrictive than those imposed on medical and surgical benefits.
Previously, benefits for in-hospital services related to mental illness and
alcohol/drug dependence could be limited to 30 days per year, and
outpatient services could be limited to 24 visits per year, which was not
in compliance with PPACA or the Mental Health Parity and Addiction Act of
2008.
SB 2820 »
July 15, 2014
On July 3, 2014, Gov. Abercrombie signed SB 2469 into law. The law revises the
state's requirement related to telemedicine. All statutory references to
telemedicine have been changed to telehealth. Any policy issued by a mutual
benefit society or health maintenance organization must provide coverage for
telehealth services. Reimbursement for such services must be equivalent to
reimbursement for the same services provided via face-to-face contact between a
health care provider and a patient.
The term "telehealth" is defined as the use of telecommunicatios –
including real-time video conferencing-based communication, secure interactive
or non-interactive Web-based communication and secure asynchronous information
exchange – to transmit patient medical information, including
diagnostic-quality digital images and laboratory results for medical
interpretation and diagnosis, for the purposes of delivering enhanced health
care services and information to parties separated by distance, establishing a
physician-patient relationship, evaluating a patient or treating a patient. The
law is effective July 3, 2014.
SB 2469
»
June 17, 2014
On June 6, 2014, Hawaii Insurance Commissioner Gordon Ito announced that
insurers will be allowed to renew noncompliant individual and small group
non-grandfathered plans with policy years beginning on or before Oct. 1, 2016.
This is related to the March 5, 2014, CMS announcement of a two-year extension
to the transitional policy for non-PPACA-compliant health benefit plans
(covered in the March 11, 2014, edition of Compliance Corner). The
department will allow insurers to renew noncompliant individual and small group
non-grandfathered plans with policy years beginning on or before Oct. 1, 2016.
Such plans must have existed before Oct. 1, 2013 and would not be required to
provide coverage for essential health benefits during the transition period.
Announcement »
On May 30, 2014, Hawaii Insurance Commissioner Gordon Ito issued a press
release related to a proposed rate increase by Hawaii Medical Service
Association (HMSA). HMSA had submitted a proposed increase of 13.1 percent for
its small employer group community rated policies. After review, Commissioner
Ito approved a rate increase of 8.9 percent, which represents approximately a 5
percent increase due to medical costs and 4 percent due to PPACA fees and
taxes.
Press Release »
Idaho
May 14, 2019
Conditional Renewal for Non-ACA-Compliant Plans Extended
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»
On April 4, 2019, Idaho Department of Insurance Director Cameron released Bulletin No. 19-02 related to the extension of non-ACA compliant small group and individual policies and plans. As background, on March 25, 2019, CMS provided guidance for a transition policy extension that allows insurers the option to renew non-grandfathered non-ACA-compliant plans, as long as the state allows. Such transition policies are not required to be in compliance with certain ACA mandates including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions, and the annual out-of-pocket maximum limit.
Transitional relief for these “grandmothered” plans has been extended several times before, and this bulletin applies the most recent federal extension to ID and allows insurers to renew policies in the individual market and the small group market according to the extended transitional policy through December 31, 2020. Please note, however, that such carriers must continue to abide by requirements outlined in Bulletin 16-03 (meaning that all grandmothered plans will be on a calendar-year renewal schedule).
Additionally, carriers are required to provide a notice at renewal which informs the individual or small employer of the option to renew the existing coverage or to enroll in a new plan on or off the ID marketplace. The notice must also inform them that some ACA market reforms are not included in their current plans. There is a model notice available on the department’s website that must be used without modification, and must be mailed without any other materials except for a cover letter, which may include the renewal premium.
Small employers that are interested in renewing their non-ACA-compliant plan should work with their advisors and insurers.
Bulletin 19-02 »
May 16, 2017
Rule Amended to Allow Medicare Supplemental Coverage Regardless of Age
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»
On May 1, 2017, the Idaho Department of Insurance issued a news release
announcing an amendment to its rule regarding Medicare Supplement insurance
(often referred to as Medigap). The amendment now allows Medicare-eligible
individuals under age 65 with disabilities or end-stage renal disease to be
eligible for the supplemental coverage. Previously, Medicare Supplement
policies were only available to individuals age 65 and older.
Carriers will be developing and submitting Medicare Supplemental plans
incorporating this rule for 2018. This news release has little
applicability to employers, but employers should be aware of the change as
a resource for employees in case any questions arise.
News
Release »
May 2, 2017
Abortifacient Drugs No Longer Prohibited From Being Prescribed Through
Telemedicine
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»
On April 4, 2017, Gov. Otter signed H.B. 250 into law, amending existing
abortion law by no longer requiring that a physician must have examined a
woman in person to determine the medical appropriateness of the
administration of an abortifacient. Specific to telemedicine, the law
removes language providing that no drug for purposes of causing an abortion
may be prescribed through telehealth services.
The amendments were effective upon passage.
H.B. 250 »
April 4, 2017
Conditional Extension of Renewal for Non-PPACA-Compliant Plans
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»
On March 8, 2017, Idaho Department of Insurance Director Cameron released
Bulletin No. 17-01 related to the extension of non-PPACA-compliant small
group and individual policies and plans. As background, on Feb. 23, 2017,
the federal government announced an additional transition policy that
allows insurers (if allowed by the state) to renew non-grandfathered
non-PPACA-compliant plans (this transitional relief has been extended twice
before). Such policies are not required to be in compliance with certain
PPACA mandates including community rating, coverage of essential health
benefits, prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The Bulletin states that Idaho will allow insurers to renew policies in the
individual market and the small group market according to the extended
transitional policy. Please note, however, that such carriers must continue
to abide by requirements outlined in Bulletin 16-03 (meaning that all
grandmothered plans will be on a calendar-year renewal schedule).
Carriers are required to provide a notice at renewal which informs the
individual or small employer of the option to renew the existing coverage.
The notice must also inform them that some PPACA market reforms are not
included in their current plans. It must be mailed without any other
materials except for a cover letter, which may include the renewal premium.
Small employers that are interested in renewing their non-PPACA-compliant
plan should work with their advisors and insurers.
Bulletin
No. 17-01
July 26, 2016
On June 28, 2016, the Idaho Department of Insurance released the final version
of Bulletin 16-04. The bulletin relates to third-party payment of premiums or
cost-sharing expenses. According to the bulletin, carriers must accept
third-party payments (towards premiums and cost-sharing-expenses) from
individuals (such as family and friends), religious institutions and other
not-for-profit organizations, if the assistance is provided on the basis of the
individual’s financial need, the institution/organization is not a health care
provider and is not financially interested. An example of financial interest
would be if the institution/organization receives funding from entities with a
pecuniary interest in the payment of health insurance claims.
If the third-party payments meet those requirements, the carrier must accept
those payments (both towards premiums and cost-sharing expenses) and those
payments must count toward deductibles and out-of-pocket maximums as if the
insured made the payment directly. This is effective as of the date of the
bulletin as to those health insurance policies regulated under Title 41 of the
Idaho Code.
The bulletin applies to carriers, but employers will want to be aware of the
bulletin, should issues arise with respect to third-party payments of
employee-related premiums and other cost-sharing expenses.
Bulletin
16-04 »
May 3, 2016
On Apr. 19, 2016, Idaho Department of Insurance Director Cameron issued
Bulletin No. 16-03 related to the Feb. 29, 2016, CMS announcement of an
additional extension to the transitional policy for non-PPACA-compliant health
benefit plans (as covered in the March 8, 2016, edition of Compliance
Corner). The Department of Insurance previously announced – in
Bulletin No. 13-05- that insurers in Idaho could renew non-PPACA-compliant
plans, as long as certain conditions are met. Bulletin No. 14-01 allowed a
two-year CMS extension for Idaho insurers, and explained additional
requirements for insurers. Such policies are not required to be in compliance
with certain PPACA mandates including community rating, coverage of essential
health benefits, prohibition on pre-existing condition exclusions and the
annual out-of-pocket maximum limit. Bulletin No. 16-03 now allows these plans
to be further extended through December 31, 2017.
The transitional policy permits issuers in the individual and small group
markets to renew non-grandfathered policies that had plan or policy years
beginning on or before December 31, 2013. Such coverage may now be renewed for
plan or policy years starting between January 1, 2014 and October 1, 2017, so
long as all policies end by December 31, 2017.
The Bulletin provides the following consumer protections. It addresses
accumulation periods for deductibles and out-of-pocket maximums for plans who
calculate them on a plan year, rather than on a calendar year basis. This is
key because a carrier must not apply accumulation periods consisting of fewer
than 12 months, even when the policy period is less than 12 months. To solve
this, carriers may either have a longer than 12-month accumulation period or
overlapping 12-month accumulation periods.
Finally, the bulletin includes a reminder that these plans must still comply
with the following ACA provisions:
- Elimination of annual dollar limits on EHB as defined by the Idaho
benchmark plan, to the extent the plans cover EHB
- No pre-existing condition exclusion (small groups)
- Waiting periods not to exceed 90 days (small groups)
- Mental health parity rules (individual plans upon renewal July 1, 2014 or
later; not applicable to small group plans)
Small employers that are interested in renewing their non-PPACA-compliant plan
should work with their advisors and insurers.
Bulletin No.
16-03 »
October 20, 2015
On Oct. 15, 2015, the Idaho Department of Insurance issued a news release on
their decision on small employer group size. Idaho will retain its existing
definition of ‘small employer’ as groups of up to 50 employees.
As background, PPACA included a provision to change the definition of small
employer from 1-50 to 1-100 employees effective Jan. 1, 2016. On Oct. 1, 2015,
the US Congress passed HR 1624, called the PACE Act. The PACE Act repeals the
mandated small-group expansion from groups of up to 50 employees to groups of
up to 100 employees. Thus, unless a state has expanded its definition of small
employer, PPACA’s insurance mandates would not apply to employers in the 51-100
group in that state.
News Release »
August 25, 2015
On Aug. 6, 2015, the DOL announced an MOU with the Idaho DOL aimed at
protecting employees’ rights by preventing misclassification. Under the MOU,
both agencies may share information and coordinate law enforcement to ensure
that workers are properly classified and that employers are not infringing on
rights by misclassifying a worker into independent contractor or other
non-employee status. Idaho joins 24 other states who have signed similar
agreements with the DOL.
Idaho 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.
DOL
News Brief re: Memorandum of Understanding »
ID DOL Announcement »
November 4, 2014
On Oct. 7, 2014, in Latta v. Otter, No. 14-35420 (9th Cir. 2014), the
U.S. Court of Appeals for the 9th Circuit found Idaho’s same-sex marriage
ban unconstitutional. A stay was granted by the U.S. Supreme Court giving the
state an opportunity to plead as to why it should be allowed to appeal. That
stay was dissolved on Oct. 15, 2014.
The rapid changes in state marriage laws have important effects for individuals
in Idaho 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
Idaho 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 Idaho
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.
Latta v. Otter »
Order Dissolving Stay »
September 23, 2014
On July 8, 2014, CMS approved Idaho’s proposed small group composite
premium rating method. As background, final rules issued by HHS on 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. On June 10, 2014, the Idaho Department of Insurance submitted a
request to use a four-tiered calculation: employee, employee plus spouse,
employee plus children and employee plus family.
This means that while health insurance carriers issuing small group market
plans in Idaho will continue to provide per-member billing, they may also
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. Carriers will have the flexibility to choose which (if any) small group
products will permit employers the composite premium option.
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.
Composite rates would be determined at the time the policy is issued and at
renewal, and would not vary during the policy year. Any tobacco surcharge is
excluded from the composite rate and added to the applicable individual’s
premium.
Importantly, the bulletin does not apply directly to small employers, and is
important for all employers to understand. Small employers in Idaho may request
composite rates, rather than per-member rates, from the insurance carrier 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 for
policy years beginning on or after Jan.1, 2015.
Idaho Department of Insurance Request »
Idaho Department of Insurance, Carrier Frequently Asked
Questions 2014, No. 8 »
May 20, 2014
On May 9, the Idaho Department of Insurance issued Bulletin No. 14-02 related
to pediatric dental coverage. As background, PPACA requires that
non-grandfathered individual and small group policies provide coverage for all
10 categories of essential health benefits, including pediatric dental care. If
the qualified health plan is purchased from the marketplace, the plan is not
required to provide pediatric dental care if there is at least one
exchange-certified stand-alone dental plan available through the marketplace in
the service area. If the qualified health plan is purchased outside of the
marketplace, coverage of pediatric dental care may be excluded if, prior to the
issuance, the carrier becomes reasonably assured that an individual has
obtained such coverage through an exchange-certified stand-alone dental plan.
The bulletin clarifies that an individual or small employer who purchases a
qualified health plan through the state marketplace, Your Health Idaho, is not
required to purchase separate pediatric dental coverage. If an individual or
small employer purchases a qualified health plan outside of the marketplace,
the carrier must include a written disclosure as part of the application
materials stating that the plan does not include coverage for pediatric dental
care and instructions for how to purchase such coverage. The carrier must not
require that the consumer purchase such coverage.
Bulletin No.
14-02 »
On May 1, 2014, Idaho Department of Insurance Director Deal issued Bulletin No.
14-01. The bulletin is 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). The department will allow insurers to renew noncompliant
individual and small group non-grandfathered plans with policy years beginning
on or before Oct. 1, 2016.
Bulletin No.
14-01 »
April 8, 2014
On March 26, 2014, Gov. Otter signed HB 475 into law. The new law requires that
the state exchange portal be constructed in a way that allows consumers to
comparison shop without entering personal information. Passwords, login and
personal information would not be required until an application is submitted.
Additionally, the application for premium assistance must include a warning
that consumers should estimate income carefully and that underestimating income
could result in an overpayment of premium assistance and an owed amount to the
IRS. The law is effective July 1, 2014.
HB
475 »
Illinois
April 30, 2019
Extension for Grandmothered Plans
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»
On March 28, 2019, the Illinois Department of Insurance published Company Bulletin CB# 2019-03. The bulletin relates to the March 25, 2019, CMS guidance titled “Extension of Limited Non-Enforcement Policy through 2020,” which is CMS’s latest transitional policy extension for so-called “grandmothered plans” in the individual and small group markets. According to the bulletin, plans issued in Illinois continually since January 1, 2014, may renew such coverage for a policy year starting on or before October 1, 2020, so long as the policies do not extend past December 31, 2020.
Company Bulletin CB# 2019-03 »
November 28, 2018
Review of Federal Regulation of Association Health Plans and State Law
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»
On Sept. 19, 2018, Insurance Director Rauner issued Bulletin 2018-07. The
bulletin discusses the state and federal regulation of association health
plans (AHPs), after the DOL’s final rules on AHPs were issued this summer.
