Reporting to Medicare

The purpose of these reporting requirements is to enable the Centers for Medicare & Medicaid Services (CMS) to determine whether those covered by Medicare are also covered by other insurance that, by law, must pay primary to Medicare.

For employer-sponsored group health plan benefits, the employer who sponsors the plan will generally not have any reporting obligations; instead, the insurer or the third-party administrator will usually be the responsible reporting entity (RRE). However, the employer will have a reporting responsibility for a self-insured workers’ compensation program. In that case, the employer will have to register with CMS as the RRE. An RRE may use an agent to submit required data, but the RRE remains responsible for timely and accurate reporting.

Reporting for group health plans is scheduled to begin October 1, 2009, and you may want to verify that your insurer/third-party administrator is reporting on your behalf. For other benefit programs, such as a self-insured workers’ compensation program, RREs should have registered electronically by September 30, 2009, and reporting is scheduled to begin July 1, 2010. CMS has provided User Guides for both group health plans and non-group health plans, which are available at http://www.cms.hhs.gov/MandatoryInsRep/.

The COBRA Subsidy in 2010

The American Recovery and Reinvestment Act of 2009 (known as “ARRA”) provides a 65% COBRA premium subsidy for individuals who lose health coverage because of involuntary termination of employment anytime between September 1, 2008, and December 31, 2009. This was intended to make COBRA more affordable to unemployed families during these difficult economic times and, in fact, it is reported that COBRA enrollment rates have doubled (from 19% to 38%) since the new subsidy was enacted. Involuntary termination of employment is broadly interpreted under the new law and includes layoffs, terminations on account of buy-outs, and failure to renew an expiring employment contract. Employers initially provide the subsidy subject to reimbursement through payroll tax offsets (IRS Form 941).

Employers were also required to update their COBRA election notices and election forms to contain information on the subsidy. You should continue to use these special COBRA notices and election forms for individuals both: (i) who experience qualifying events on or before December 31, 2009 (all qualifying events, not just involuntary termination of employment) and (ii) for whom COBRA coverage would begin by December 31, 2009. If Congress does not extend the COBRA subsidy program beyond December 31, 2009, employers may resume using their prior pre-ARRA COBRA notices and election forms for 2010. The Department of Labor has model COBRA notices available at www.dol.gov/cobra.

GINA

GINA is the Genetic Information Nondiscrimination Act of 2008, a law that prohibits group health plans and their insurance companies from discriminating on the basis of genetic information. Genetic information includes genetic testing as well as information about manifestation of a disease or disorder affecting an employee’s family members.

For plan years beginning after May 21, 2009 (January 1, 2010, for a calendar year plan), group health plans and insurance companies in the group market are prohibited from any of the following: adjusting group premiums or contribution amounts on the basis of genetic information; requesting or requiring an individual or an individual’s family members to undergo genetic testing; or requesting, requiring or purchasing genetic information for underwriting purposes or before enrollment.

While there are some exceptions for research, claims payment and other limited purposes, a number of questions remain to be addressed in regulations that are to be issued. Meanwhile, employers who request information on the medical history of family members in a health risk assessment that is part of their wellness program need to consider whether that request will put them in violation of GINA. Further guidance is needed.

HIPAA – Breach Notification

Although employers who sponsor self-insured health plan benefits have been operating under HIPAA privacy and security regulations for a number of years, there’s never been a clear duty under these laws to notify individuals if there has been a data breach. Recent amendments to HIPAA now require notification, and new HIPAA breach notification regulations have been issued. If your plan is subject to HIPAA, you will need to evaluate incidents of inappropriate acquisition, access, use or disclosure of protected health information – whether by your company, your TPA, or some other contractor – to determine whether individuals who may be affected by the incident must be notified of the data breach.

The regulations went into effect on September 23, 2009, and require you to adopt written policies and procedures describing how you will comply with the new law.

HIPAA – Revised Business Associate Agreements and Other New Requirements

HIPAA has also been amended to require revisions to business associate agreements, changes to the “minimum necessary” rule, additional restrictions on marketing, expansion of certain individual rights, and substantially higher penalties for HIPAA violations. Most of these changes will go into effect February 17, 2010. To comply, you will need to review and probably revise your HIPAA policies and procedures and amend your business associate agreements with third-party administrators and other contractors who provide services for your self-insured health plans.

Bringing Parity to Mental Health and Addiction Benefits

Health plans that include mental health or substance abuse benefits must begin offering these benefits on the same terms as most other medical and surgical benefits offered under the plan. This means that your health plan cannot have:

lower annual or lifetime dollar maximums for mental health and substance abuse treatment benefits;

more restrictive limits on the number of covered office visits, days of inpatient coverage, or similar limits on the duration or scope of treatments available;

higher copays, deductibles or out-of-pocket limits for mental health and substance abuse treatment benefits than for medical and surgical benefits;

exclusions for out-of-network treatment if out-of-network benefits are provided for medical and surgical services.

Before the start of your next plan year after October 3, 2009 (January 1, 2010 for a calendar year plan), you will need to align your mental health and substance abuse benefits with these new requirements and make sure that these are reflected in benefits-at-a-glance summaries, summary plan descriptions, and other documents related to your health plan.

These new mental health parity requirements do not apply to employers with 50 or fewer employees during the preceding calendar year.

Special Enrollment Rights under Medicaid and SCHIP Programs

Effective April 1, 2009, federal legislation expanded the State Children’s Health Insurance Program (SCHIP) to require new health plan enrollment rights for employees and their dependents. The new special enrollment rights apply when employees or their dependents become eligible for a premium subsidy for coverage under an employer’s group health plan through Medicaid or SCHIP, or when employees or their dependents lose Medicaid or SCHIP coverage. Employees must request coverage under their employer’s health plan within 60 days of becoming eligible for the premium subsidy or losing Medicaid or SCHIP coverage. In addition to updating your plan, SPDs, and enrollment materials, you will eventually have to provide notice to employees about the premium assistance opportunities available under state law after the Department of Health & Human Services has issued model notices.

Students Medical Leave Coverage under Michelle’s Law

Many group health plans cover dependent children over age 18 only if they are full-time students. For plan years beginning on or after October 9, 2009 (January 1, 2010, for a calendar year plan), a group health plan must continue coverage of a dependent child who is a full-time student for up to one year when the dependent takes a “medically necessary leave of absence” from a college or other post-secondary educational institution. A “medically necessary leave of absence” is one that starts while the dependent is suffering from a serious illness or injury, is medically necessary, and causes the dependent to lose student status for purposes of coverage under the group health plan. Written certification from a physician is required. To comply with Michelle’s Law, you will need to review and update your plan, SPDs, enrollment and election change materials. In addition, if your plan requires periodic certification of student status, you must include a notice regarding Michelle’s Law with each certification request.

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This entry was posted by Adam V. Russo on Wednesday, October 28th, 2009 at 2:20 pm and is filed under Exclusion, HIPAA, Medicare, Summary Plan Description, Welfare Benefit Plans. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.