Employee Regulatory Notices
BAS Notice Preparation and Distribution Services
BAS can assist your organization with its ongoing responsibility to provide the following notices required by law.
Newborns’ and Mothers’ Health Protection Act
The Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act) provides protections for mothers and their newborn children relating to the length of their hospital stays following childbirth.
Group health plans that are subject to the Newborns’ Act may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section. However, the at ending provider may decide, after consulting with the mother, to discharge the mother and/or her newborn child earlier.
What group health plans must comply with the Newborns’ Act?
If a plan oﬀers benefits for hospital stays in connection with childbirth, the Newborns’ Act applies if the coverage is “self-insured” by an employment-based plan and if the coverage is “fully-insured” by an insurance company or HMO.
If the coverage is provided by an insurance company or HMO and your state has its own version of the Newborns’ Act, a state law that is more generous to the mother and newborn can govern in lieu of the Federal requirements. If this is the case, the State law may diﬀer slightly from the Newborns’ Act requirements, so it is important to know which law applies to the coverage oﬀered by your plan.
For those plans with coverage that is insured by an insurance company or HMO, contact your State insurance department for the most current information on the State laws that pertain to hospital length of stay in connection with childbirth. For those plans covered by the Federal law, the following questions apply:
When does the 48-hour (or 96-hour) period start?
If a woman delivers her baby in the hospital, the 48-hour period (or 96-hour period) starts at the time of delivery. As an example: if a woman goes into labor and is admitted to the hospital at 10 p.m. on June 11, but gives birth by vaginal delivery at 6 a.m. on June 12, the 48-hour period begins at 6 a.m. on June 12. However, if the woman delivers outside the hospital and is later admitted to the hospital in connection with childbirth (as determined by the attending provider), the period begins at the time of the hospital admission.
Who is the attending provider?
An attending provider is an individual licensed under State law who is directly responsible for providing maternity or pediatric care to a mother or newborn child. A nurse midwife or a physician assistant may be an attending provider if licensed in the State to provide maternity or pediatric care in connection with childbirth. A health plan, hospital, insurance company, or HMO, however, would not be an attending provider.
The attending provider cannot receive incentives or disincentives to discharge the mother or her child earlier than 48 hours (or 96 hours).
May a group health plan require an individual to get permission (sometimes called prior authorization or precertiﬁcation based upon medical necessity) for a 48-hour or 96-hour hospital stay?
A plan cannot deny a mother or her newborn child coverage for a 48-hour stay (or 96-hour stay) because the plan claims that the mother or her attending provider has failed to show that the 48-hour stay (or 96-hour stay) is medically necessary.
However, plans generally can require an individual to notify the plan of the pregnancy in advance of an admission in order to use certain providers or facilities or to reduce the individual’s out-of-pocket costs.
Under the Newborns’ Act, may group health plans impose deductibles or other cost-sharing provisions for hospital stays in connection with childbirth?
Yes, but only if the deductible, coinsurance, or other cost-sharing for the later part of a 48-hour (or 96-hour) stay is not greater than that imposed for the earlier part of the stay. For example, with respect to a 48-hour stay, a group health plan is permitted to cover only 80 percent of the cost of the hospital stay. However, a plan covering 80 percent of the cost of the ﬁrst 24 hours could not reduce coverage to 50 percent for the second 24 hours.
Does the Newborns’ Act require a plan to offer maternity benefits?
No. The Newborns’ Act does not require plans to provide coverage for hospital stays in connection with childbirth. However, other legal requirements, including Title VII of the Civil Rights Act of 1964, may require this type of coverage. Questions regarding Title VII should be directed to the Equal Employment Opportunity Commission.
Are group health plans required to tell participants and beneficiaries about the Newborns’ Act and any applicable State law protections?
A group health plan that provides maternity or newborn infant coverage must include in its SPD a statement describing the Federal or State law requirements applicable to the plan (or any health insurance coverage oﬀered under the plan) relating to hospital length of stay in connection with childbirth for the mother or newborn child. If the Federal Newborns’ Act law applies in some areas in which the plan operates and State laws apply in others, the SPD must describe the Federal and State law requirements that apply in each area covered by the plan.
BAS can provide annual notice preparation and distribution services to satisfy your organization’s Newborns’ Act disclosure obligation. Contact us to learn more: Sales@BASusa.com or 1.800.945.5513 menu option #5.
The Women’s Health and Cancer Rights Act
The Women’s Health and Cancer Rights Act (WHCRA) provides protections for individuals who elect breast reconstruction after a mastectomy. Under WHCRA, group health plans oﬀering mastectomy coverage must also provide coverage for certain services relating to the mastectomy, in a manner determined in consultation with the attending physician and the patient. Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema.