As background, AHPs are MEWAs and can fall under the jurisdiction of both
federal and state law. This bulletin addresses fully insured group health
plans and how Illinois law applies to them.
The bulletin essentially confirms that insurers in IL may issue group
health insurance to associations that either satisfy the requirements under
state law or the DOL’s final rule. Additionally, IL laws regarding the
filing and review of group health coverage apply to policies issued to
associations that meet the DOL’s requirements.
Finally, the IL Department of Insurance will not require entities to file
documents demonstrating an association's qualification for a group health
insurance policy, unless the policy incorporates by reference the
association's documents.
Bulletin
2018-07 »
June 26, 2018
Extension of Non-ACA-Compliant Small Group and Individual Policies and
Plans
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»
On May 1, 2018, Director of Insurance Hammer released Company Bulletin
2018-02, related to the extension of non-ACA-compliant small group and
individual policies and plans. As background, on April 9, 2018, the federal
government announced an additional transition policy that allows insurers
(if allowed by the state) to renew non-grandfathered non-ACA-compliant
plans (this transitional relief has been extended several times before).
Such policies aren’t required to be in compliance with certain ACA
mandates, including community rating, coverage of essential health
benefits, prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The bulletin states that Illinois will allow insurers to renew policies in
the individual market and the small group market as long as the policy ends
by Dec. 31, 2019, according to the extended transitional policy. Employers
with non-ACA-compliant plans should work with their insurer and advisor on
any policy extension.
Company
Bulletin 2018-02 »
September 19, 2017
Synchronization of Prescription Drug Refills
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»
On Aug. 18, 2017, Gov. Rauner signed HB 2957, enacting Public Act 100-0138,
which requires plans that provide coverage for prescription drugs to
provide coverage for synchronization of prescription drug refills at least
once a year for each plan participant if certain conditions are met.
Specifically, this law requires insurers to provide prorated daily
cost-sharing rates to any medication dispensed by a network pharmacy when
necessary.
"Synchronization" is defined to mean the coordination of medication refills
for a patient taking two or more medications for one or more chronic
conditions (rather than for a single chronic condition) such that the
patient's medications are refilled on the same schedule for a given time
period. For a policy of health and accident insurance to provide for
synchronization of prescriptions drug refills, the prescription drugs must
be covered by the policy's clinical coverage policy or have been approved
by a formulary exceptions process, among other specified conditions.
This law is effective immediately.
Public Act 100-0138 »
Mammography Screenings
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»
On Aug. 25, 2017, Gov. Rauner signed SB 0314, enacting Public Act 100-0395.
This law amends the Illinois Insurance Code regarding coverage for low-dose
mammography screenings. The law now includes coverage for MRI of an entire
breast or breasts if a mammogram demonstrates heterogeneous or dense breast
tissue and is determined by licensed physicians to be medically necessary.
This law is effective Jan. 1, 2018.
Public Act 100-0395 »
Treatment of Serious Mental Illness
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»
On Aug. 24, 2017, Gov. Rauner signed HB 1332, enacting Public Act 100-0305.
The law regarding coverage for treatment of serious mental illnesses is now
expanded to include coverage for eating disorders, including, but not
limited to, anorexia/bulimia nervosa, avoidant/restrictive food intake
disorder and any other eating disorders contained in the most recent
version of the Diagnostic and Statistical Manual of Mental
Disorders
published by the American Psychiatric Association. Additionally, an insurer
that provides coverage for hospital or medical expenses under an individual
policy of accident and health insurance must also provide coverage for
treatment of serious mental illnesses, including eating disorders.
This law is effective immediately.
Public Act 100-0305 »
Disclosure of Genetic Information
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»
On Aug. 25, 2017, Gov. Rauner signed SB 0318, enacting Public Act 100-0396.
This law, amending the Illinois Genetic Information Privacy Act (IGIPA),
prohibits an employer from penalizing an employee who does not disclose his
or her genetic information or chooses not to participate in a program
requiring disclosure of the employee’s genetic information.
As background, under the IGIPA, employers must treat genetic information
and testing in such a manner that is consistent with the requirements of
federal law (e.g., GINA, the ADA, Title VII of the Civil Rights Act, the
FMLA, etc.).
GINA defines “genetic information” as information about an individual's
genetic tests, about the genetic tests of an individual's family members,
or about the manifestation of a disease or disorder in an individual's
family members. Genetic information includes any request for, or receipt
of, genetic services (including genetic testing, counseling or education),
or participation in clinical research, which includes such services, by the
individual or family member. Genetic information also includes genetic
information of any fetus carried by an individual or by a pregnant woman
who is a family member, as well as genetic information of any embryo
legally held by an individual or family member who is utilizing assisted
reproductive technology. Genetic information does not, however, include
information about the sex or age of any individual, or information about
the race or ethnicity of the individual or family members that is not
derived from a genetic test.
GINA defines a “genetic test” as “an analysis of human DNA, RNA,
chromosomes, proteins or metabolites, which detects genotypes, mutations or
chromosomal changes.” The final regulations contain many examples of tests
that fall within this definition. Also included in the regulations are
examples of tests or procedures that are not genetic tests, among which are
complete blood counts, cholesterol tests, liver-function tests, and alcohol
and drug tests.
This amendment of the IGIPA is important because, under the current IGIPA,
employers are generally prohibited from using genetic information or
genetic testing in furtherance of a workplace wellness program benefiting
employees, unless four conditions are met. Now, an employer cannot penalize
an employee who does not disclose his or her genetic information or chooses
not to participate in the program if it requires such disclosure.
In order to ensure compliance with IGIPA and the requirements of federal
law, employers should take various actions, including, but not limited to,
reviewing their group health plan design, provisions and administrative
procedures.
The law is effective Jan. 1, 2018.
Public Act 100-0396 »
July 25, 2017
New Law Mandates Coverage for PANDAS and PANS
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»
On July 18, 2017, Gov. Rauner signed HB 2721 into law, amending the
Illinois Insurance Code and creating Public Act 100-0024, or Charlie’s Law.
This new law will provide coverage for treatments for two pediatric
autoimmune disorders: Pediatric Autoimmune Neuropsychiatric Disorders
Associated with Strep (PANDAS) and Pediatric Acute-Onset Neuropsychiatric
Syndrome (PANS).
Specifically, a group or individual policy of accident and health insurance
or managed care plan that is amended, delivered, issued or renewed after
the effective date of this new law must provide coverage for treatment of
PANDAS and PANS, including, but not limited to, the use of intravenous
immunoglobulin therapy.
The implementation of this new law may require affected employers (those
that are fully insured) to review and revise their benefits policies with
their carrier to be compliant with these new requirements.
This law is effective immediately.
Public Act 100-0024 »
June 13, 2017
Cook County Publishes Procedural Rules for Sick Leave Ordinance
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»
In the Oct. 18, 2016, Compliance Corner, we reported on the
passage of the Cook County Earned Sick Leave Ordinance 16-4229, which
enacts Cook County Code Chapter 42, Human Relations, Article 1. The
ordinance creates paid sick leave provisions that provide paid sick and
safe leave to employees performing more than 80 hours of work in Cook
County for an employer within any 120-day period. Further, the Cook County
Commission on Human Rights (“the Commission”) will administer and enforce
the ordinance.
After engaging in a public rulemaking process, the Commission adopted
interpretative and procedural rules for its enforcement of the ordinance.
Some of the highlights of the ordinance and its procedural rules are as
follows:
- Employers that gainfully employ at least one covered employee and who
have at least one place of business within Cook County are covered by
the ordinance. Some exemptions from coverage apply, such as
construction workers who are covered by a collective bargaining
agreement, Indian tribes and governmental employers.
- The ordinance covers employees who work within Cook County for at least
two hours in a two-week period for a covered employer while physically
present in Cook County. Some exceptions from coverage apply.
- The ordinance is not limited to full-time employees, but also covers
part-time, temporary, seasonal, occasional and new or re-hired
employees.
- New employees can use accrued sick leave after an initial six-month
probationary period, and employers that offer combined leave benefits
such as paid time off (PTO) are exempt from these requirements so long
as employees could accrue and use up to five days (40 hours) of PTO
within a calendar year.
- The ordinance requires employers to provide employees with one hour of
paid sick and safe leave for every 40 hours worked.
- Employees may accrue a maximum of 40 hours of paid sick leave over the
course of one year and can roll over up to half of their unused accrued
earned sick leave to the following year, up to a maximum of 20 hours.
- If an employer is subject to FMLA, each of the employer's covered
employees shall be allowed, at the end of his or her 12-month accrual
period, to carry over up to 40 hours of unused accrued earned sick
leave, in addition to the allowed 20-hour carryover, to use exclusively
for FMLA-eligible purposes.
- Employers may establish reasonable notice requirements for employees to
use sick leave under the ordinance.
- Certain employer notices and postings are required. A model notice is
available from the Commission.
As a reminder, the ordinance goes into effect on July 1, 2017. The
implementation of the ordinance may require affected employers to review
and revise their benefits policies to be compliant with these new
requirements.
Ordinance 16-4229 »
Procedural
Rules »
Model
Notice »
March 21, 2017
Extension of Non-PPACA-Compliant Small Group and Individual Policies and
Plans
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»
On March 10, 2017, Illinois Director of Insurance Hammer released Company
Bulletin 2017-01 related to the extension of non-PPACA-compliant small
group and individual policies and plans. As background, on Feb. 23, 2017,
the federal government announced an additional transition policy that
allows insurers (if allowed by the state) to renew non-grandfathered
non-PPACA-compliant plans (this transitional relief has been extended twice
before). Such policies are not required to be in compliance with certain
PPACA mandates including community rating, coverage of essential health
benefits, prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The Bulletin states that Illinois will allow insurers to renew policies in
the individual market and the small group market according to the extended
transitional policy. Employers with non-PPACA-compliant plans should work
with their insurer on any policy extension.
Company
Bulletin 2017-01 »
February 7, 2017
New Law Amends Employee Sick Leave Act
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»
On Jan. 13, 2017, Gov. Rauner signed SB 2799 into law, creating Public Act
99-0921, which amends the recently-enacted Employee Sick Leave Act (covered
in the Aug. 23, 2016, edition of Compliance Corner).
As background, the Employee Sick Leave Act (the Act) went into effect on
Jan. 1, 2017, and provides flexibility for caregivers by providing that
employees may use personal sick leave benefits provided by the employer for
absences due to an illness, injury or medical appointment of the employee's
family member.
The amendments or clarifications in this new Act are as follows:
- Revises the definition of "personal sick leave benefits" to include
paid or unpaid time accrued and available to an employee, as provided
through an employment benefit plan or policy;
- Provides that an employment benefit plan or paid time off policy does
not include long term disability, short term disability, an insurance
policy, or other comparable benefit plan or policy;
- Adds stepchildren and domestic partners to the list of persons for whom
an employee may use personal sick leave benefits;
- Provides that an employer may request written verification of the
employee's absence from a health care professional if such verification
is required under the employer's employment benefit plan or paid time
off policy;
- Allows employers who base personal sick leave benefits on an
employee's years of service instead of annual or monthly accrual to
limit the amount of sick leave to be used under the law to half of the
employee's maximum annual grant;
- In a provision prohibiting retaliation, it provides that nothing
prohibits an employer from applying the terms and conditions set forth
in the employment benefit plan or paid time off policy applicable to
personal sick leave benefits;
- Stipulates that the law does not apply to an employee of an employer
subject to certain provisions of the Railway Labor Act, or to an
employer or employee as defined in either the federal Railroad
Unemployment Insurance Act or the Federal Employers' Liability Act;
- Provides that the law does not affect collective-bargaining agreements
or any party’s power to collectively bargain; and
- Grants the Illinois Department of Labor rulemaking authority.
As stated above, the Act went into effect Jan. 13, 2017. The implementation
of the Act may require affected employers to review and revise their
benefit policies to be compliant with these new requirements.
Public Act 99-0921 »
Employee Sick Leave Act FAQs »
October 18, 2016
New County Ordinance Mandates Employee Sick Leave
On Oct. 5, 2016, the Cook County Commissioners passed the Cook County Earned
Sick Leave Ordinance 16-4229, which enacts Cook County Code Chapter 42, Human
Relations, Article 1. This ordinance creates paid sick leave provisions that
provide paid sick and safe leave to employees performing more than 80 hours of
work in Cook County for an employer within any 120-day period. Further, these
requirements may sound familiar because this ordinance is very similar to the
Chicago Minimum Wage Ordinance, which was reported on in the July 26, 2016,
Compliance
Corner. Note, the Cook County Commission on Human Rights will
administer and enforce this ordinance.
The ordinance requires employers to provide employees with one hour of paid
sick and safe leave for every 40 hours worked, excluding those employed in
construction work who are covered by a collective bargaining agreement, Indian
tribes and government employers.
Employees may accrue a maximum of 40 hours paid sick leave over the course of
one year and can roll over up to half of his or her unused accrued earned sick
leave to the following year, up to a maximum of 20 hours. If an employer is
subject to FMLA, each of the employer's covered employees shall be allowed, at
the end of his or her 12-month accrual period, to carry over up to 40 hours of
his or her unused accrued earned sick leave, in addition to the allowed 20 hour
carryover, to use exclusively for FMLA eligible purposes. New employees can use
accrued sick leave after an initial six month probationary period, and
employers that offer combined leave benefits such as Paid Time Off (PTO) are
exempt from these requirements so long as employees could accrue and use up to
five days (40 hours) of PTO within a calendar year.
Certain notices and postings are required. Employers must comply with the new
law starting on July 1, 2017.
Ordinance 16-4229 »
October 4, 2016
Employer Data Breach Obligations
On May 6, 2016, Gov. Rauner signed HB 1260 into law, creating Public Act
99-0503, which amends the Illinois Personal Information Protection Act (PIPA).
The legislation amends the PIPA by broadening the definition of "personal
information" and requiring entities that are required to give notice to HHS to
also provide a copy of the notice to the Illinois Attorney General’s office.
The data breach statute now defines personal information to include:
- Health insurance information;
- Medical information;
- Unique biometric data; and
- An individual’s user name or email address, in combination with a password
or security question and answer that would permit access to an online
account.
Illinois employers should review and update, as necessary, their data breach
notification plans to ensure the obligations of this amended law are met.
This law is effective on Jan. 1, 2017.
