Health Insurance Events/Documents

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Health Insurance Events/Documents

Summary Plan Descriptions (SPD), Summary Material Modifications (SMM), Loss of Coverage notices. Qualified Life Events, Special Enrollment Periods, Notices of Privacy Policies, COBRA notices, and Accounting of Disclosures are all important events or documents an individual might experience or obtain regarding activities associated with their health insurance plan. The website of the Department of Health and Human Services, the Department of Labor, and Healthcare.gov are all excellent resources and contain a wealth of additional information on the subject.

Summary Plan Descriptions (SPD) and Summary of material modifications (SMM)

  • A Summary Plan Description (SPD) is a document that informs participants and beneficiaries about the details of their health insurance plan.
  • SPDs are mandated by federal law, ERISA (The Employee Retirement Income Security Act), and must be made readily available, either through an employer or other means, to any plan participants within 90 days of initial enrollment.
  • An SPD must be written using language that is clear and comprehensive, detailing all benefits, rights, and obligations of the participant and the provider under the plan.
  • An SPD must be current, including accurate details within the last 120 days prior to the SPD's disclosure.
  • SPDs must also include the details of participants' COBRA rights associated with the plan.
  • A Summary of Material Modifications (SMM) is required if there are changes made to the plan and should be provided to participants no more than 210 days following the end of the plan year in which the changes took effect.
  • If an SMM includes a material reduction in plan benefits or covered services, the SMM must be provided to covered individuals no later than 60 days after the reduction becomes effective.

Loss of coverage notice

  • A Loss of Coverage notice is issued to a plan participant either by the plan provider, former employer, or both. It is required when attempting to enroll in new healthcare coverage following that coverage loss, due to either loss of employment or other qualifying circumstances.
  • According to COBRA, the Consolidated Omnibus Budget Reconciliation Act, and additional state laws, when a participant loses a job, an employer is required to send a Loss of Coverage notice letter that must be on the employer's stationery or letterhead and include the employer’s signature.
  • A Loss of Coverage notice must include the participant's name and the names of any dependents that were covered under the plan the participant was enrolled in during the employment period, and the date that the healthcare plan coverage ceased.
  • Loss of coverage due to job loss, qualifying life events, or other special circumstances entitles an individual to access and enroll in a variety of new health coverage options outside of the prospective plan's open enrollment period.

Qualifying life events

  • Qualifying Life Events include but are not limited to:
1) Pregnancy
3) Losing the minimal essential coverage, as defined by the Affordable Care Act, due to events such a losing a job or loss of eligibility as a dependent.
  • Qualifying life events entitle plan participants to change or update current healthcare coverage, or enroll in new coverage, within the prescribed period as outlined by the coverage plan, which is generally 90 days, but may be different depending on the qualifying circumstance and the plan rules.
  • The responsibility to report a qualifying event in order to elect continuing coverage under COBRA depends on the type of event that is being reported.
  • Employers are required to notify plan providers in the case of a participant's death, loss of a job, loss of coverage due to a decrease in hours worked, an employee becomes eligible for Medicare coverage, or the employer declares bankruptcy.
  • An employee is responsible for notifying his or her healthcare plan provider of loss of coverage due to a qualifying life event if the qualifying event is a divorce or a separation, or if a covered child loses dependent eligibility.

Special enrollment period

  • There are some circumstances that may qualify an applicant to be eligible for a special enrollment period, outside of qualifying life events. Some examples include:
1) If a participant experienced a serious medical condition or a natural disaster that prevented them from selecting
benefits during the open enrollment period.
2) If a participant received misinformation or was deceived by someone working as a representative of an insurance
company, a certified application counselor, or broker.
3) If a technical error occurred when an applicant attempted to select coverage during an open enrollment period that
either prevented them from enrolling in a plan or resulted in the health insurance company not receiving correct
enrollment information.
4) If the participant had a change in address in the last 60 days that made him/her eligible for Medicaid (a move from a state that does not
participate in expanded Medicaid to a state that does, for example).
5) If a participant becomes responsible for a new dependent or became a dependent of someone else. For instance, a
parent is court-ordered to provide healthcare coverage for a child dependent outside of the open enrollment period.
6) An appeal regarding a denial of coverage is ruled in the participant favor after the open enrollment period has expired.
  • Special enrollment periods for extenuating circumstances are not always available to participants that are enrolled through a private insurance company or have group health insurance coverage through an employer.

