Regulatory Issues

Introduction

Welcome to the Regulatory Issues and Advisories page. This page is designed to inform you of emerging federal regulations affecting your professional activities as a health insurance professional. As a health care professional, you will need to stay abreast of emerging regulations as they affect your business. We will update this list of regulations to keep you informed.

Background

Q. What is the role of the federal agency?
A. When the President signs congressional legislation, it becomes public law. The intent of the law is then interpreted by the federal agency with responsibility for implementation. The result of their deliberations are reflected in regulations issued by the responsible agency and published in the Federal Register.

Q. What agencies typically shape health care regulations?
A. The Departments of Labor, Health and Human Services and the Treasury Department, are federal agencies that most notably issue regulations affecting the administration of health care operations.

Regulations

COBRA

Model General Notice of COBRA Continuation Coverage Rights - Department of Labor

Department of Labor publishes final rule on Health Care Continuation Coverage (COBRA) in Fedearl Register, May 26, 2004 - Sample forms are included in the appendices.

Claims Procedures; Final Rule (29 CFR Part 2560) Department of Labor Federal Register: Tuesday, November 21, 2000 - This document is the complete Federal Register notice as published on November 21, 2000.

Amendments to Summary Plan Description Regulations; Final Rule (29 CFR Part 2520) Department of Labor Federal Register: Tuesday, November 21, 2000 - Effective Date: April 13, 2001 Implementation Date: April 13, 2003. An amendment was published in the Federal Register dealing with the Summary of Plan Description requirements. This link provides the complete Federal Register notice as published November 21, 2000.

NAHU Analysis of Claims Procedures for Group Health and Disability Plans - Produced by NAHU's government relations staff, this document provides a summary and description of the Claims procedures as outlined in the final regulation.

Whether Health Savings Accounts established in connection with employment-based group health plans constitute "employee welfare benefit plans" for purposes of Title I of ERISA? - U.S. Department of Labor - April 7, 2004.

Guide on Employer Compliance Issues

Privacy Regulations

45 CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule

Nondiscrimination in Health Coverage in the Group Market, Interim Final Rule, (45 CFR Part 146), Department of Health and Human Services (HHS) Federal Register: Monday, January 8, 2001. - This regulation removes (8) health factors that formerly excluded individuals from qualifying for coverage in the group market. Requires uniform application of rules governing benefits, eligibility / enrollment determinations for all similarly situated individuals, and must not be directed at individual participants or beneficiaries based any health factors. Stipulates exception to uniform premium setting for all similarly situated individuals (see bona fide wellness proposed rule).

Notice of Proposed Rulemaking for Bona Fide Wellness Programs, (45 CFR Part 146), Department of Health and Human Services (HHS) Federal Register: Monday, January 8, 2001. - This proposed rule would implement and clarify the term "bona fide wellness program" as it relates to regulations implementing the nondiscrimination provisions. Bona fide wellness programs are the single exception to the general rule prohibiting discrimination based on a health factor if the reward, such as a premium discount or waiver of a cost-sharing requirement, is based on participation in a program of health promotion or disease prevention.

HIPAA

Regulatory Advisories

At Issue

The Health Care Financing Administration (HCFA), now the Centers for Medicare and Medicaid Services (CMS), has issued several important bulletins related to HIPAA implementation that have been promulgated through the regulatory process. These regulations and bulletin clarifications affect the daily business of health underwriters. The issues addressed range from establishing group size to agent commissions.

Resources

Department of Labor - Annual Return/Report Form 5500 Series - Each year, pension and welfare benefit plans generally are required to file an annual return/report regarding their financial condition, investments, and operations. The annual reporting requirement is generally satisfied by filing the Form 5500 Annual Return/Report of Employee Benefit Plan and any required attachments.

EBSA Clarifies Position on Reporting of Commissions and Fees - ERISA requires insurance companies that provide health and welfare benefit insurance coverage to furnish information to ERISA plan administrators on commissions and fees paid to brokers,a gents and others.

A number of states have recently reported encounters with entities claiming to be exempt from state insurance laws under ERISA. These entities profess to be "ERISA plans" or "union plans," but are in fact unlicensed insurers who are subject to state insurance regulation because they meet the definition of Multiple Employer Welfare Arrangements (MEWAs) under ERISA.

• Introductory cover letter
• Consumer notice
• Agent notice

The Centers for Medicare and Medicaid Services (CMS), formerly HCFA, has prepared a wide array of resources regarding HIPAA issues.

• Medicare's regulatory web page
• HIPAA OnLine - An interactive tool to answer commonly asked questions.
• HIPAA Enforcement Is Not Preempted By COBRA; Non-HIPAA-Related State Insurance Law Is Not Preempted By Public Sector COBRA - Bulletin 04-01
• How Selling Coverage Exclusively Through Bona Fide Associations Affects an Issuer's Guaranteed Renewability Obligations Under Title XXVII of the PHS Act - Bulletin 02-05
• Characteristics of Bona Fide Associations, and How Selling Coverage Exclusively Through Them Affects an Issuer's Guaranteed Availability Obligations Under Title XXVII of the PHS Act - Bulletin 02-04
• The Obligations Health Insurance Issuers Have to Association Members and Associations Under Title XXVII of the PHS Act With Respect to Guaranteed Renewability of Coverage - Bulletin 02-03
• Application of Group and Individual Market Requirements Under Title XXVII of the Public Health Service (PHS) Act When Insurance Coverage is Sold To, or Through, Associations - Bulletin 02-02
• How to Apply the "Product Withdrawal" and "Market Exit" Exceptions to the Guaranteed Renewability Requirements of Title XXVII of the PHS Act - Bulletin 02-01
• Identifying Federally Eligible Individuals in States Electing to Use Alternative Mechanisms to Comply with Guaranteed Availability Requirements under Title XXVII of the PHS Act - Bulletin 01-02
• Guaranteed Renewability of Conversion Policies - Bulletin 01-01
• Circumstances Under Which Health Insurance Regulated as "Individual" Coverage Under State Law is Subject to the Group Market Requirements of HIPAA - Bulletin 00-06.
• Guaranteed Availability Under Title XXVII of the Public Health Service Act - Applicability of Group Participation Rules - Bulletin 00-05.
• State "Succeeding Carrier" or "Extension of Benefits" Laws and an Issuer's Obligation Under HIPAA to Enroll an Eligible Individual Who is Disabled - Bulletin 00-04
• The Relationship of Certain Types of State Laws to the Application of the Guaranteed Availability Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the Small Group Market - Bulletin 00-03.
• Issue Related to Eligible Individual Status Under Section 2741(b) of the Public Service Act - Bulletin 00-02
• Imposing Nonconfinement Clauses on Eligible Individuals - Bulletin 00-01
• Group Size Issues under Title XXVII of the Public Health Services Act - Bulletin 99-03
• Issues Related to Eligible Individual Status Under the Health Insurance Portability and Accountability Act of 1996 - Bulletin 99-02
• Secondary Coverage and Continuing Coverage - Bulletin 99-01
• Agent Commissions and Application Processing Delays - Bulletin 98-01
• Medigap Issuers' Payment Responsibilities Under the Long-Term Care Hospital PPS - Transmittal No. 03-01

For more information, please contact John Greene.

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