Public Act 099-0503 »
August 23, 2016
New Law Mandates Employee Sick Leave
On Aug. 19, 2016, Gov. Rauner signed HB 6162 into law, creating Public Act
99-0841 or the Employee Sick Leave Act. This law is intended to provide
flexibility for caregivers by providing that employees may use personal sick
leave benefits provided by the employer for absences due to an illness, injury
or medical appointment of the employee's family member. Family member includes:
child, spouse, sibling, parent, mother-in-law, father-in-law, grandchild,
grandparent or stepparent. Employers may limit employees to use up to six
months of accrued sick leave benefits for reasonable periods of time as the
employee's attendance may be necessary, under the same employer conditions and
policies upon which the employee is able to use sick leave benefits for their
own illness or injury.
The implementation of this new law may require affected employers to review and
revise their benefit policies to be compliant with these new requirements.
This law takes effect Jan. 1, 2017.
HB 6162 »
New Law Mandates Unpaid Child Bereavement Leave
On July 29, 2016, Gov. Rauner signed SB 2613 into law, creating Public Act
99-0703 or the Child Bereavement Leave Act. This law provides an employee may
use up to two weeks or ten work days of bereavement leave (unpaid leave) to
grieve the death of the employee's child, attend services in relation to the
death of the employee's child or make arrangements necessitated by the death of
the employee's child. Child is defined broadly to include an employee’s son or
daughter who is a biological, adopted, or foster child, a stepchild, legal ward
or a child of a person standing in loco parentis.
This law is applicable to employers who are subject to FMLA (those with 50 or
more employees) and employees eligible to take leave under FMLA. So, if an
employee has exhausted their FMLA leave or is not eligible, then it appears
they may not take an additional 10 days of leave under this new law. Further,
in the event an employee suffers the death of more than one child in any
12-month period, then the employee is entitled to take up to six weeks of
unpaid bereavement leave in the 12-month period. However, this new law does not
create a right for an employee to take unpaid leave that exceeds the time
allotted under FMLA.
Employees must provide their employers with at least 48 hours’ advance notice
of the employee’s intention to take bereavement leave, unless providing the
notice is not reasonable or practicable.
The implementation of this new law may require affected employers to review and
revise their benefit policies to be compliant with these new requirements.
This law is effective immediately.
SB 2613 »
July 26, 2016
On June 22, 2016, the City of Chicago passed the Chicago Minimum Wage Ordinance
O2016-2678, which amends Municipal Code Chapter 1-24 and Chapter 2-25. This
ordinance amends the Code to include paid sick leave provisions that provide
paid sick and safe leave to employees performing more than 80 hours of work in
the City of Chicago for an employer within any 120-day period.
The ordinance requires employers to provide employees with one hour of paid
sick and safe leave for every 40 hours worked, excluding work-study students
and those employed in construction work who are covered by a collective
bargaining agreement. The complete definition of “employee” can be found in the
Illinois Minimum Wage Law at 820 ILCS 105/1(d), with the exception that all
domestic workers are included under this ordinance.
Employees may accrue a maximum of 40 hours paid sick leave over the course of
one year and can roll over up to 2.5 days to the following year. New employees
can use accrued sick leave after an initial six month probationary period, and
employers that offer combined leave benefits such as Paid Time Off (PTO) are
exempt from these requirements so long as employees could accrue and use up to
five days of PTO within a calendar year.
Certain notices and postings are required. Employers must comply with the new
law starting on July 1, 2017.
Ordinance O2016-2678 »
April 5, 2016
On March 30, 2016, the Illinois Department of Insurance issued Bulletin CB#
2016-03, which states that insurers in the individual and small group major
medical health insurance markets can choose to renew transitional policies
through Dec. 31, 2017. As discussed in the March 8, 2016, edition of
Compliance
Corner, CMS announced an extension for small group transitional
policies. Such policies are not required to be in compliance with certain PPACA
mandates including community rating, coverage of essential health benefits,
prohibition on pre-existing condition exclusions and the annual out-of-pocket
maximum limit. The policy must have been in place on Dec. 13, 2013.
Additionally, insurers that offer this short term extension of coverage are
required to send each policyholder (the employer for a group policy) a renewal
notice that explains the offer to continue the transition policy to the end of
2017.
Bulletin
CB# 2016-03 »
February 9, 2016
On Feb. 5, 2016, the Illinois Department of Insurance issued Company Bulletin
CB #2016-02. The bulletin is directed at insurers and details how they should
calculate premiums for non-grandfathered small group policies for policy years
beginning on or after Jan. 1, 2016. While much of the bulletin is technical,
there are a few key points for small employers to understand about their
upcoming plan year premiums.
Insurers are not required to provide small employers with composite rates. An
insurer has the choice of charging a per member rate (based on age, geographic
area, and tobacco usage) or a composite rate. If the insurer chooses to use
composite rates, they must offer that method to all small employers. The
employer will then have the choice of composite or per member rates. If
composite rates are elected, the insurer must calculate the average premium at
the time the policy is issued based on the number of participants enrolled at
that time. The insurer must provide a four tier-rate structure: Employee only,
employee plus spouse, employee plus children and employee plus family. The
composite rate would remain unchanged during the entire policy year regardless
of enrollment changes under the policy. Lastly, tobacco surcharges are applied
to the applicable participants and are not factored into composite rates.
CB
#2016-02 »
October 20, 2015
On Oct. 16, 2015, the Illinois Department of Insurance released Revised CB
2015-10. This bulletin acknowledged the passage of the PACE Act, which was
signed into federal law Oct. 8, 2015 and repealed PPACA’s mandated small-group
expansion. As a result of the PACE act, the federal government will continue to
define small groups as those with 1-50 employees. Illinois reported that the
state will continue to define small group as those employers with 2-50
employees.
Although the PACE Act came too late to allow for changes in the rates that will
be imposed by many carriers on Jan. 1, 2016, Illinois will allow carriers to
submit revisions to their small group rates on a quarterly basis beginning in
April 2016.
CB
2015-10 »
September 8, 2015
On Aug. 19, 2015, Gov. Rauner signed SB 54 into law. This law amends the
Illinois Insurance Code by including breast tomosynthesis in the definition of
“low-dose mammography.” “Breast tomosynthesis” is a radiologic procedure that
involves the acquisition of projection images over the stationary breast to
produce cross-sectional, digital three-dimensional images of the breast.
As background, Illinois requires fully insured plans to cover low-dose
mammography to detect the presence of occult breast cancer in plan participants
who are age 35 and older. As such, this amendment requires plans to cover
breast tomosynthesis.
This law takes effect July 1, 2016, but only if:
- PPACA is repealed by Congress or invalidated by a decision of the U.S.
Supreme Court;
- HHS promulgates a rule, regulation or comment that eliminates the state’s
responsibility to defray the cost of state-mandated benefits or that
requires breast tomosyntheses to be covered as an essential health benefit
under a qualified health plan.
SB
54 »
On Aug. 20, 2015, Gov. Rauner signed SB 1764 into law. This law requires fully
insured plans that cover more than 25 employees to provide coverage for the
diagnosis and treatment of infertility if the plan covers pregnancy-related
benefits. Specifically, such plans must cover in vitro fertilization, uterine
embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian
tube transfer, zygote intrafallopian tube transfer and low tubal ovum transfer.
The law defines "infertility" as the inability to conceive after one year of
unprotected sexual intercourse, the inability to conceive after one year of
attempts to produce conception, the inability to conceive after being diagnosed
with conditions affecting infertility or the inability to sustain successful
pregnancies.
Further, coverage for vitro fertilization, gamete intrafallopian tube transfer
or zygote intrafallopian tube transfer is required only if three conditions are
met:
- The participant must be unable to attain, maintain or sustain a viable and
successful pregnancy through other covered, reasonable and less costly
infertility treatments.
- The participant must not have gone through four completed oocyte
retrievals. However, if a live birth follows one oocyte retrieval, then two
more oocyte retrievals must be covered.
- The procedures must be performed at a medical facility that conforms to the
American College of Obstetrics and Gynecology guidelines for in vitro
fertilization clinics or to the American Fertility Society minimal
standards for programs of in vitro fertilization.
The law also provides an exemption for religious institutions and organizations
if such coverage violates their religious and moral teachings and beliefs.
The law takes effect for plans issued on or after Jan. 1, 2016.
SB
1764 »
On Aug. 21, 2015, Gov. Rauner signed HB 3673 into law. This law amends the
state benefit mandates pertaining to mammogram coverage by requiring a
screening MRI, when medically necessary, for women 35 years of age or older who
are at high risk for breast cancer. This provision became effective Aug. 21,
2015.
The law also provides additional access to breast imaging for clients of the
Illinois Department of Healthcare and Family Services and stipulates a minimum
reimbursement rate for providers who participate in the Department’s breast
cancer treatment quality improvement program. These provisions take effect in
January 2016 and January 2017, respectively.
HB
3673 »
August 25, 2015
On July 27, 2015, Gov. Rauner signed HB 235 into law. This law requires plans
to provide coverage for anesthesia and expenses related to dental care for
participants under age 19 who are diagnosed with autism spectrum disorders or
with developmental disabilities. For purposes of this law, “developmental
disabilities” is defined as intellectual disabilities or related conditions
that are attributable to cerebral palsy, epilepsy or other conditions, except
for mental illnesses; are likely to continue indefinitely; and result in
substantial functional limitations in three or more of the following major life
activities: capacity for independent living, language, learning, mobility,
self-care and self-direction. Additionally, plans can require that plan
participants make two visits to the dental care provider before receiving
additional treatment under this law.
The law takes effect Jan. 1, 2016.
HB 235 »
On Aug. 3, 2015, Gov. Rauner signed HB 3137 into law. This law, entitled the
“Topical Eye Medication Prescription Act”, requires insurers to cover topical
eye medication refills when the following conditions are met:
- The medication is to treat a chronic condition of the eye.
- The refill is requested by the insured before the last day of the
prescribed dosage period and after at least 75 percent of the predicted
days of use.
- The prescribing doctor indicates on the prescription that refills are
permitted and that the early refills do not exceed the total number of
refills prescribed.
The law takes effect for policies issued or renewed on or after Jan. 1, 2016.
HB 3137 »
February 10, 2015
On Jan. 22, 2015, the Illinois Department of Healthcare and Family Services
released a notice providing guidance on federal restrictions on individuals who
are eligible for both Medicare and Medicaid. Specifically, the Social Security
Act does not allow insurance policies (Medigap) to be sold to individuals who
are eligible for both programs. The notice also includes a link to a CMS
bulletin that includes FAQs on the prohibition.
Informational
Notice »
January 13, 2015
On Jan. 4, 2015, Governor Pat Quinn signed the Illinois Secure Choice Savings
Plan Act into law, creating Public Act 098-1150. The new legislation provides
an individual retirement savings program for private-sector employees who
don’t have access to an employer-sponsored retirement plan. Employers
that have been in business for at least two years and employ 25 or more
employees are required to participate by enrolling their participants in the
plan and remitting after-tax contributions to the plan. The new law is
effective June 1, 2015, and implementation must be completed within 24 months
of the Act.
Public Act 098-1150 »
November 18, 2014
On Aug. 26, 2014, Illinois enacted Public Acts 98-1050 and 98-1051, both of
which are effective Jan. 1, 2015. Under Public Act 98-1050, employers will be
required to include information in their employee handbooks concerning employee
rights under the discrimination prohibitions. Employers must also post a notice
that summarizes the discrimination prohibitions. Public Act 98-1050 also
requires employers with one or more employees to comply with the pregnancy
discrimination prohibitions, which were amended to require employers to make
reasonable accommodations for medical or common conditions of pregnancy, unless
the accommodations impose undue hardship. Public Act 98-1050 also states that
employers may not retaliate against employees and applicants who request or use
reasonable accommodations.
Public Act 98-1051 gives the Illinois Department of Labor the authority to
refer complaints alleging equal pay violations to the Department of Human
Rights if the complaints also allege violations of fair employment practices.
Public Act 098-1050 (H.B. 8) »
Public Act 098-1051 (H.B. 5563) »
On Nov. 7, 2014, the Illinois Department of Insurance announced more carriers
and consumer plan options for the 2015 year of the Illinois health insurance
marketplace, also known as Get Covered Illinois (GCI). Three additional
insurers, IlliniCare Health Plan, Inc., Time Insurance Company and
UnitedHealthcare of the Midwest, Inc., will be offering plans on the
marketplace in 2015. A minimum of 56 different plans will be offered in all
Illinois counties, which is an increase from the 48 plans offered in 2014. Open
enrollment for GCI began on Nov. 15, 2014, and will continue through Feb. 15,
2015.
News Release »
August 12, 2014
On July 28, 2014, Director of Insurance Boron issued Company Bulletin 2014-10
related to health care for transgender individuals. Group health policies
issued in Illinois must provide coverage for the treatment of gender dysphoria
or gender identity disorder on the same terms and conditions as hospital and
medical benefits provided under the plan. Non-grandfathered policies must
provide coverage for sex change surgery.
Bulletin
2014-10 »
On Aug. 5, 2014, the Illinois Department of Insurance issued a press release
announcing that consumers now have access to insurers' filings, which will
include rate and product information. The System for Electronic Rate and Form
Filing (SERFF), maintained by the National Association of Insurance
Commissioners, will make available filings for all products, including group
major medical, dental, vision, life and disability policies.
Press Release »
SERFF
Filing Access »
June 3, 2014
On May 23, 2014, Director of Insurance Andrew Boron issued Company Bulletin CB
2014-08, which summarizes the Department of Insurance's view on
HIV/AIDS-related coverage as an essential health benefit (EHB). As background,
non-grandfathered individual and small group health plans are required to
provide coverage for EHB. The bulletin states that insurers may be found
discriminatory and out of compliance with the EHB requirement if they fail to
provide coverage for preferred and alternative drug regimens recommended by HHS
for treating HIV/AIDS. The department may reach a similar determination if an
insurer redundantly requires preauthorization for refills of HIV/AIDS
medications without any justification, such as a change to the enrollee's other
prescriptions. While the bulletin is directed toward insurers offering plans
through the exchange, it does provide insight into how the department may view
the EHB offerings of a group health plan purchased off of the exchange.
CB
2014-08 »
May 20, 2014
On May 2, 2014, Illinois Department of Insurance Director Andrew Boron issued
Company Bulletin CB 2014-04. The bulletin is 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). The department will allow insurers to
renew noncompliant individual and small group non-grandfathered plans with
policy years beginning on or before Oct. 1, 2016.
CB
2014-04 »
Indiana
December 11, 2018
Guidance for Short-Term Health Insurance
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»
On Sept. 4, 2018, Insurance Commissioner Robertson released Bulletin 244 to
remind carriers and producers who issue policies in Indiana of the state
insurance requirements for short-term health insurance. This bulletin is
intended to remind carriers doing business in the state that state law
isn’t preempted regarding short-term health insurance and, thus, carriers
doing business in Indiana must continue to comply with state law.
