Health Insurance Laws at Work and Related Rights
A Guide for Families of Children with Special Health Care Needs
The purpose of this information is to help families learn what rights and protections may benefit their children with disabilities, chronic illnesses or other special needs under federal laws concerning health insurance and leave benefits at work.
The U.S. Department of Labor is responsible for oversight and accountability in the application of the laws presented in this brochure. Informational bulletins and fact sheets can be obtained from the DOL and are available through the Internet at: www.dol.gov/pwba/health.htm.
Families should also check with their state’s insurance authority to find out how state specific rules relate to the laws discussed here. Some states have chosen to expand certain provisions in the U.S. code and some have elected not to participate in a few optional provisions.
State Consumer Guides for Getting and Keeping Health Insurance are available from the Institute for Health Care Research and Policy, located at George Washington University. The consumer guides can be downloaded from: www.healthinsuranceinfo.net
Health Insurance Laws
COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 helps workers and their families keep their group health coverage during times of voluntary or involuntary job loss, reduced work hours, transition between jobs and in certain other cases including divorce or death of a covered employee, or transition from dependent child status. COBRA generally applies to group health plans offered by employers with 20 or more employees. The covered employee pays for the continuation benefits, which generally last up to 18 months. This 18-month period may be extended for up to 36 months in cases where a qualified beneficiary meets specific disability criteria.
HIPAA: The Health Insurance Portability and Accountability Act of 1996 offers protections for workers that improve portability and continuity of health insurance coverage. HIPAA provides the following benefits and more: limits exclusions for preexisting medical conditions; prohibits discrimination in enrollment and in premiums charged to employees and their dependents based on health status-related factors; preserves the states’ role in regulating health insurance, including the states’ authority to provide greater protections than those available under federal law; and improves disclosure about group health plans. Dependent children may be eligible for a special enrollment period under HIPAA provisions.
ERISA: The Employee Retirement Income Security Act of 1974 governs health benefit plans sponsored by private sector employers. Under ERISA, workers and their families are entitled to receive a summary plan description (SPD) that gives information about the plan, what benefits are available under the plan, the rights of participant and beneficiaries under the plan, and how the plan works, including the appeals process.
MHPA: The Mental Health Parity Act of 1996 established that lifetime and annual dollar limits on mental health benefits must be equal to any lifetime and dollar limits set on the medical/ surgical benefits offered by group health plans, insurance companies and HMOs. The MHPA does not require health plans to offer mental health benefits and it does not apply to benefits for substance abuse or chemical dependency. Also, health plans may set policies for cost-sharing and determine the amount, duration and scope of mental health benefits it offers to plan subscribers.
Leave Benefits
FMLA: The Family Medical Leave Act of 1993 grants covered employees up to 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons: for the birth and care of the newborn child of the employee; for placement with the employee of a son or daughter for adoption or foster care; to care for an immediate family member (spouse, child, or parent) with a serious health condition; or to take medical leave when the employee is unable to work because of a serious health condition.
Other Considerations
Marriage, divorce, birth or adoption of a child or the death of a spouse are life events that may signal a need to review and possibly change your health benefits. There are ways to learn about the quality of health plans and the service providers within those plans. Look for these quality measures and compare plans when given a choice of plans. A good source for this information is the booklet: Your Guide to Choosing Quality HealthCare, which is available at: www.ahcpr.gov/consumer
Acknowledgments : Family Voices of TN; Institute for Health Care Research and Policy at George Washington University; Pension and Welfare Benefits Administration, US Dept. of Labor: 1-866-4-USA DOL.
Where to find more information:
Agency for Healthcare Research & Quality: www.ahcpr.gov
Families USA: www.familiesusa.org
George Washington University Institute for Health Care Research and Policy: www.healthinsuranceinfo.net
National Health Law Project: www.healthlaw.org
PACER Center, Inc. Health Information & Advocacy Center (phone: 952-838-9000) www.pacer.org
Who to contact in Tennessee:
Tennessee Disability Coalition, 955 Woodland Street , Nashville , TN 37204
Phone: 615-383-9442; ext. 13
Toll-free: 1-888-643-7811
Email: familyvoices@tndisability.org
www.tndisability.org/familyvoices
Who to contact Nationally:
Family Voices, 3411 Candelaria N.E., Suite M, Albuquerque , NM 87107
Toll free: 1-888-835-5669
Phone: (505) 872-4774
Fax: (505) 872-4780
Email: kidshealth@familyvoices.org
www.familyvoices.org
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