Notice of privacy practices

  • Healthcare plan providers and physicians are required to give plan participants and/or patients a Notice of Privacy Practices.
  • A Notice of Privacy Practices tells you how the healthcare plan or provider may use or share his or her personal health information.
  • A Notice of Privacy Practices from a healthcare plan provider is shared with participants at the time of enrollment and at least once every three years thereafter. It also must be available on the provider's website.
  • A Notice of Privacy Practices from a physician or healthcare facility is generally provided to patients during an initial visit or at the time of service. It must also be posted on any associated website.
  • A new Notice of Privacy Practices must be provided to a participant or patient any time there are changes to the way a plan or provider uses or shares private health information.
  • Receipt of a Notice of Privacy Policy does not convey a participant's consent to share private health information, but participants are not required to sign either.
  • Details regarding how an individual can obtain copies of their own personal health records or release them to a third party are included in any Notice of Privacy Policy.

Cobra

  • COBRA, the Consolidated Omnibus Budget Reconciliation Act, is a government-mandated program that allows employees to continue coverage after they have lost their job with that employer.
  • COBRA can be prohibitively expensive as it involves paying the participant's portion of the monthly plan premium and the employer's portion, and an administrative fee.
  • The maximum amount a participant can be charged for COBRA coverage is 102% of the total combined premium paid by both employee and employer before the participant separated from the employer.
  • When a plan provider receives a notice of a qualifying event, the plan must provide an election notice, which details the participant's rights and explains how to continue coverage.
  • A COBRA election notice must be provided by the plan administrator to participants within 14 days after the plan receives notice of the qualifying event.
  • COBRA election notices should contain any information participants will need to continue coverage and make an informed decision on which, if any, coverage they would like to elect, including the name of and contact information for the plan’s COBRA administrator.
  • COBRA extends healthcare plan coverage for 18 to 36 months from the date of the qualifying event, depending on the nature of the qualifying event and other factors such as the participant's eligibility for Medicare.

Accounting of disclosures

  • Identity thieves can obtain and use victims' names and health insurance information to seek medical treatment, obtain prescription drugs, and file claims with healthcare insurance providers.
  • Victims of medical identity theft then may have incorrect information in their health records that can affect treatment, insurance benefits and eligibility, and even credit reports.
  • To avoid medical identity theft, individuals should ask health plans and medical providers for an Accounting of Disclosures from their medical records.
  • An Accounting of Disclosures is a record of any entity that received copies of someone's private medical records from a healthcare plan or medical care provider, and individuals are legally entitled to ask for one free copy from each healthcare plan or medical provider every 12 months.
  • Once received, an Accounting of Disclosures should be reviewed and any incorrect information that has been shared with a patient's healthcare plan or other providers can be corrected.
  • An Accounting of Disclosures will show who has copies of any mistaken records and healthcare plans. Providers are legally obligated to contact them and correct any erroneous information.

Further information

  • There are numerous additional forms and events that affect participants and are regulated by federal law, most covered by two laws, ERISA (The Employee Retirement Income Security Act) and HIPAA (Health Insurance Portability and Accountability Act).
  • The Employee Retirement Income Security Act of 1974 (ERISA) sets minimum standards for voluntarily retirement and health plans offered by private employers to protect individuals participating in these plans.
  • ERISA requires plans to provide participants with plan information, including information about features and funding. It mandates financial responsibilities of the plan administrators, and also requires that all plans incorporate an appeals process for participants who are denied coverage of any kind under the plan.
  • ERISA gives plan participants the right to sue for benefits if they believe plan administrators have acted illegally. (Source 6)
  • The Health Insurance Portability and Accountability Act (HIPAA) is an amendment to ERISA and is intended to protect working Americans and their dependents and beneficiaries from health coverage discrimination based on factors such as preexisting conditions.
  • HIPAA gives participants and patients the right to view what is in their medical records and also define any third parties that should have access to those records.