As background, the federal government issued a rule in August 2018 that
extended the initial contract term of short-term policies issued on or
after Oct. 2, 2018, to be no more than 12 months while limiting renewals or
extension of such policies to no more than 36 months. Unlike the federal
rule, Indiana law limits a short-term policy to a term that is less than 6
months. Moreover, short-term policies in Indiana are nonrenewable.
This bulletin was for informational purposes only and employers need not
take any action at this time. The intent was to remind carriers that
Indiana insurance law continues to apply to short-term health insurance,
and carriers must factor in Indiana policies before issuing a product in
response to the federal guidelines.
Bulletin
244 »
November 28, 2018
Review of Federal Regulation of Association Health Plans and State Law
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»
On Oct. 17, 2018, Insurance Commissioner Robertson issued Bulletin 245. The
bulletin discusses the state and federal regulation of association health
plans (AHPs), after the DOL’s final rules on AHPs were issued this summer.
As background, AHPs are MEWAs and can fall under the jurisdiction of both
federal and state law. The bulletin identifies the different types of AHPs
and how Indiana law applies to them.
The bulletin essentially confirms that IN still has the same regulatory
authority over MEWAs and AHPs as it did before the DOL published its final
rule. Specifically, IN still requires self-insured AHPs to be licensed
under state law.
While this bulletin doesn’t necessarily provide any new information, it’s a
reminder to entities that might want to establish an AHP for IN employers
that they must comply with state law.
Bulletin
245 »
May 1, 2018
Extension of Non-ACA-Compliant Small Group and Individual Policies and
Plans
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»
On April 18, 2018, Indiana Insurance Commissioner Robertson released
Bulletin 243, related to the extension of non-ACA-compliant small group and
individual policies and plans. As background, on April 9, 2018, the federal
government announced an additional transition policy that allows insurers
(if allowed by the state) to renew non-grandfathered non-ACA-compliant
plans (this transitional relief has been extended several times before).
Such policies aren’t required to be in compliance with certain ACA
mandates, including community rating, coverage of essential health
benefits, prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The bulletin states that Indiana will allow insurers to renew policies in
the individual market and the small group market as long as the policy ends
by Dec. 31, 2019, according to the extended transitional policy. Employers
with non-ACA-compliant plans should work with their insurer and advisor on
any policy extension.
Bulletin
243 »
September 19, 2017
Electronic Authorization for Prescription Drugs
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»
On April 13, 2017, Gov. Holcomb signed SB 73, creating Public Law 45-2017,
which requires a health insurance policy and a health maintenance
organization contract to accept and respond to electronic prior
authorization requests according to a particular electronic transaction
standard.
As background, electronic prior authorization is the transmission of
information between the prescriber and payer to determine whether or not
the prior authorization is granted. This process improves the covered
individual’s ability to obtain needed medications and provides an effective
line of communication between prescribing health care providers, dispensing
pharmacist and health plans.
Although this new law is aimed at insurers, it is important for employers
to be aware of what insurers may be doing and what they are now required to
do when issuing policies.
This law is effective Jan. 1, 2018.
Public Law 45-2017 »
Synchronization of Prescription Drug Refills
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»
On April 26, 2017, Gov. Holcomb signed HB 1540, creating Public Law
202-2017, which provides that a health insurance policy and a health
maintenance organization contract that provide coverage for prescription
medications must provide for synchronized refill schedule coordination for
prescription medications for chronic conditions.
“Synchronize" means to use a single pharmacy dispensing process as a means
of coordinating the covered individual's medications at the same time when:
- A particular medication:
- is of a formulation that can be effectively split, and
- does not have quantity limits or dose optimization criteria as
specified in the policy’s formulary and prior authorization
requirements;
- The covered individual is on a stabilized treatment plan for a chronic
condition and the synchronization is for those drugs treating a chronic
condition; and
- The medication is not:
- an opioid, stimulant, sedative or hypnotic medication, or
- another medication that is addictive and subject to abuse
Although this new law is aimed at insurers, it is important for employers
to be aware of what insurers may be doing and what they are now required to
do when issuing policies.
This law is effective July 1, 2017.
Public Law 202-2017 »
April 18, 2017
Extension of Non-PPACA-compliant Small Group and Individual Policies and
Plans
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»
On March 16, 2017, Indiana Insurance Commissioner Robertson released
Bulletin 237 related to the extension of non-PPACA-compliant small group
and individual policies and plans. As background, on Feb. 23, 2017, the
federal government announced an additional transition policy that allows
insurers (if allowed by the state) to renew non-grandfathered
non-PPACA-compliant plans (this transitional relief has been extended twice
before). Such policies are not required to be in compliance with certain
PPACA mandates including community rating, coverage of essential health
benefits, prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The bulletin states that Indiana will allow insurers to renew policies in
the individual market and the small group market according to the extended
transitional policy.
Bulletin
237 »
April 19, 2016
On March 21, 2016, Gov. Pence signed SB 41 into law, creating Public Law 19,
regarding pharmacy benefits. This law prevents health insurance issuers that
use formularies or require cost sharing or utilization review for prescription
drug coverage from removing drugs from formularies or changing the cost sharing
or utilization review requirements unless certain conditions are met.
This law also requires that health insurance issuers establish a procedure for
a covered individual's use in requesting an exception to a step therapy
protocol used by the issuer with respect to coverage for certain prescription
drugs, including time frames for a determination concerning an exception and
reasons for granting an exception.
This law is effective July 1, 2016.
SB 41 »
April 5, 2016
On March 21, 2016, Governor Pence signed HB 1263 into law, creating Public Law
78. This law will enable the expanded use of telemedicine in Indiana by
permitting prescriptions for certain drugs and devices to be issued during
remote patient visits.
The law even allows a provider to issue a prescription for certain drugs and
devices to a patient who is receiving services through the use of telemedicine
even if the patient has not been seen previously by the provider in person if
certain conditions are met.
This new law will take effect July 1, 2016.
HB 1263
»
December 15, 2015
On Nov. 30, 2015, Insurance Commissioner Robertson issued Bulletin 221
regarding the definition of small group for purposes of providing employer
health coverage. Indiana will continue to consider a small employer to be one
who employs no more than 50 employees. There has been some confusion on how to
count employees, so the department will issue an emergency rule to conform
Indiana’s definition of “employee” for determining group size to the federal
definition.
The department will define an employee as individual employed by an employer
but not an individual owner or partner. Part-time and seasonal employees should
be counted. The new rule will apply to non-grandfathered, PPACA-compliant plans
with an effective date on or after Jan. 1, 2016.
Further, Bulletin 221 explains that because of the Protecting Affordable
Coverage for Employees (PACE) Act, Bulletin 215 is withdrawn. Bulletin 2015 was
issued June 4, 2015 (addressed in the June 30, 2015 edition of Compliance
Corner), and allowed for transitional policies for employers with
51-100 employees to continue through renewal no later than Oct. 1, 2016. Those
policies will not be considered transitional and will continue to be large
group policies that may be renewed until Oct. 1, 2016. After that period, they
must transition to a fully compliant policy.
Finally, another calculation affected by group size is MLR. The department
considers groups of one to 100 employees to be a small group for purposes of
calculating MLR. This policy will not change through the end of 2015. For plan
years beginning before Jan. 1, 2016, premium rebate requirements of the ACA
continue to apply in the small group market in Indiana only if the MLR is less
than 80 percent. For plan years beginning on or after Jan. 1, 2016, groups of
51 or more employees will be considered large groups for purposes of
calculating MLR.
Additional questions and examples are available within a small group FAQ found
on the department’s website.
Bulletin
221 - Small Employer Definition »
FAQs
»
October 6, 2015
On Apr. 23, 2015, Gov. Pence signed SB 26 into law, creating Public Law 43.
This law requires that Indiana plans cover refills of prescription eye drops
under specified conditions. The plan must provide coverage for a 30-day supply
if the covered individual requests the refill not earlier than 25 days after
the prescription eye drops were last dispensed and if there are refills
remaining on the prescription. If the individual is seeking a 90-day supply,
the request can come no earlier than 75 days after they were last dispensed.
This requirement is effective for fully insured health plans delivered, issued
for delivery or renewed in Indiana on or after Jan. 1, 2016.
SB 26 »
On May 5, 2015, Gov. Pence signed HB 1269 into law, creating Public Law 185.
This law provides that plans must include coverage for health care provided
through telemedicine services to the same extent as coverage provided in
person. ‘Telemedicine services’ means health care services delivered by use of
interactive audio, video or other electronic media, including medical
examinations and consultations and behavioral health evaluations and treatment.
The law prohibits a provider from having to obtain written consent for use of
telemedicine. This requirement is effective for fully insured health plans
delivered, issued for delivery or renewed in Indiana on or after July 1, 2015.
HB 1269 »
On May 5, 2015, Gov. Pence signed SB 464 into law, creating Public Law 209.
This law places restrictions on coverage under a health insurance policy for
methadone used in pain management. An Indiana group health plan may only
provide coverage for methadone if the daily dosage is no more than 60
milligrams and is for the treatment of pain or pain management. The daily
dosage may exceed 60 milligrams only if prior authorization is obtained and a
determination of medical necessity has been shown by the provider. This
requirement is effective for fully insured health plans delivered, issued for
delivery or renewed in Indiana on or after July 1, 2015.
SB 464 »
June 30, 2015
On June 4, 2015, Insurance Commissioner Robertson issued Bulletin 215 regarding
the transitional renewal of group health plans for groups with 51-100
employees. As background, on Jan. 1, 2016, under PPACA the definition of small
employer changes from 1-50 employees to 1-100 employees. According to the
advisory memorandum, Indiana has adopted a transitional policy for small
employers, as allowed by the CCIIO (outlined in a March 5, 2014, CCIIO bulletin
which allows transition relief for non-PPACA-compliant plans with years
beginning on or before Oct. 1, 2016).
The Department previously issued Bulletin 205 (addressed in the April 8, 2014
edition of Compliance Corner) which permitted these transitional
policies to be renewed in the individual and small group markets. Bulletin 215
now extends a similar opportunity to large group health insurance policies for
employers with 51-100 employees.
The Indiana Department of Insurance will allow insurers to determine whether to
renew these non-PPACA-compliant policies as long as the determination is made
on a non-discriminatory basis. Importantly for employers sponsoring such
policies, a policy that has been cancelled cannot be reinstated. Further,
insurers are not required to renew policies, so employers should inquire with
their insurance carrier as to whether such policies will continue to be
available. Finally, employers will not be able to purchase new
non-PPACA-compliant policies or switch to a different insurer to replace a
non-PPACA-compliant policy.
Bulletin
215 »
On June 17, 2015, Insurance Commissioner Robertson issued Bulletin 216 to
clarify provisions of Indiana law and health care reform related to the payment
of benefits during the appeals process. Under Indiana law, it is considered an
unfair settlement practice for a company to fail to make prompt payment of a
claim where liability is reasonably clear. Furthermore, a health insurance
payer is forbidden from retaliating against an individual who has exercised
their right to an external grievance review.
It has been reported that health insurance payers may be discontinuing coverage
of treatment during the appeals process, even when a portion of the treatment
plan is undisputed. The Department of Insurance views the undisputed portion of
a plan under appeal as a claim in which liability has become reasonably clear,
that discontinuing all benefits during the appeals process may be retaliatory
and that any undisputed portion must be covered during the appeals process.
Insurers found in violation of Indiana’s Unfair Settlement Practices Act are
subject to fines of up to $25,000 per act or violation, or $50,000 if the
violation was knowing; and/or suspension or revocation of the company’s
certificate of authority.
Although this bulletin is directed at insurers, awareness of it will help
employers ensure that insurers are acting in compliance and that their
employees are protected.
Bulletin
216 »
March 10, 2015
On Feb. 25, 2015, Insurance Commissioner Robertson issued Bulletin 214
encouraging all entities to use a common form, included in the bulletin, for
prior authorizations, thereby reducing cost to insurers and providers and
reducing delays for patients. This bulletin is directed to all insurers, HMOs,
TPAs and other persons involved in reviewing claims and providing prior
authorization procedures. Prior authorization includes any preapproval,
preauthorization, prior approval, prior notification or similar requirement in
a policy or contract, but does not include pre-treatment payment estimates.
Prior authorization requests and approvals should be made in writing to avoid
disputes over oral agreements. It is up to the insurer whether prior
authorization requests are permitted over the phone or orally when a written
request is not possible. The Indiana Insurance Department has worked with many
industry representatives and has determined that the recommended form,
substantially similar to the common form already in use in Texas, requests the
necessary information to determine whether prior approval is appropriate.
The Department is aware that no prior authorization is necessary when a
condition is life-threatening. Therefore, this form would not be applicable in
those situations. Further, the Department encourages insurers, HMOs, and TPAs
not to deny coverage solely for a lack of prior approval when an unforeseen
additional related procedure is medically necessary during an authorized
procedure. Denials should be explained to the requesting provider.
The Department is considering an administrative rule that would require use of
a standard prior authorization form. Voluntary use of this form will provide
practical experience and yield valuable feedback during any rulemaking.
Coverage for those who qualify began Feb. 1, 2015.
Bulletin 214 »
February 10, 2015
On Jan. 27, 2015, Gov. Pence announced that he had reached an agreement with
the federal government to allow the state's Medicaid expansion alternative to
proceed. The state has received approval to use an updated version of the
Healthy Indiana plan, known as “HIP 2.0.” The proposal provides a
two-tiered coverage system: one for residents living above 100 percent of the
federal poverty line, and one below. Those above the line will have to
contribute to the cost of coverage while those under the line will have free
access to basic health coverage.
The announcement may prove of interest to employers. Specifically, individuals
with income between 100 and 133 percent of the FPL who may have previously
qualified for Medicaid may instead qualify for federal subsidies to purchase
health insurance through an exchange. Since the employer mandate penalty
(affecting employers with over 50 employees) is tied to individuals who qualify
for a subsidy unless the individuals are Medicaid-eligible, employers with 50
or more employees would have potentially been exposed to more penalties than if
the state had not pursued Medicaid expansion.
Coverage for those who qualify began Feb. 1, 2015.
Gov. Pence Announcement »
HIP 2.0 FAQs »
September 23, 2014
On Sept. 4, 2014, the U.S. Court of Appeals for the Seventh Circuit, in
Baskin
v. Bogan, Nos. 14-2386 (7th Cir. 2014), upheld a district
court’s ruling that struck down Indiana’s same-sex marriage ban.
