CKD(LEGAL) - INSURANCE AND ANNUITIES MANAGEMENT: HEALTH AND LIFE INSURANCE

Uniform Group Insurance Program

Health Insurance Portability and Accountability Act of 1996, Pub. Law 104-191, 45 C.F.R. 146.111(a); Insurance Code Chapter 1551; 34 TAC Chapter 81

State Consumer-Directed Health Plan

Eligibility

Ineligible Employees

Insurance Code 1551.110(a)–(c)

Current and Former Board Member

Continuation Coverage

During Military Leave

  1. The 24-month period beginning on the date on which the person's absence begins; or
  2. The day after the date on which the person fails to apply for or return to a position of employment. [See DECB]

38 U.S.C. 4317(a)(1)

During FMLA Leave

Upon Termination or Other Qualifying Event (COBRA)

42 U.S.C. 300bb-1(a), 300bb-2(1)

"Qualifying Event"

  1. The death of the covered employee.
  2. The termination, other than by reason of such employee's gross misconduct, or reduction of hours, of the covered employee's employment.
  3. The divorce or legal separation of the covered employee from the employee's spouse.
  4. The covered employee becoming entitled to benefits under Medicare, 42 U.S.C. 1395 et seq.
  5. A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan.

42 U.S.C. 300bb-3

Period of Coverage

  1. In the case of the termination or reduction of hours of a covered employee as described at "QUALIFYING EVENT," the date which is 18 months after the date of the termination or reduction of hours.
  2. If a qualifying event occurs during the 18 months after the date of the termination or reduction of hours, the date which is 36 months after the date of the termination or reduction of hours.
  3. In the case of a qualifying event other than termination or reduction of hours, the date which is 36 months after the date of the qualifying event.
  4. In the case of the termination or reduction of hours of a covered employee as described at "QUALIFYING EVENT" that occurs less than 18 months after the date the covered employee became entitled to benefits under Medicare, 42 U.S.C. 1395 et seq., the period of coverage for qualified beneficiaries other than the covered employee shall not terminate under this provision before the close of the 36-month period beginning on the date the covered employee became so entitled.
  5. In the case of a qualified beneficiary who is determined, under Title II or XVI of the Social Security Act, 42 U.S.C. 401 et seq., 1381 et seq., to have been disabled at any time during the first 60 days of continuation coverage, any reference in paragraph 1 or 2 to 18 months is deemed a reference to 29 months with respect to all qualified beneficiaries, but only if the qualified beneficiary has provided notice of such determination under 42 U.S.C. 300bb–6(3) before the end of such 18 months.

42 U.S.C. 300bb-2(2)

Premium

Notice

42 U.S.C. 300bb-6(2)–(3)

Note: See also DEB for continuation benefits that are available to survivors of college district peace officers under certain conditions.

Preexisting Conditions

Health Insurance Portability and Accountability Act (HIPAA)

Election to Be Exempted

  1. Limitations on preexisting condition exclusion periods in accordance with section 2701 of the PHS Act as codified before enactment of the Affordable Care Act;
  2. Special enrollment periods for individuals and dependents described under section 2704(f) of the PHS Act;
  3. Prohibitions against discriminating against individual participants and beneficiaries based on health status under section 2705 of the PHS Act, except that the sponsor of a self-funded non-federal governmental plan cannot elect to exempt its plan from requirements under section 2705(a)(6) and 2705(c) through (f) that prohibit discrimination with respect to genetic information;
  4. Standards relating to benefits for mothers and newborns under section 2725 of the PHS Act;
  5. Parity in mental health and substance use disorder benefits under section 2726 of the PHS Act;
  6. Required coverage for reconstructive surgery and certain other services following a mastectomy under section 2727 of the PHS Act; and
  7. Coverage of dependent students on a medically necessary leave of absence under section 2728 of the PHS Act.

42 U.S.C. 300gg-21(a)(2); 45 C.F.R. 146.180(a)

Form of Election

  1. Be made in an electronic format in a form and manner as described by the U.S. Secretary of Health and Human Services in guidance.
  2. Be made in conformance with all of the plan sponsor's rules, including any public hearing requirements.
  3. Specify the beginning and ending dates of the period to which the election is to apply. This period is a single specified plan year, as defined in 45 C.F.R. 144.103.
  4. Specify the name of the plan and the name and address of the plan administrator, and include the name and telephone number of a person the Centers for Medicare and Medicaid Services (CMS) may contact regarding the election.
  5. State that the plan does not include health insurance coverage, or identify which portion of the plan is not funded through health insurance coverage.
  6. Specify each requirement described in 45 C.F.R. 146.180(a)(1) of this section from which the plan sponsor elects to exempt the plan.
  7. Certify that the person signing the election document, including, if applicable, a third party plan administrator, is legally authorized to do so by the plan sponsor.
  8. Include, as an attachment, a copy of the notice described in 45 C.F.R. 146.180(f).

42 U.S.C. 300gg-21(a)(2); 45 C.F.R. 146.180(b)

Timing of Election

42 U.S.C. 300gg-21(a)(2)(A); 45 C.F.R. 146.180(c), (f)

Contents of Notice

Privacy of Health Information

Definitions

"Covered Entity"

  1. A health plan;
  2. A health-care clearinghouse; or
  3. A health-care provider who transmits any health information in electronic form in connection with a transaction covered by 45 C.F.R. Subtitle A, Subchapter C.

45 C.F.R. 160.103

"Protected Health Information"

  1. Education records covered by the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g.
  2. Medical treatment records described at 20 U.S.C. 1232g(a)(4)(B)(iv) on a student who is at least 18 years of age.
  3. Employment records held by a covered entity in its role as employer.

"Plan Sponsor"

Sponsors of Group Health Plans

  1. Obtaining premium bids from health plans for providing health insurance coverage under the group health plan; or
  2. Modifying, amending, or terminating the group health plan.

45 C.F.R. 164.504(f)

Pharmacy Benefit Manager Services Contracts

Disclosure

Gov't Code 2158.402

Redisclosure

"State Agency"

Vernon College

CKD(LEGAL)-LJC

UPDATE 32

DATE ISSUED: 4/13/2017