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Health Insurance Reform for Consumers

Federal law gives you and your family members some valuable - though limited - protections when you need to buy, change, or continue your health insurance. These important laws can affect the health benefits of millions of Americans and their families. Understanding these protections, as well as laws in your State, can help you make a more informed choice if you need to make a change in health coverage. It also can help you better understand the health coverage protections you have under the law.

 

The purpose of this on-line information is to give you an overview of how you may be affected by health insurance coverage changes that may apply to four different types of coverage:

 

  1. Self-funded group health plans (CMS has jurisdiction over self-funded public sector (non federal governmental) plans while the Department of Labor (866-444-3272) has jurisdiction over private sector self-funded group health plans.);
  2. Fully insured group health plans;
  3. Individual (non-employment based) health insurance policies; and
  4. Comparable coverage through State high risk pools, if applicable in your State.

 

Contact your state's insurance department to find out about whether additional protections apply to your coverage if you are in a fully insured group health plan or have individual market (non-employment based) health coverage.

 

Medicare and Medicaid are not issuers of health insurance.  They are public health plans through which individuals obtain health coverage.  Contact your specific Medicare or Medicaid contractor to discuss your level of benefits.

 

Employment related group health plans that provide benefits through insurance are known as fully insured group health plans. Employment related group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-funded group health plans.  Contact your plan administrator to find out if your group coverage is fully insured or self-funded.  Non-employment related individual health insurance policies are sold to individual policyholders.  If applicable, your State of residence may offer comparable coverage through a State high risk pool.

 

If you have coverage in one of the four categories listed above, you may have some protections under title XXVII of the Public Health Service Act, as added by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and amended by the following:  The Mental Health Parity Act of 1996 (MHPA); The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA); and The Women's Health and Cancer Rights Act of 1998 (WHCRA).  In 2008 and 2009, Congress enacted four important laws that amended title XXVII and provided additional protection for consumers:  The Genetic Information Nondiscrimination Act (GINA); The Mental Health Parity and Addiction Equity Act (MHPAEA) (see The Mental Health Parity Act Web page located in the left hand column); Michelle's Law and the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).  These new laws will take effect in 2009 and are now posted for your review.

 

This on-line information does not cover all the details of these laws. But it does give you and your family information about your rights and protections. As you read this information, it also is important to remember that health insurance coverage is a complex issue. Your coverage and protections will depend on your specific situation. For example, you may have access to different health coverage protections depending on whether you work and get insurance through your workplace (also known as employment based coverage), or whether you have individual (non-employment based) coverage. To help you better understand this and other issues, this on-line information includes general information about these Federal laws.

 

The HIPAA certificate of creditable coverage indicates how long an individual had a group market, individual market or other health coverage.  Retain this document for your records.  This document or a copy of this document should not be sent to CMS.

 

For additional information, you may e-mail us at phig@cms.hhs.gov.

 

Note:  A nonfederal government employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan (opt-out) from requirements of title XXVII of the PHS Act, with the exception of requirements pertaining to GINA, the certification and disclosure of an individual's creditable coverage under the plan, and notices to enrollees regarding the fact and consequences of an opt-out election.  For more information go to http://www.cms.gov/SelfFundedNonfedGovPlans/ in the left hand column scroll down and select "Procedures and Requirements".

 

For information on health care reform see the Related Links Outside CMS.  For more links scroll to the left hand side of the page, click on "What HIPAA Does and Does Not Do" and scroll to the Related Links Outside CMS. 

 

Persons with disabilities having problems accessing the pdf files below may call 410-786-1565 for assistance.