The Seventh Circuit’s decision has been stayed, pending an appeal to the
U.S. Supreme Court. This means that at this time same-sex marriages may not be
performed in Indiana. This is the third federal appeals court to rule that a
state’s same-sex ban is unconstitutional. While not entirely clear, it is
likely that the Supreme Court will review this case or another case related to
same-sex marriage in its next session. The issue is an important one for
employers as it may impact, among other things, whether an employer plan
sponsor is required to offer coverage for same-sex spouses under its group
health plan. Until further notice, a policy issued in Indiana is not required
to provide coverage for same-sex spouses. We will continue to monitor this
issue and report any new developments.
Baskin v. Bogan »
August 12, 2014
The Indiana Department of Insurance recently released guidance regarding
Indiana's small group health composite rating for use in preparing 2015 small
group health rates. As background, in March, HHS established the federal
composite rating methodology, a two-tier rating system. At that time, HHS also
authorized states to utilize a different composite rating strategy, provided
they are submitted to and approved by HHS. In the current Indiana small group
legacy market, employees of larger-sized small groups pay an average rate
adjusted by tier factors based on the type of coverage purchased (four-tier
system). To minimize disruption in the small group market in 2015, Indiana will
apply this four-tiered composite rating methodology to all small groups outside
the marketplace.
The methodology for developing small group premiums in Indiana and allocating
them to participants is as follows:
-
Development of Aggregate Small Group Premiums — For
each employee and dependent, the premium must be determined as follows:
- For each covered adult 21 and over, you multiply the base rate by
the applicable age and geographic factors without applying any
tobacco factor.
- For each covered child age 0-20, you calculate the rate for the
three oldest children by multiplying the base rate by the
applicable age and geographic factors without applying any tobacco
factor.
Age and geographic area are determined at the time the coverage is issued.
-
Allocation of Composite Premiums — Once the small
group's aggregate premium has been calculated, it must be allocated back to
covered employees based on their tier factor. Indiana has adopted the
following four-tier approach and corresponding factors:
- Employee only = 1
- Employee + spouse = 2
- Employee + children (including all covered children up to age 26) =
1.85
- Employee + family = 2.85
-
Final Employee Premium — Final employee premium =
[group aggregate premium] / [weighted employee count] x [employee's tier
factor]
-
Recalculation of Average Monthly Premiums — The
methodology above determines an employee's monthly premium based on a
census of employees (and covered dependents) at the time the policy was
issued. The average monthly premium for each tier must remain the same for
the entire policy period despite changes to the census. The average monthly
premium must be recalculated annually, based on the census at the time the
policy is rated.
-
Application of Tobacco Use Factors — The family
composite premiums does not include a tobacco use factor. Any tobacco use
factor must be applied to the specific individual's premium contributed to
the aggregate premium. The additional premium is then added to the monthly
premium for that individual based upon the tier allocation. The tobacco
factor must not be applied if the individual enrolls in a tobacco cessation
program.
Indiana
Composite Premium Basis for Plans Issued on or After Jan. 1, 2015
»
July 1, 2014
On June 25, 2014, a U.S. district court judge ruled that Indiana's ban on
same-sex marriage is unconstitutional. In Baskin, et al. v. Bogan, et
al.,
1:14-cv-00355-RLY-TAB (S.D. Ind. June 25, 2014), U.S. District Judge Young
issued a preliminary injunction on the state's ban. However, Indiana Attorney
General Zoeller quickly filed a notice of appeal and emergency request for a
stay of the order. On June 27, 2014, a federal appeals court issued an
emergency order stopping same-sex marriages in the state of Indiana pending the
outcome of the appeal.
The rapid changes in state marriage laws have important effects for individuals
in these states 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
Indiana should work closely with their attorneys and tax advisors to ensure
plan design compliance in light of the ongoing developments in this area.
Baskin, et al. v. Bogan, et al. »
April 8, 2014
On March 25, 2014, Gov. Mike Pence signed HEA 1123 into law. HEA 1123 prohibits
accident and insurance policies from covering abortion in most circumstances
except through a separate rider. The bill allows the purchase of a separate
“rider” at additional cost to cover abortion care. The new law
includes exceptions for rape, incest and threats to the life or “major
bodily function” of the pregnant woman. The new law is effective July 1,
2014.
HEA 1123 »
2014 Signed
Bill List »
On March 31, 2014, Indiana Insurance Commissioner Stephen Robertson issued
Bulletin 205. The bulletin is 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). While the transitional policy allows the continuation of
noncompliant plans at a federal level, individual and small group policies must
be approved by state insurance regulators. The Indiana Department of Insurance
will allow insurers to determine whether to renew these non-PPACA-compliant
policies as long as the determination is made on a non-discriminatory basis.
Put simply, an insurer must renew or non-renew all of its individual or small
group policies. However, it may choose to renew small group policies and
non-renew individual policies, or vice versa. Plans that have been cancelled
cannot be reinstated. The department is not requiring insurers to renew
policies. Furthermore, consumers may not purchase new non-PPACA-compliant
policies or switch to a different insurer to replace a non-PPACA-compliant
policy.
Bulletin
205 »
Iowa
May 15, 2018
Telemedicine Coverage
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»
On March 29, 2018, Gov. Reynolds signed HF 2305 into law, creating Acts
Chapter 1055. This law requires insurers to cover telehealth services to
the same extent as comparable services not offered by telehealth.
Specifically, a policy, contract or plan providing for third-party payment
or prepayment of health or medical expenses shall not discriminate between
coverage benefits for health care services that are provided in person and
the same health care services that are delivered through telehealth. This
law is effective in Iowa on or after Jan. 1, 2019.
Acts Chapter 1055 »
May 1, 2018
Extension of Non-ACA-Compliant Small Group and Individual Policies and
Plans
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»
On April 19, 2018, Iowa Insurance Commissioner Ommen released Bulletin
18-01 related to the extension of non-ACA-compliant small group and
individual policies and plans. As background, on April 9, 2018, the federal
government announced an additional transition policy that allows insurers
(if allowed by the state) to renew non-grandfathered non-ACA-compliant
plans (this transitional relief has been extended several times). Such
policies aren’t required to be in compliance with certain ACA mandates,
including community rating, coverage of essential health benefits,
prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The bulletin states that Iowa will allow insurers to renew policies in the
individual market and the small group market as long as the policy ends by
Dec. 31, 2019, according to the extended transitional policy. Employers
with non-ACA-compliant plans should work with their insurer and advisor on
any policy extension.
Bulletin 18-01 »
May 31, 2017
Override Exceptions for Step Therapy Protocol
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»
On May 10, 2017, Gov. Reynolds signed HB 233 into law. The new law provides
that when a step therapy protocol is in use, plan participants and
prescribing health-care practitioners must be able to request a step
therapy exception or override determinations under certain conditions.
As background, step therapy involves protocols or programs that establish a
specific order in which prescription drugs are prescribed. This bill
requires plans that cover prescription drugs through step therapy to allow
participants and their practitioners to request step therapy override
exceptions. Specifically, the participant must be allowed to request, in
writing, that step therapy be overridden in a particular situation where
immediate coverage of prescription drugs would be more medically
appropriate. The override exception requests must be granted if the plan
participant previously received step therapy that was ineffective or caused
a diminished effect or adverse event. This law is effective for policies
delivered, issued or renewed on or after Jan. 1, 2018.
HB 233 »
March 21, 2017
Extension of Non-PPACA-Compliant Small Group and Individual Policies and
Plans
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»
On Feb. 24, 2017, Iowa Commissioner of Insurance Ommen released Bulletin
17-01 related to the extension of non-PPACA-compliant small group and
individual policies and plans. As background, on Feb. 23, 2017, the federal
government announced an additional transition policy that allows insurers
(if allowed by the state) to renew non-grandfathered non-PPACA-compliant
plans (this transitional relief has been extended twice before). Such
policies are not required to be in compliance with certain PPACA mandates
including community rating, coverage of essential health benefits,
prohibition on pre-existing condition exclusions and the annual
out-of-pocket maximum limit.
The Bulletin states that Iowa will allow insurers to renew policies in the
individual market and the small group market according to the extended
transitional policy. Employers with non-PPACA-compliant plans should work
with their insurer on any policy extension.
Bulletin 17-01 »
January 12, 2016
On Jan. 6, 2016, the Iowa Department of Insurance published final regulations
related to prior authorizations for prescription drugs. Effective Feb. 6, 2016,
all health insurers and pharmacy benefit managers subject to Iowa regulations
must comply with a standardized prior authorization process for prescription
drugs, including use of a standardized form. Each insurer must post on its
website a listing of drugs requiring prior authorization. Urgent claims must be
approved or denied within 72 hours. Non-urgent claims must be processed within
five calendar days.
While the new law directly applies to health insurers, employer plan sponsors
will be interested in its impact on the group health plan’s pharmacy benefits.
Final Regulations »
April 22, 2014
On April 3, 2014, Gov. Terry Branstad signed SF 2259 into law, which amends the
state’s requirements related to breaches of security. Previously,
entities were only required to notify individuals when there was a breach of
their personal information that was maintained in computerized form. Effective
July 1, 2014, the term “security breach” includes the unauthorized
acquisition of personal information in any form, including on paper. If the
breach affects more than 500 Iowa residents, the entity must provide written
notice to the director of the Consumer Protection Division of the Office of the
Attorney General within five business days after providing notice of the breach
to any consumer.
SF 2259 »
Kansas
August 21, 2018
Plans Can’t Deny Mammograms
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»
On Aug. 8, 2018, Commissioner of Insurance Selzer issued Bulletin 2018-2.
The bulletin clarifies the requirements found in K.S.A. 40-2230, which
require insurers that cover laboratory or x-ray services to cover
mammograms. The Bulletin clarifies that for these purposes, the term
“mammogram” includes tomosynthesis (3D mammography). Additionally, the cost
sharing limits imposed on tomosynthesis must be the same as the ones
applied to any other type of mammography.
The clarification in this Bulletin applies to plan years beginning on or
after Jan. 1, 2019.
Bulletin 2018-2 »
June 12, 2018
Kansas Enacts Pharmacy Patients Fair Practices Act
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»
On March 29, 2018, Gov. Colyer signed SB 351 into law, enacting the
Pharmacy Patients Fair Practices Act. This Act requires that copayments on
prescription drugs not exceed the total charges submitted by the network
pharmacy. Additionally, pharmacists and pharmacies have the right to
provide individuals covered under the plan with information on the amount
of the cost share of the prescription and information on more affordable
alternatives, if available. The law doesn’t apply to polices that provide
coverage for limited benefits, such as specified disease, accident-only,
credit, dental, disability income, hospital indemnity or long-term care
insurance coverage.
The law is effective for contracts entered into or renewed on or after Jan.
1, 2019. Although this law doesn’t directly affect employer plan sponsors,
they should be aware of plan participants’ rights under this law.
SB 351 »
Plans Can’t Exclude Telemedicine
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»
On May 12, 2018, Gov. Colyer sign HB 2028 into law, establishing the Kansas
Telemedicine Act. This act provides that plans can’t exclude health care
services from coverage solely because they’re provided through telemedicine
rather than through in-person treatment. Under the Act, telemedicine means
the delivery of health care services for a plan participant that’s located
at an originating site from a health care provider located at a distant
site.
That Act also defines which practitioners can constitute health care
providers and mandates that plans can’t require additional documentation of
telemedicine patients. Additionally, insurance issuers must establish
payment or reimbursement for telemedicine expenses in the same way they
establish them for in-person services.
Plan sponsors should consider this requirement to offer telemedicine for
fully-insured plans based out of Kansas.
HB 2028 »
May 3, 2016
On April 28, 2016, the Kansas Insurance Department amended K.A.R. 40-4-34,
which adopts by reference the Department’s “policy and procedure relating to
coordination of benefits”. This amendment to the existing regulation adds
individual health insurance plans sold after Jan. 1, 2014, to the list of plan
types that may coordinate benefits. This amendment will save insurers money in
the form of claims that will not be paid more than once for the same service.
While this regulation generally applies to insurance carriers, it is important
for employer plan sponsors to understand participant rights under the group
policy.
K.A.R. 40-4-34 »
April 19, 2016
On March 24, 2016, Gov. Brownback signed HB 2454 into law regarding health
services rendered by participating providers.
This law permits a health carrier licensed to offer accident and sickness
insurance in Kansas to offer an insurance product (commonly referred to as an
exclusive provider organization product) that requires some or all of the
health care services to be rendered by participating providers, but requires
emergency services to be covered even if not delivered by a participating
provider. The bill allows such a policy to include a requirement that the
insured obtain a referral from a primary care professional in order to access
specialty care. This allows the health carrier to determine the cost-sharing
amount for services rendered by nonparticipating providers.
The law is effective April 7, 2016.
HB 2454 »
September 22, 2015
On Aug. 25, 2015, the Kansas Insurance Department announced that they had
finalized rates for 2016 individual policies sold through the marketplace. The
rates increased from 9.4 percent to 25.4 percent compared to 2015 premium
rates. The department expects 96 plans to be available through the marketplace,
76 individual plans and 20 group plans. Open enrollment begins Nov. 1, 2015 and
runs through Jan. 31, 2016.
While the announcement does not directly affect employers, it is important for
employers to understand the marketplace options and they may compare to the
employer’s offerings.
Press Release »
July 15, 2014
On April 30, 2014, Gov. Brownback signed SB 309 into law. The law permits
qualified trade, merchant, retail or professional associations or business
leagues and farmers' cooperatives to provide self-insured health coverage to
members. The coverage will be exempt from the jurisdiction of the Kansas
Insurance Department. To qualify, the association or league must be in
existence for at least five calendar years and be composed of at least five
employers. The law previously only allowed for six specifically identified
association groups to provide such coverage: American Institute of Architects
– Kansas, Kansas Dental Association, Community Bankers Association of
Kansas, National Association of Independent Truckers, Kansas Bankers
Association and an association of physicians practicing in the Kansas City
metropolitan area. The law is effective July 1, 2014.
SB 309 »
On July 8, 2014, Commissioner of Insurance Praeger issued Bulletin 2014-2 in
relation to SB 309. Associations and leagues that provide coverage for medical,
surgical and other health care services outside of the jurisdiction of the
department are required to pay a premium tax of 1 percent per year on the
annual gross premium collected in Kansas during the preceding calendar year.
The tax is due May 1 of each year. If the association or league contracts with
a licensed insurer or third-party administrator for plan administration
services, the insurer or administrator must report such activity to the
department by March 1 of each calendar year.