Written notice about the availability of these mastectomy-related benefits must be delivered to participants in a group health plan upon enrollment and then each year afterwards. BAS can automate the preparation and delivery of these notices for your organization when you purchases BAS’ WHCRA services.
Does WHCRA apply to individuals who have not been diagnosed with cancer but who must undergo a mastectomy due to other medical
Despite the title, nothing in the law limits entitlement to WHCRA benefits to cancer patients. If an individual is receiving benefits in connection with a mastectomy and the group health plan covers mastectomies, then the individual should be entitled to WHCRA benefits.
Also, despite the title, nothing in the law limits WHCRA entitlements to women.
Does WHCRA mandate minimum hospital lengths of stay in connection with mastectomy or breast reconstruction?
No, but many State laws applicable to insured coverage provide more protections than WHCRA. Thus, if a plan provides coverage through an insurance company or HMO, covered individuals may be entitled to minimum hospital stays under State law. If your plan is insured, check with your State insurance department for more information.
May group health plans impose deductibles or coinsurance requirements on the coverage specified in WHCRA?
Yes, but only if the deductibles and coinsurance are consistent with those established for other medical/surgical beneﬁts under the plan or coverage.
Can an insurance company refuse to cover reconstructive surgery benefits because an individual’s mastectomy was performed when the individual was covered under a different insurance company?
Even though the new insurance company did not cover the individual’s mastectomy, as long as the new insurance company provides benefits for mastectomies, it is generally required to provide coverage for breast reconstruction as well as other required beneﬁts under WHCRA if the individual is receiving beneﬁts under the plan related to the mastectomy.
Any restrictions on benefits imposed by the new insurance company because the mastectomy occurred before it covered the individual must comply with HIPAA’s rules limiting a plan or health insurance issuer’s ability to impose a preexisting condition exclusion.
What information should be included in the notice provided when participants enroll in the plan?
The enrollment notice must state that, for an individual who is receiving mastectomy-related beneﬁts, coverage will be provided in a manner determined in consultation with the attending physician and the patient for:
- All stages of reconstruction of the breast on which the mastectomy was performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance;
- Prostheses; and
- Treatment of physical complications of the mastectomy, including lymphedema.
The enrollment notice must also describe any deductibles and coinsurance limitations applicable to such coverage. Under WHCRA, coverage of breast reconstruction and other benefits specified in WHCRA may be subject only to deductibles and coinsurance limits consistent with those established for other medical/surgical benefits under the plan or coverage.
What information should be included in the annual notice to participants in the plan?
The annual notice should describe the four categories of coverage required and should contain information on how to obtain a detailed description of the mastectomy-related beneﬁts available under the plan. To satisfy this annual notice requirement, your plan may provide the same notice it provided to individuals upon enrollment in the plan if it contains the appropriate information as described above.
How must the plan provide these notices to participants?
These notices must be delivered in accordance with the Department of Labor’s disclosure rules applicable to furnishing summary plan descriptions. For example, the notices may be provided by ﬁrst class mail or any other means of delivery prescribed in the regulation. A separate notice must be furnished to a group health plan beneficiary where the last known address of the beneficiary is different than the last known address of the covered participant.
To avoid duplication of notices, a group health plan can satisfy the WHCRA notice requirements by contracting with another party that provides the required notice. For example, in the case of an insured group health plan, the plan will satisfy the notice requirements with respect to a particular participant if the issuer timely provides the notice including the information required by WHCRA.
BAS can provide annual notice preparation and distribution services to satisfy your organization’s WHCRA disclosure obligation. Contact us to learn more: Sales@BASusa.com or 1.800.945.5513 menu option #5.
Medicare Part D Creditable Coverage Disclosure
The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders if their prescription drug coverage is creditable coverage or not. Coverage is creditable if the coverage is expected to pay on average as much as the standard Medicare Part D prescription drug coverage.
These entities must provide a written disclosure notice to all Medicare eligible individuals annually who are covered under its prescription drug plan, prior to October 15th each year and at various times as stated in the regulations, including to a Medicare eligible individual when he/she joins the plan. This disclosure must be provided to Medicare eligible active working individuals and their dependents, Medicare eligible COBRA individuals and their dependents, Medicare eligible disabled individuals covered under your prescription drug plan and any retirees and their dependents. The MMA imposes a late enrollment penalty on individuals who do not maintain creditable coverage for a period of 63 days or longer following their initial enrollment period for the Medicare prescription drug benefit. Accordingly, this information is essential to an individual’s decision whether to enroll in a Medicare Part D prescription drug plan.
BAS can provide annual notice preparation and distribution services to satisfy your organization’s Medicare Part D Creditable Coverage disclosure obligation. Contact us to learn more: Sales@BASusa.com or 1.800.945.5513 menu option #5.