Sources
Sources

Quotes
  • "A change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period."
Quotes
  • "You faced a serious medical condition or natural disaster that kept you from enrolling. For example: An unexpected hospitalization or temporary cognitive disability, or were otherwise incapacitated A natural disaster, such as an earthquake, massive flooding, or hurricane"
  • "If you’re already enrolled in a plan and you get a Special Enrollment Period, you can stay in your current plan in most cases, or you can switch plans. In some limited cases, you may qualify for an earlier effective date of coverage. Remember, you must make the first premium payment before your coverage becomes effective."
  • "If your request for a Special Enrollment Period is denied, you can file an appeal. If the denial is found incorrect, you can get coverage back to the date your Special Enrollment Period was denied."
Quotes
  • "Most qualifying events trigger a special enrollment period whether you have a marketplace plan, individual plan or workplace plan; however, that is not always the case. According to Kaiser Family Foundation, some events only qualify you for a special enrollment period in the Marketplace and do not apply to the outside market. The exceptions are situations related to citizenship, native status and exceptional circumstances."
  • "COBRA is costly, since you continue to pay your portion of the fee, plus the portion your employer was paying, plus an administrative fee."
Quotes
  • "The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan."
  • ""
Quotes
  • "This Reporting and Disclosure Guide for Employee Benefit Plans has been prepared by the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) with assistance from the Pension Benefit Guaranty Corporation (PBGC). It is intended to be used as a quick reference tool for certain basic reporting and disclosure requirements under the Employee Retirement Income Security Act of 1974 (ERISA)."
Quotes
  • "The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans."
  • "ERISA requires plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty."
  • "Another amendment to ERISA is the Health Insurance Portability and Accountability Act (HIPAA) which provides important protections for working Americans and their families who might otherwise suffer discrimination in health coverage based on factors that relate to an individual's health."
Quotes
  • "Letter from your previous health carrier indicating an involuntary loss of coverage. The supporting document must indicate your name, the names of any dependents that were covered under the prior plan and the date the previous health coverage ended. The date the previous health coverage ended must be within 60 days from the date your application was submitted. "
  • "This letter must be on company letterhead or stationery with the employer’s signature. It must indicate your name, the names of any dependents that were covered under the prior plan and the date the previous health coverage ended."
Quotes
  • "COBRA requires continuation coverage to be offered to covered employees, their spouses, their former spouses, and their dependent children when group health coverage would otherwise be lost due to certain specific events. Those events include the death of a covered employee, termination or reduction in the hours of a covered employee’s employment for reasons other than gross misconduct, divorce or legal separation from a covered employee, a covered employee’s becoming entitled to Medicare, and a child’s loss of dependent status (and therefore coverage) under the plan."
  • "The COBRA rights provided under the plan must be described in the plan’s Summary Plan Description (SPD). The SPD is a written document that gives important information about the plan, including what benefits are available under the plan, the rights of participants and beneficiaries under the plan, and how the plan works."
  • "ERISA requires group health plans to give you an SPD within 90 days after you first become a participant in a plan (or within 120 days after the plan is first subject to the reporting and disclosure provisions of ERISA). In addition, if there are material changes to the plan, the plan must give you a Summary of Material Modifications (SMM) not later than 210 days after the end of the plan year in which the changes become effective; if the change is a material reduction in covered services or benefits, the SMM must be furnished not later than 60 days after the reduction is adopted. A participant or beneficiary covered under the plan may request a copy of the SPD and any SMMs (as well as any other plan documents), which must be provided within 30 days of a written request."
  • "Group health plans must give each employee and each spouse who becomes covered under the plan a general notice describing COBRA rights. The general notice must be provided within the first 90 days of coverage"
  • "Before a group health plan must offer continuation coverage, a qualifying event must occur, and the group health plan must be notified of the qualifying event. Who must give notice of the qualifying event depends on the type of qualifying event. "
  • "When the plan receives a notice of a qualifying event, the plan must give the qualified beneficiaries an election notice, which describes their rights to continuation coverage and how to make an election. The notice must be provided to the qualified beneficiaries within 14 days after the plan administrator receives the notice of a qualifying event. The election notice should contain all of the information you will need to understand continuation coverage and make an informed decision whether or not to elect continuation coverage. "
Quotes
  • "Your health care provider and health plan must give you a notice that tells you how they may use and share your health information. It must also include your health privacy rights. In most cases, you should receive the notice on your first visit to a provider or in the mail from your health plan. You can also ask for a copy at any time."
  • "If an organization has a website, it must post the notice there."
  • "A health plan must give its notice to you at enrollment. It must also send a reminder at least once every three years that you can ask for the notice at any time."
Quotes
  • "Ask each of your health plans and medical providers for a copy of the “accounting of disclosures” for your medical records. The accounting is a record of who got copies of your records from the provider. The law allows you to order one free copy of the accounting from each of your medical providers every 12 months"
  • "Write to your health plan and medical providers and explain which information is not accurate. Send copies of the documents that support your position. You can include a copy of your medical record and circle the disputed items. Ask the provider to correct or delete each error. Keep the original documents."
  • "The health plan or medical provider that made the mistakes in your files must change the information. It should also inform labs, other health care providers, and anyone else that might have gotten wrong information. If a health plan or medical provider won’t make the changes you request, ask it to include a statement of your dispute in your record."