Bulletin
2014-2 »
May 6, 2014
On April 17, 2014, Gov. Sam Brownback signed HB 2744 into law, which requires
group plans to provide coverage for the diagnosis and treatment of autism
spectrum disorder in children under the age of 12. For the first four years,
beginning on the later of the date of diagnosis or Jan. 1, 2015, the coverage
must include applied behavior analysis up to 1,300 hours per calendar year for
children from birth to age 5 and 520 hours for children under the age of 12.
The law is effective for large group health insurance policies (employers with
51 or more employees) for plan years starting on or after Jan. 1, 2015. Small
group policies must comply for plan years starting on or after Jan. 1,
2016.
HB 2744 »
April 8, 2014
On March 6, 2014, Commissioner of Insurance Sandy Praeger issued a press
release 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). The
Kansas Insurance Department will allow insurers to renew noncompliant
individual and small group non-grandfathered plans with policy years beginning
on or before Oct. 1, 2016.
This bulletin, effective Aug.1, 2013, does not apply to plans or policies that
are regulated under ERISA or otherwise outside the state’s regulatory
jurisdiction, such as a self-insured plan sponsored by a private employer.
Press Release »
Kentucky
December 11, 2018
Guidance for Short-Term Health Insurance
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»
On Oct. 18, 2018, Commissioner Atkins released Bulletin 2018-02 to remind
carriers and producers that issue policies in Kentucky of the state
insurance requirements for short-term health insurance. This bulletin is
intended to remind carriers doing business in the state that state law
isn’t preempted regarding short-term health insurance and, thus, carriers
doing business in Kentucky must continue to comply with state law.
As background, the federal government issued a rule in August 2018 that
extended the initial contract term of short-term policies issued on or
after Oct. 2, 2018, to be no more than 12 months while limiting renewals or
extension of such policies to no more than 36 months. Like the federal
rule, Kentucky law limits a short-term policy to a term that is less than
12 months, and a maximum 36-month duration (including renewals and
extensions, if applicable) for the same contract. Moreover, in Kentucky,
short-term policies are subject to state coverage mandates.
The Department also included a reminder that the commissioner may
disapprove any form or withdraw previous approval where the benefits
provided within an individual health insurance policy (i.e., short-term
health insurance policy) “are unreasonable in relation to the premium
charged.”
This bulletin was for informational purposes only, and employers need not
take any action at this time. The intent is to remind carriers that
Kentucky insurance law continues to apply to short-term health insurance,
and carriers must factor in Kentucky requirements and recommendations
before issuing a product in response to the federal guidelines.
Bulletin 2018-02 »
June 26, 2018
Prescription Drug Cost-Sharing
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»
On April 10, 2018, Gov. Bevin signed HB 463 into law, which provides that
insurers or pharmacy benefit managers can't impose cost-sharing amounts on
prescription drugs that are greater than prescription drug prices for
participants not using plans or paying cash.
Insurers or pharmacy benefit managers also can't penalize pharmacy
providers that provide plan participants with information relating to the
applicable limitations on their cost-sharing expenses for prescription
drugs.
Although this new law is aimed at insurers and pharmacy benefit managers,
it’s important for employers to be aware of what insurers and pharmacy
benefit managers may be doing and what they’re now required to do.
This law is effective for insurers (and pharmacy benefit managers) issuing
or renewing health benefit plans on or after Jan. 1, 2019.
HB 463 »
Treatment of Autism Spectrum Disorder
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»
On April 10, 2018, Gov. Bevin signed HB 218 into law, which amends the
rules for health benefit plans issued or renewed on or after Jan. 1, 2019.
Specifically, plans must still provide coverage for the diagnosis and
treatment of autism spectrum disorders. Further, insurers can't terminate
coverage or refuse to deliver, execute, issue, amend, adjust or renew
coverage for a plan participant solely due to a diagnosis of or treatment
for an autism spectrum disorder. This new law also removes maximum annual
benefit limits, including any limits on the number of visits to autism
service providers, and removes age limitations on coverage.
Although this new law is aimed at insurers, it’s important for employers to
be aware of what insurers may be doing and what they’re now required to do
when issuing policies.
HB 218 »
May 30, 2018
Coverage for Telehealth Services
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»
On April 26, 2018, Gov. Matt Bevin signed SB 112 into law, requiring health
insurers in Kentucky to pay for covered services delivered by telehealth or
telemedicine technology as long as the services and providers are otherwise
covered.
"Telehealth" means the delivery of health-care services by
health-care providers licensed in Kentucky to plan participants through
face-to-face encounters using real-time interactive audio and video
technologies or store-and-forward services provided via asynchronous
technologies as the standard practice of care where images are sent to
specialists for evaluation. Telehealth doesn't include email, text
messaging, fax transmissions or audio-only telephone calls.
These services will be subject to annual deductibles and coinsurance, and
other terms and conditions of coverage, in the same way already established
for the same services when not provided via telemedicine or telehealth.
This law is effective for plans issued or renewed on or after July 1, 2019.
SB112 »
October 31, 2017
Summary of 2017 Legislative Changes Relating to Health Insurance
Coverage
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»
The Kentucky (KY) Department of Insurance published Insurance Bulletin
Number 2017-03. The bulletin summarizes the changes made by the KY
legislature during 2017. Outlined below are the legislative changes
described in the bulletin relating to health insurance coverage — including
those previously covered in Compliance Corner. The effective date
of the legislation discussed below is June 29, 2017.
The first legislative change relates to experimental treatment for terminal
illnesses and was contained in SB 21, which was signed into law by KY Gov.
Matt Bevin on March 21, 2017. Specifically, this law allows manufacturers
of investigational drugs, biological products and devices, as defined in
the bill, to make them available upon request to eligible patients. Patient
eligibility depends on a number of factors, including whether they have:
- A terminal illness that’s attested to by the patient’s treating health
care provider
- Considered all other treatment options currently approved by the U.S.
FDA
- Received a recommendation from the patient’s treating health care
provider for an investigational drug, biological product or device
- Given written informed consent for the use of the investigational drug,
biological product or device
- Documentation from the treating health care provider that the patient
meets these requirements
As part of the informed consent process, the patient agrees that their
health plan, third-party administrator or provider will not be liable for
the cost of such treatment or any care consequent to the use of such
treatment (unless otherwise required). The bill does not expand or mandate
coverage for such treatments by an insurer, but it authorizes health plans,
administrators and governmental agencies to provide coverage for these
types of services.
The second relates to garnishment and health savings accounts. On March 27,
2017, KY Gov. Matt Bevin signed SB 62 into law, amending KRS 427.010 by
including an exemption from wage attachment and garnishment for funds
deposited in a health savings account under IRC Section 223.
The third legislative change relates to smoking cessation. On March 21,
2017, Gov. Bevin signed SB 89 into law, which requires insured group health
benefit plans to provide coverage for certain smoking cessation medications
and services. Specifically, plans must provide coverage for all tobacco
cessation, including:
- Medications approved by the U.S. FDA
- Services recommended by the U.S. Preventive Services Task Force,
including, but not limited to, individual, group and telephone
counseling or any combination of these services
Additionally, coverage for tobacco cessation services can't be subject to
any of the following:
- Counseling requirements for medication
- Limits on duration of services, including but not limited to annual or
lifetime limits on number of attempts to quit
- Copayments or other out-of-pocket cost sharing, including deductibles
Utilization management requirements cannot be imposed on any tobacco
cessation services, including prior authorization and step therapy, except
in the following circumstances where plans can require prior authorization:
- For a treatment that exceeds the duration recommended by the most
recent U.S. Public Health Service clinical practice guidelines on
treating tobacco use and dependence; or
- For services associated with more than two attempts to quit smoking
within a 12-month period
The fourth change was contained in HB 78, which was signed into law by Gov.
Bevin on April 11, 2017. This law requires insurers that provide
individual, expense-incurred policies (under KRS Chapter 304.17), health
benefit plans (under KRS 304.17A) and group plans (under KRS 304.18) to
include coverage for digital mammography. The benefit is limited to $50 per
mammogram, and any deductible and coinsurance are required to be “no less
favorable than for coverage for physical illness.”
Physicians are now statutorily encouraged to utilize digital mammography
(i.e., breast tomosynthesis) when ordering mammograms. The definition of
“mammogram” pursuant to KRS 304.17-316 now incorporates digital mammograms.
The bulletin and new laws do not contain any new employer compliance
obligations. But KY employers will want to be aware of the changes to the
insurance laws in KY should employees have questions regarding health
insurance coverage.
Insurance Bulletin Number 2017-03 »
SB
21 »
SB 62 »
SB 89 »
HB
78 »
April 18, 2017
Garnishment and Health Savings Accounts
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»
On March 27, 2017, Kentucky Gov. Bevin signed legislation (SB 62) into law
amending KRS 427.010 by including an exemption from wage attachment and
garnishment for funds deposited in a health savings accounts under IRC
Section 223.
The law takes effect 90 days after close of the Kentucky legislative
session, which is projected to be on or about June 29, 2017.
SB 62 »
Smoking Cessation
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»
On March 21, 2017, Kentucky Gov. Matt Bevin signed legislation (SB 89) into
law, which requires insured group health benefit plans to provide coverage
for certain smoking cessation medications and services.
Specifically, plans must provide coverage for all tobacco cessation:
- Medications approved by the U.S. Food and Drug Administration; and
- Services recommended by the U.S. Preventive Services Task Force,
including, but not limited to, individual, group and telephone
counseling or any combination of these services.
Additionally, coverage for tobacco cessation services can't be subject to:
- Counseling requirements for medication;
- Limits on duration of services, including but not limited to annual or
lifetime limits on number of attempts to quit; or
- Copayments or other out-of-pocket cost sharing, including deductibles.
Utilization management requirements cannot be imposed on any tobacco
cessation services, including prior authorization and step therapy, except
in the following circumstances where plans can require prior authorization:
- For a treatment that exceeds the duration recommended by the most
recent U.S. Public Health Service clinical practice guidelines on
treating tobacco use and dependence; or
- For services associated with more than two attempts to quit smoking
within a 12-month period.
The law takes effect 90 days after close of the Kentucky legislative
session, which is projected to be on or about June 29, 2017.
SB 89 »
May 17, 2016
On April 28, 2016, SB 18 became law without Gov. Bevin’s signature. It amends
the state’s existing mandate that health plans which provide prescription drug
coverage must provide coverage for therapeutic food, formulas, supplements and
low-protein modified food products to treat inborn errors of metabolism or
genetic conditions. Effective Jan. 1, 2017, mitochondrial disease is included
among the conditions for which the coverage must be provided. Additionally,
dietary treatment includes the prescribed use of vitamins and nutritional
supplements such as coenzyme Q10, vitamin E, vitamin C, vitamin B1, vitamin B2,
vitamin K1 and L-carnitine.
SB 18
»
May 3, 2016
On April 13, 2016, Gov. Bevin signed HB 100 into law. This law relates to
insurance coverage of autism. As background, group health plans are already
required to provide coverage for diagnosis and treatment of autism under
existing state law for participants aged one to 21. Treatment includes medical
care, facilitative or rehabilitative care, pharmacy care (if covered by the
plan), psychiatric care, psychological care, therapeutic care and applied
behavior analysis.
Large group plans may impose an annual benefit limit of $50,000 for autism
related expenses for participants aged one to seven and $1,000 per month for
participants aged seven through 21. Small group plans may impose a monthly
limit of $1,000 for participants aged one to 21 and may also impose a
limitation on the number of visits. While the state permits an annual dollar
limitation, it is important to remember that under the federal ACA
non-grandfathered plans are not permitted to implement an annual or lifetime
dollar limit on essential health benefits. Coverage of autism is identified as
an essential health benefit in the Kentucky state benchmark plan.
Effective July 14, 2016, insurers must make a liaison available to
participants. The liaison will help explain the plan’s coverage for autism, any
prior authorization treatments and appeal rights.
HB
100 »
January 26, 2016
The Franklin Circuit Court has issued an order authorizing the Kentucky
Insurance Commissioner to liquidate the Kentucky Health Cooperative (KYHC). The
KYHC will be closed and the assets will be distributed by the Insurance
Department. As background, the co-op was a member owned non-profit organization
providing health insurance for individuals and small employers. If members have
outstanding claims that have not yet been paid by the KYHC, the member will be
responsible for any deductible, coinsurance or copayment amount. However, a
health care provider is prohibited from balance billing any member for a claim
amount that is the responsibility of KYHC.
Order of Liquidation »
FAQs
»
May 19, 2015
On May 12, 2015, the Kentucky Commissioner of Insurance issued Advisory Opinion
2015-3 which provides clarification on colorectal cancer screenings required by
SB 61. Colorectal cancer screenings, as specified by the American Cancer
Society guidelines, must be covered at no cost to the insured when performed by
participating providers. The opinion provides an example as further
clarification. If a fecal immunochemical test indicates that the insured needs
further testing, such as a colonoscopy, then the test and the colonoscopy must
be covered as a preventative service, meaning no deductible or coinsurance can
be applied. The new law is effective Jan. 1, 2016.
Advisory Opinion 2015-3
May 5, 2015
On March 30, 2015, Gov. Beshear signed HB 465 into law. The new law requires
insurers to provide the same reimbursement for services performed by
optometrists as would be paid to physicians and osteopaths for performing the
same services. Also, insurers may not place conditions on optometrists to
participate in the provider network that are not placed on physicians or
osteopaths. The law is effective June 22, 2015.
HB 465 »
On March 20, 2015, Gov. Beshear signed SB 44 into law. The new law entitles
health plan participants who have a chronic illness to synchronize the refill
of multiple medications. To qualify, the prescriptions cannot be a Schedule II
or Schedule III controlled substance containing hydrocodone. The law is
effective Jan. 1, 2016.
HB SB 44 »
On March 19, 2015, Gov. Beshear signed SB 61 into law. The law revises the
state’s requirements regarding colorectal cancer examinations and laboratory
tests. Current law provides coverage for such services for asyptomatic
individuals aged 50 and older or those less than age 50 who are at high risk
for colorectal cancer. Previously, plans could apply a deductible to the
coverage. Effective Jan. 1, 2016 plans are required to provide such coverage
without application of deductible or coinsurance.
HB 61 »
February 10, 2015
On Jan. 21, 2015, Commissioner of Insurance Clark issued Advisory Opinion
2015-01. The opinion reminds self-insured non-ERISA plans that they are subject
to the state's external review process. As a reminder, governmental and church
plans are considered non-ERISA plans. Employers that sponsor a self-insured
governmental or church plan in Kentucky should review their governing plan
documents to make sure they are in compliance with the state's requirements.
Under state statute, a participant who has had a claim denied in whole or in
part (called an “adverse benefit determination”) has the right to
request an external review after the plan's internal appeals process has been
exhausted. The request must be made within 60 days of the adverse benefit
determination. The independent review organization must issue a decision with
21 days from receipt of information, with an expedited review available upon
request for certain circumstances. The self-insured entity or their third party
administrator must register with eServices in order to administer the review
process.
Advisory Opinion 2015-01
On Jan. 16, 2015, the U.S. Supreme Court agreed to decide whether Kentucky must
permit same-sex marriage and recognize such marriages lawfully performed
out-of-state (Bourke v. Beshear, cert. granted (U.S. Jan. 16, 2015) (No.
14-574)). The Supreme Court will evaluate the following issues for Kentucky and
three other states (Tennessee, Michigan, and Ohio):
1) Does the Fourteenth Amendment require a state to license a marriage between
two people of the same sex?
2) Does the Fourteenth Amendment require a state to recognize a marriage
between two people of the same sex when their marriage was lawfully licensed
and performed out-of-state?
We are expecting further guidance and will report such in future editions of
Compliance Corner.
No. 14-574
December 2, 2014
On Oct. 30, 2014, Commissioner of Insurance Clark issued Advisory Opinion
2014-4. The opinion clarifies that all health benefit plans issued in Kentucky
must provide coverage for hospice care at a level that is at least equal to
coverage provided under Medicare. This means a participant receiving hospice
care cannot be charged more than $5 for each prescription drug and other
similar products for pain relief and symptom control. Additionally, the plan
cannot impose cost-sharing greater than 5 percent of the Medicare-approved
amount for inpatient respite care. The opinion clarifies existing requirements
under Kentucky law. Thus, plans should already be in compliance with these
requirements or amend the plan to immediately get into compliance. For a fully
insured plan, the responsibility is on the insurer, but it is important for the
employer plan sponsor to understand the plan’s covered benefits.
Advisory Opinion 2014-4 »
June 3, 2014
On April 10, 2014, Gov. Beshear signed HB 232 into law, creating Chapter 84.
The new law applies to entities, including employers, that maintain
computerized data that contains personally identifiable information. A state
resident must be notified if it is reasonably believed that his/her unencrypted
personally identifiable information was acquired by an unauthorized person
(i.e., security breach). For this purpose, personally identifiable information
includes the individual's first name or first initial and last name in
combination with the Social Security number, driver's license number or
financial account information. Following the breach, the entity must notify the
individual in the most expedient time possible and without unreasonable delay.
If more than 1,000 residents are affected, the entity must also notify all
national consumer reporting agencies and credit bureaus. The law is effective
July 15, 2014.
Chapter
84 »
On Feb. 20, 2015, the Louisiana Department of Insurance published Bulletin
2015-02, which informs health insurance issuers and HMO issuers that the use of
family composite premiums for the 2016 plan year has been approved in the small
group market. The bulletin also provides the method of calculation to be used
in determining family composite premiums.
Bulletin 2014-02 »
Chapter
47 »
May 6, 2014
On April 25, 2014, Insurance Commissioner Sharon Clark issued a press release
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). The Kentucky
Department of Insurance will allow insurers to renew noncompliant individual
and small group non-grandfathered plans with policy years beginning on or
before Oct. 1, 2016.
Press Release »
Louisiana
September 5, 2018
Review of State and Federal Regulation of Association Health Plans
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»
On Aug. 30, 2018, Commissioner of Insurance Donelon issued Advisory Letter
2018-03 (“the Letter”). The Letter discusses the state and federal
regulation of association health plans (AHPs), after the DOL’s final rules
on AHPs were issued this summer. As background, AHPs are MEWAs and can fall
under the jurisdiction of both federal and state law. The Letter identifies
the different types of AHPs and how Louisiana law applies to them.
The Letter essentially confirms that Louisiana still has the same
regulatory authority over MEWAs and AHPs as it did before the DOL published
its final rule. Specifically, Louisiana still requires self-insured AHPs to
be licensed under Louisiana state law. While fully insured AHPs don’t have
to be licensed, the insurer that issues the policy must file the
association’s constitution, by-laws, membership application, agreement and
brochure for review when filing for a health insurance contract.
The Letter also includes a chart that lists some of the laws and
regulations applicable to MEWAs and whether or not the different types of
MEWAs have to comply. It ends by listing the applicability dates of the
DOL’s final rule.
While this Letter doesn’t necessarily provide any new information, it’s a
reminder to entities that might want to establish an AHP for Louisiana
employers that they must comply with Louisiana law.
James J. Donelon. “Advisory Letter 2018-03.” Laws and
Bulletins, www.ldi.la.gov »
July 24, 2018
Mandated Changes for Coverage of Opioid Prescriptions
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»
On May 20, 2018, Gov. Edwards signed SB 285 into law, creating Act No. 372.
This law prohibits insurance carriers from denying coverage of a
physician-prescribed nonopioid medication in favor of an opioid
prescription drug. Further, when an opioid prescription is prescribed as
medically necessary, the insurer cannot deny coverage of the opioid and
attempt to substitute an alternative that requires an increased number of
pills per prescription, is a higher Drug Enforcement Administration
schedule medication than the one prescribed, or substitutes an
extended-release medication that doesn’t have defined abuse deterrent
properties for a prescription of a medication that does.
Although the insurance carriers will implement this law, employers should
be aware of the change. The law is effective Jan. 1, 2019.
Act
No. 372 »
Required Mammography Coverage
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»
On May 23, 2018, Gov. Edwards signed HB 460 into law, creating Act No. 494.
This law requires plans to provide coverage for minimum mammography
examination. Specifically, plans must allow mammographic examinations,
including digital breast tomosynthesis. These examinations must be allowed
as follows:
- Female participants who are age 35 to 39 must be allowed one baseline
mammogram
- Female participants who are age 40 to 49 must be allowed one mammogram
every 24 months, or more frequently if recommended by the participant’s
physician
- Female participants who are age 50 and older must be allowed one annual
mammogram
Plans cannot apply deductibles to mammography, and participants don’t need
a referral from a physician to receive their mammogram.
Although the insurance carriers will implement this law, employers should
be aware of the change. The law is effective Jan. 1, 2019.
Act
No. 494 »
Required Cancer Screening
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»
On May 23, 2018, Gov. Edwards signed HB 690 into law, creating Act No. 461.
This law requires plans to provide coverage for annual cancer screening for
participants who were previously diagnosed with breast cancer, completed
treatment for breast cancer, underwent a bilateral mastectomy and were
later determined to be cancer-free.
The law also requires plans to issue a written notice regarding this
available screening. The notice must be provided at enrollment and
annually.
Although the insurance carriers will implement this law, employers should
be aware of the change. The law is effective Jan. 1, 2019.
Act
No. 461 »
February 6, 2018
Definition of "Small Employer" for Medical Loss Ratio Purposes
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»
On Jan. 26, 2018, the Louisiana Department of Insurance issued Bulletin
2018-03. This Bulletin rescinded Bulletin 2011-03, which defined the term
“small employer” for purposes of determining the medical loss ratio (MLR)
under ACA. Under the previous definition, small employers were those who
employed an average of at least one but not more than 100 employees during
the preceding calendar year, and at least one employee on the first day of
the plan year. This amended Louisiana law to line it up with ACA.
This bulletin changes the definition for MLR purposes to recognize small
employers as those who employed an average of at least one but not more
than 50 employees during the preceding calendar year, and at least one
employee on the first day of the plan year. This change comes as a result
of the Protecting Affordable Coverage for Employees (PACE) Act, which
amended the definition of “small employer” under the ACA.
Although this bulletin doesn’t directly impact Louisiana-based employers,
such employers should remain abreast of these changes under Louisiana law
(as they’ll determine how insurers administer fully insured plans).
Bulletin 2018-03 »
Louisiana Coordination of Benefits Regulations Finalized
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»
On Jan. 20, 2018, the Louisiana Department of Insurance finalized
Regulation 32, which outlines Louisiana’s coordination of benefits rules.
Specifically, this regulation establishes a uniform order of benefit
determination for plans to pay claims. The amended regulation also
clarifies the implementation of calculating benefits reserves.
The regulation applies to all fully insured health plans that are issued in
Louisiana, and it’s effective as of Jan. 20, 2018. Employers should
familiarize themselves with this regulation to gain a better understanding
of how claims will be administered when participants have dual coverage.
Regulation 32 »
March 7, 2017
Transitional Relief for the 2018 Plan Year
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»
On March 3, 2017, the Department of Insurance issued Bulletin 2017-02,
informing health insurance issuers that they may elect to continue
transitional health insurance plans. As background, these plans are not
subject to certain provisions of the PPACA. This bulletin reflects the
Center for Consumer Information and Insurance Oversight’s (CCIIO) guidance
allowing states the option to extend transitional policies for individual
and small group health insurance plans to policy years beginning on or
before October 1, 2018 provided that all policies end by December 31, 2018.
Bulletin No. 2017-02 »
September 7, 2016
Coordination of Benefits
The Louisiana Department of Insurance has amended its regulations related to
group policy coordination of benefits (COB). The new rules are effective for
plan years on or after July 20, 2016. The COB rules are still voluntary for
group health insurance policies, but if the policy coordinates benefits, then
those rules must be consistent with the state’s regulations.
The rules kept the prohibition on a policy to reduce benefits on the basis that
a participant was eligible for another plan and did not enroll. However, there
is an exception for a plan that would not be primary to Medicare and the
participant is eligible for Medicare Part B. In those cases, the policy may
reduce benefits for a participant who is eligible for Medicare and did not
enroll in Medicare Part B. This could occur:
- If the participant is eligible for Medicare due to age and the employer has
fewer than 20 employees.
- If the participant is eligible for Medicare due to disability and the
employer has fewer than 100 employees.
- If the participant has non-active employee coverage such as COBRA or
retiree.
A common COB provision involves the birthday rule for children who are covered
by more than one plan of parents who are married. The new regulations clarify
that the birthday rule also applies when the parents live together, but who are
not married. As a reminder, the birthday rule provides that the plan of the
parent whose birthday occurs earlier in the year is primary.
Alternatively, if the parents are divorced, separated or not living together
(regardless if ever married), the primary plan is determined by a court order
or custody.
Revised model language is provided for plan documents. The new law is
applicable to insurers with no action required of employers. However, since COB
is a common question for participants, it may be helpful for employers to
familiarize themselves with the COB rules applicable to their plan.
Regulation 32, Group Coordination of Benefits »
August 23, 2016
Disaster Relief
On Aug. 15, 2016, the IRS announced tax relief for affected taxpayers in
covered disaster areas in Louisiana, which include the parishes of Acadia,
Ascension, Avoyelles, East Baton Rouge, East Evangeline, Feliciana, Iberia,
Iberville, Jefferson Davis, Lafayette, Livingston, Pointe Coupee, St. Helena,
St. Landry, St. Martin, St. Tammany, Tangipahoa, Vermilion, Washington and West
Feliciana.
The term “affected taxpayer” includes any business whose principal place of
business is located in a covered disaster area. It also includes a taxpayer who
is unable to obtain necessary information in a timely manner because an
insurance company, bank or service provider is located in a covered disaster
area.
Relief is granted for most tax returns (including individual, corporate, and
estate and trust income tax returns; partnership returns, S corporation
returns, and trust returns; estate, gift, and generation-skipping transfer tax
returns; and employment and certain excise tax returns) and related tax
payments, that have either an original or extended due date occurring on or
after Aug. 11, 2016, and on or before Jan. 17, 2017. The new filing deadline
for these returns is Jan. 17, 2017.
Importantly, the relief specifically extends to the filing of Form 5500
returns. Those that were due between Aug. 11, 2016, and Jan. 17, 2016, will now
be due Jan. 17, 2017, for affected taxpayers.
IRS Announcement »
July 26, 2016
On June 17, 2016, Gov. Edwards signed HB1151 into law, creating Act No. 573.
This law requires health insurance issuers to provide notice to plan
participants who are taking prescription drugs or receiving intravenous
infusions when there are any proposed changes to coverage of those drugs. The
notice must be provided at least 60 days before the changes become effective.
Participants who receive the notices must also be allowed to appeal the changes
during the 60-day notification period. The law is effective Jan. 1, 2017.
Although insurers are responsible for this notice, employers should familiarize
themselves with this law.
Act
No. 573 »
June 28, 2016
On June 8, Gov. Edwards signed SB 476 into law, creating Act No. 405. This law
requires insured plans in the large group market to provide coverage for the
diagnostic, therapeutic or surgical procedures related to temporomandibular
joint (TMJ) and associated musculature or neurological conditions. Such TMJ
coverage must be subject to the same quantitative and non-quantitative
conditions as the coverage for other bones or joints of the human skeleton.
The law applies to all new policies issued on or after Jan. 1, 2018, and
applies to all existing policies upon renewal, but in no case later than Jan.
1, 2019.
Act
No. 405 »
June 14, 2016
On May 26, 2016, Gov. Edwards signed SB 258 into law, creating Act No. 206.
This law requires insured and certain self-insured plans (not to include single
employer self-insured plans) that provide coverage for prescription eye drop
refills if certain conditions are met. Plans may not deny coverage for these
refills if:
- The insured requests refills for a 30-day supply between 23 and 30 days
after he/she receives an original prescription or the last prescription
refill, whichever is later;
- The insured requests refills for a 60-day supply between 45 and 60 days
after he/she receives an original prescription or the last prescription
refill, whichever is later;
- The insured requests refills for a 90-day supply between 68 and 90 days
after the date he/she receives an original prescription or the last
prescription refill, whichever is later; and
- The prescriber indicates on the original prescription that additional eye
drops are needed and original prescriptions don't exceed the number of
additional quantities needed for treatment of the medical condition for
which the original prescription is issued.
The Act further holds that coverage for these eye drops is limited to the
remaining dosages initially approved for coverage. However, this limitation on
refills cannot limit or restrict coverage for previously or subsequently
approved prescriptions and is subject to plans' terms and conditions.
The law is effective on Jan. 1, 2017. Plan sponsors should review and edit plan
terms to reflect this change in the law.
Act
No. 206 »
June 1, 2016
On May 19, 2016, Gov. Edwards signed HB 694 into law, creating Act No. 145.
This law seeks to ensure that Louisiana insurance law mirrors the federal
Women’s Health and Cancer Rights Act. In addition to delineating the covered
components of reconstruction and clarifying the notice requirements, this law
amends the prior statute by requiring that reconstructive surgery after
mastectomies be provided even if the mastectomy was performed under a different
health coverage policy. Additionally, the law prohibits insurers from reducing
or limiting coverage of patients who have selected certain reconstructive
procedures in consultation with their doctor.
Act
No. 145 »
April 5, 2016
On March 15, 2016, the Louisiana Department of Insurance issued Bulletin
2016-01, which provides guidance related to transitional small group policies.
As background, on Feb. 29, 2016, CMS announced that states would have the
option of renewing transitional small group and individual policies for policy
years beginning on or before Oct. 1, 2017. The non-grandfathered policies had
to be in place prior to 2014 and must end by Dec. 31, 2017. If the policy meets
requirements, it is exempt from certain coverage mandates including community
rating, coverage of clinical trials and essential health benefits. See the
March 6, 2016 edition of Compliance Corner.
The bulletin confirms that insurers in Louisiana will have the option to
continue such policies until Dec. 31, 2017.
Bulletin 2016-01 »
January 26, 2016
On Jan. 12, 2016, Governor Edwards signed Executive Order No. JBE 16-01,
expanding Medicaid to adults who are at or below 138 percent of the FPL. The
Louisiana Department of Health and Hospitals (DHH) is to create state plan
amendments, adopt any administrative rules, and take any necessary action to
implement this expansion by July 1, 2016.
The Medicaid announcement may prove of interest to employers, because there are
concerns in states which reject the expansion of Medicaid. Specifically,
individuals who may have previously qualified for Medicaid may instead qualify
for federal subsidies to purchase health insurance through an exchange. Since
the employer mandate penalty affecting employers with over 50 employees is tied
to individuals who qualify for a subsidy unless the individuals are
Medicaid-eligible, employers with over 50 employees may be subject to more plan
affordability penalties than they would were their state to pursue Medicaid
expansion. This will no longer be an issue in Louisiana due to this executive
order.
Executive
Order No. JBE 16-01 »
October 20, 2015
On Oct. 12, 2015, Louisiana Commissioner of Insurance Donelon, issued Bulletin
2015-07, granting transitional relief for small-group rating purposes. As
background, the Louisiana legislature previously amended La. R.S.
22:1091(B)(13), changing the definition of ‘small employer’ to make it
consistent with the PPACA-mandated change that was to take place under the
PPACA on Jan. 1, 2016.
However, the PACE Act recently repealed the upcoming change to the definition
of small employer, and allows states to choose how to define ‘small employer.’
In order to address this discrepancy, Commissioner Donelon is providing
transitional relief from La. R.S. 22:1091(B)(13) which allows issuers to
continue to define small employer as those with 1-50 employees during the
preceding calendar year. This transitional relief will be effective for any
policy that is issued or renewed on or before Dec. 31, 2016.
Bulletin 2015-07 »
April 21, 2015
On March 26, 2015, a federal judge granted an injunction in response to suits
filed by attorneys general in the states of Arkansas, Louisiana, Texas and
Nebraska. The injunction suspends enforcement of the DOL’s final rule related
to same-sex spouses in those states. The final rule, which went into effect for
46 other states on March 27, 2015, expanded the definition of spouse under the
FMLA to include same-sex spouses who were legally married in a place that
recognizes such marriages, regardless of their place of residence (please see
the March 10, 2015 edition of Compliance Corner for more information).
The attorneys general argue that the DOL’s final rule puts states in the
position of either violating state law or federal regulation.
Subsequently, on March 31, 2015, the DOL confirmed in a request for hearing
court filing that they will not enforce the rule in the four states covered by
the decision, stating:
“[W]hile the preliminary injunction remains in effect, the [DOL does] not
intend to take any action to enforce the provisions of the Family and
Medical Leave Act (FMLA) . . . against the states of Texas, Arkansas,
Louisiana, or Nebraska, or officers, agencies, or employees of those states
acting in their official capacity, in a manner that employs the definition
of the term “spouse” contained in the February 25, 2015, final rule . . .
.”
The court’s injunction temporarily suspends enforcement until a final ruling is
made. Oral arguments occurred April 13. In the meantime, employers with
operations in these four states should be aware that FMLA requests (or, if not
requested, the employer’s knowledge that an FMLA request might be a factor) for
the care of a same-sex spouse due to a serious health condition or other
FMLA-qualifying reason, will require the assistance of outside legal counsel
specializing in employment law until this issue is resolved. Finally, four
pending cases before the U.S. Supreme Court, with a decision expected in June,
may also indirectly resolve this issue (See the Feb. 10, 2015 Compliance
Corner, specifically articles for Kentucky, Tennessee, Michigan and
Ohio).
State of Texas vs. U.S. No. 7:15-cv-00056-O
»
DOL
Request for Hearing »
Supreme Court Pending Cases »
March 10, 2015
On Feb. 20, 2015, the Louisiana Department of Insurance published Bulletin
2015-02, which informs health insurance issuers and HMO issuers that the use of
family composite premiums for the 2016 plan year has been approved in the small
group market. The bulletin also provides the method of calculation to be used
in determining family composite premiums.
Bulletin 2015-02 »
January 13, 2015
On Dec. 24, 2014, the Louisiana Department of Insurance (LDI) released Bulletin
2014-08. The bulletin informs all health insurance issuers, health maintenance
organizations, utilization review organizations and independent review
organizations (IROs) of the electronic process established by LDI for external
reviews. The bulletin describes the new IRO Review Request Module, which will
be used to submit external review requests and to assign external reviews to
IROs. Anytime a plan enrollee requests an external review of their claims
decision, that information will go into the module. The bulletin further
discusses details of the module, and an instruction manual for the module is
attached to the bulletin. The electronic process became effective Jan. 1, 2015.
Bulletin 2014-08 »
October 21, 2014
On Sept. 22, 2014, Insurance Commissioner Donelon released Bulletin 2014-06
related to hospital and other fixed indemnity insurance products and state
enforcement of Title 45. The state has implemented new procedures and
enforcement to align with federal requirements for such policies. As
background, an individual indemnity policy would be exempt from PPACA’s
coverage mandates (regarding, for example, essential health benefits, annual
dollar limits and maximum out-of-pocket limits) if it qualified as a
HIPAA-excepted benefit.
To qualify as an excepted benefit:
- The policy must only cover individuals who have other coverage considered
minimum essential coverage (MEC).
- There is no coordination of benefits with another health plan.
- The benefits are paid as a fixed-dollar amount per day or service
regardless of the amount incurred.
- The participant is provided with a written notice explaining that the
policy would not qualify as MEC for individual mandate purposes.
In August 2014, CMS issued a letter to the National Association of Insurance
Commissioners, clarifying the applicable date of the final regulations related
to indemnity insurance products. CMS acknowledged that many states require that
issuers receive approval from the state insurance agency before amending
insurance documents. They also acknowledged that state insurance regulators may
not have time to review the updated indemnity filings in time for the issuers
to comply by the Jan. 1, 2015 applicability date. With these issues in mind,
CMS agreed not to take enforcement action against issuers who are in states
that require prior approval of amendments as long as they submit revised
materials by Oct. 1, 2014 and comply with all other requirements for the fixed
indemnity insurance to be considered an excepted benefit.
In response to the CMS letter, Insurance Commissioner Donelon suggested
specific attestation language to be used for policies issued on or after Jan.
1, 2015 and for policies issued before Jan. 1, 2015 and renewed no later than
Oct. 1, 2016. Employers offering indemnity products to employees should review
this bulletin carefully to ensure compliance.
Bulletin 2014-06 »
September 9, 2014
On Sept. 3, 2014, a U.S. district court judge ruled that Louisiana’s ban
on same-sex marriage is constitutional. This is the first federal court ruling
upholding a state’s ban since the U.S. Supreme Court struck down parts of
the Defense of Marriage Act last year. In Robicheaux v. Caldwell, 2014
WL 4347099 (E.D. Sept. 3, 2014), U.S. District Judge Feldman granted the
state’s motion for summary judgment, thereby upholding the state law.
Any appeal of this case would be heard at the U.S. Court of Appeals for the
Fifth Circuit, where an appeal of a federal court ruling striking down
Texas’ same-sex marriage ban already sits.
Other circuits are also in the process of hearing same-sex marriage cases. The
issue appears headed to the U.S. Supreme Court. 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.
Robicheaux v. Caldwell »
May 20, 2014
On April 22, 2014, Commissioner of Insurance Donelon issued Bulletin No.
2014-04. The notice is 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). Transitional relief for plan year 2015 is allowed in both the
individual and small group markets.
Bulletin No. 2014-04 »
Maine
October 16, 2018
Guidance for Short-Term Health Insurance
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On Sept. 20, 2018, Superintendent Cioppa released Bulletin 431 to remind
carriers and producers issuing policies in Maine of the state insurance
requirements for short-term health insurance. This bulletin was intended to
remind carriers doing business in the state that state law isn’t preempted
regarding short-term health insurance and, thus, carriers doing business in
ME must continue to comply with state law.
As background, the federal government issued a rule in Aug. 2018 that
extended the initial contract term of short-term policies issued on or
after Oct. 2, 2018, to be no more than 12 months while limiting renewals or
extension of such policies to no more than 36 months. Similar to the
federal rule, ME law limits a short-term policy to a term that is less than
12 months. However, in ME, short-term policies are nonrenewable and the
combined term of successive short-term policies can be no more than 24
months, regardless of whether the policies are issued by the same carrier
or a different carrier.
The bulletin also mentions that although federal law doesn’t require
short-term policies to meet the essential health benefit requirements of
the ACA, these policies are still subject to ME’s mandated benefits for
individual health insurance. In addition, short-term policies are subject
to more requirements for health plans in ME, such as preventive health
services and the prohibition against aggregate dollar limits on coverage.
The bulletin highlights that short-term policies may be appropriate for
some consumers, but producers should keep in mind that the federal
regulation expressly describes short-term coverage as “a type of health
insurance coverage that was primarily designed to fill temporary gaps in
coverage that may occur when an individual is transitioning from one plan
or coverage to another plan or coverage.” A producer has a duty of
competence to ensure that consumers considering these policies are fully
advised of the terms, benefits and limitations of the coverage.
This bulletin was for informational purposes only and employers need not
take any action at this time. The intent was to remind carriers that ME
insurance law continues to apply to short-term health insurance and
carriers must factor in ME policies before issuing a product in response to
the federal guidelines.
Bulletin 431 »
August 21, 2018
HHS Approves Maine Section 1332 Waiver
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On July 30, 2018, HHS and the Department of the Treasury approved ME’s
state innovation waiver, which requested a waiver from certain health
insurance requirements under the ACA. Specifically, ME sought waiver of the
ACA’s requirement that all enrollees in the individual market be rated
under a single risk pool in order to reinstate the ME Guaranteed Access
Reinsurance Association (the state-operated reinsurance program) from 2019
through 2023. The Departments believe that the waiver will achieve lower
individual premiums in the state and lower premium tax credits (PTC)
provided to ME residents.
The waived provisions are effective from Jan. 1, 2019 through Dec. 31,
2023, unless the waiver is extended. Superintendent Cioppa has 30 days
(from July 30, 2018) to accept the terms and conditions of the Departments’
approval. If approved, the estimated PTC savings will be provided to the
state to be used for implementation of the state’s reinsurance program.
The approval of this innovation waiver doesn’t impact employers directly,
since it’s related to the individual market. However, employers may want to
familiarize themselves with the approval in order to understand the
waiver’s effect on the individual market.
Waiver Approval »
August 7, 2018
Out-Of-Network Provider Referrals Must Be Accepted
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On July 13, 2018, Superintendent of Insurance Cioppa issued Bulletin 430 to
clarify the legislative intent behind a recently enacted law that prohibits
a carrier from denying payment for any covered health care service solely
on the basis that the referral was made by a provider that was not a member
of the carrier's provider network. The bulletin is in response to questions
the bureau received about the interpretation and scope of the law change,
including whether it prohibits so-called "gatekeeper" plans,
which are typical for HMOs, from requiring all referrals to be made by the
enrollee's designated primary care provider (PCP).
As background, effective Jan. 1, 2018, Gov. LePage signed 24-A M.R.S.
§4303(22) into law. This law prohibits a carrier from denying an enrollee's
referral for a covered service solely because it is from an out-of-network
provider. The law applies to all carriers including HMOs and also limits
carriers using tiered networks or other incentive programs that require the
use of particular designated providers and exclude
"non-designated" network providers from making referrals.
The bulletin clarifies that the law doesn't mean carriers must honor all
referrals made by out-of-network providers, or that carriers can't impose
reasonable restrictions that don't distinguish between referring providers
on the basis of network membership. For example, a carrier may still deny
the referral if the proposed service doesn't meet the carrier's documented
clinical review criteria, to the extent otherwise permitted by law. The law
does, however, prohibit any "gatekeeper" procedure traditionally
used by HMOs.
This bulletin is intended for informational purposes and is primarily
focused on carriers. So, fully insured employers don't need to take any
action.
Bulletin 430 »
24-A M.R.S. §4303(22) »
July 24, 2018
Plan Participants Must Be Notified of Adverse Formulary Changes
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On July 1, 2018, HB 487 became law. This law provides that plans must
provide plan participants with at least 60 days' notice of any adverse
changes to formularies, unless prescription drugs are being removed from
formularies because of safety concerns. A change is considered adverse if
items are removed and plan participants affected by the change must be
notified and given an ability to request exceptions to the formulary
limitation. Plans must continue to honor existing prior authorizations
until they expire, so long as plan participants continue to be covered
under the same health plan and the drugs haven’t been removed from
formularies because of safety concerns.
This bill becomes effective for plans issued or renewed on or after Jan. 1,
2019. This bill contains no new employer obligations, but employers with
fully insured plans in Maine should review the new law to better understand
the required changes.
HB 487 »
May 1, 2018
Extension of Renewal for Grandmothered Plans
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On April 18, 2017, the Maine Bureau of Insurance published Bulletin 428
(superseding Bulletin 420). According to the bulletin, the Bureau approves
the renewal of non-grandfathered small group plans issued before Jan. 1,
2014 (so-called “grandmothered plans”) for terms extending no later than
Dec. 31, 2019.
As background, on April 9, 2018, CMS issued guidance allowing extension of
grandmothered policies (i.e., non-ACA-compliant plans that have been
continued since 2013), subject to state and carrier approval. Bulletin 428
represents Maine’s approval for such an extension.
To be eligible for the extension, carriers must notify the bureau by May
31, 2018, whether or not they intend to renew grandmothered policies beyond
Oct. 1, 2018. The notice must include the number of affected policies and
whether the carrier requests discontinuance of any existing products before
Dec. 31, 2019. In addition, grandmothered policies must be terminated or
modified to be fully ACA-compliant by Jan. 1, 2020