General Facts on Women & Job Based Health Benefits

According to the Bureau of Labor Statistics, the labor force is becoming more diverse, older and more female. Today, those changing labor force demographics are already evident in terms of the increased number of working women.

Working women are likely to be the primary decision maker for the family as well as the care giver when a family member falls ill. Therefore, women need adequate knowledge and tools to satisfy their multiple roles as decision makers and consumers of health care.

Women as Major Health Care Consumers:

Approximately 83% of women age 18-64 had health insurance in 1996. The remaining 17% . which translates into 14 million women . had no health benefit coverage.

Of the women with health insurance, at least 3 out of 10 obtained their insurance coverage from public insurance, including Medicaid, Medicare, CHAMPUS and governmental plans. The remaining 70% had private insurance, mostly through their own employer or as a spouse or dependent covered by an employer plan.

Women utilize more health care than men, in part because of their need for reproductive services. In 1996, women accounted for nearly 60% of all visits to doctors. offices and over 60% of outpatient hospital visits.

Women make three-quarters of health care decisions for their families and are more likely to be the care givers when a family member falls ill.

Data show that women are the primary seekers of information about their legal rights under private employment-provided health insurance, making 66% of the calls to the Department of Labor in the latest quarter of 1998.

Women with Health Insurance in Own Names:

Concurrent with the growth in women.s employment has been an increase in the number of women with health insurance through their jobs.

These plans provide health insurance for 55 million women through coverage in their own name or as a dependent spouse.

Between 1990 and 1996, the number of women with coverage through their own job rose by over 4 million.

Newborns. and Mothers. Health Protection Act

On September 26, 1996, President Clinton signed into law the Newborns. and Mothers. Health Protection Act of 1996 (the Newborns. Act) puts the decisions affecting length of hospital stays following childbirth in the hands of mothers and the attending providers.

This law was effective for group health plans for plan years beginning on or after January 1, 1998.

On October 27, 1998, the Department of Labor, in conjunction with the Departments of the Treasury and Health and Human Services published interim regulations clarifying issues arising under the Newborns. Act. The changes made by the regulations are effective for group health plans for plan years beginning on or after January 1, 1999.

The Newborns. Act and its regulations provide that health plans and insurance issuers may not restrict a mothers. or newborns. benefits for a hospital length of stay that is in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section. However, the attending provider (who is a person such as the mother.s physician or nurse midwife) may, in consultation with the mother, discharge earlier.

The Newborns.Act, and the new regulations, prohibit incentives in any way (positively or negatively) that could encourage less than the minimum protections under the Act as described above.

Basically, a mother cannot be encouraged to accept less than the minimum protections and an attending provider cannot be induced to discharge a mother or newborn earlier than the minimum protections provided in the Newborns. Act.

The type of coverage and the state law will determine whether the Newborns Act applies to a mother.s or newborn.s coverage. For coverage that is self-insured, the Newborns. Act provisions always apply.

Many states have passed laws containing protections similar to the Newborns Act. Thus, in cases where health benefits are provided through insurance the state laws would apply. A list of states in which the federal Newborns. Act standards apply can be found in the supplement to the Question and Answer booklet and the preamble to the regulations.

Women's Health and Cancer Rights Act

The Women.s Health and Cancer Rights Act, signed into law on October 21, 1998, contains protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy. In certain cases, plans offering coverage for a mastectomy must also cover reconstructive surgery in connection with a mastectomy.

The Act applies to group health plans for plan years starting on October 21, 1998. It applies to individual health insurance policies offered, sold, issued, renewed, in effect, or operated on the date of enactment.

The new law:

applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy.
requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient.

Under the Act, reconstructive benefits must include coverage for:

reconstruction of the breast on which the mastectomy has been performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance;
prostheses and physical complications at all stages of mastectomy, including lymphedemas.

Benefits under the act may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.

The law also contains prohibitions against:

plans and issuers may not deny patients eligibility or continued eligibility to avoid the requirements of the Women.s Health Act; and
plans and issuers may not provide incentives to, or penalize, physicians to induce them to provide care in a manner inconsistent with the Act.

Group health plans, health insurance companies and HMOs covered by the law must notify individuals of the reconstructive benefit available under the Act. The Labor Department has authority to prescribe regulations clarifying how group health plans can comply with the notification requirement of the Women.s Health Act.

Mental Health Parity Act

The Mental Health Parity Act (MHPA), signed into law on September 26, 1996, requires that annual or lifetime limits on mental health benefits be no lower than that of the dollar limits for medical and surgical benefits offered by a group health plan.

MHPA applies to group health plans for plan years beginning on or after January 1, 1998 and contains a so-called .sunset" provision that provides that the parity requirements do not to apply to benefits received on or after September 30, 2001.

The law:

generally requires parity of mental health benefits with medical/surgical benefits with respect to the application of aggregate lifetime and annual dollar limits under a group health plan;

provides that employers retain discretion regarding the extent and scope of mental health benefits offered to workers and their families (including cost sharing, limits on numbers of visits or days of coverage, and requirements relating to medical necessity).

The law also contains the following two exemptions:

Small employer exemption. MHPA does not apply to any plan or coverage of any employer who employed an average of between 2 and 50 employees on business days during the preceding calendar year, and who employs at least 2 employees on the first day of the plan year.

Increased cost exemption. MHPA does not apply to a group health plan or group health insurance coverage if the application of the parity provisions results in an increase in the cost under the plan or coverage of at least one percent.

The law, however, does not apply to benefits for substance abuse or chemical dependency.

The Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA), signed into law by President Clinton on August 21, 1996, offers new protections for millions of American workers that improves portability and continuity of health insurance coverage.

HIPAA protects workers and their families by:

limiting exclusions for preexisting medical conditions;
provides credit for prior health coverage and a process for providing certificates concerning prior coverage to a new group health plan or issuer;
provides new rights that allow individuals to enroll for health coverage when they lose other health coverage or add a new dependent;
prohibits discrimination in enrollment and in premiums charged to employees and their dependents based on health status-related factors;
guarantees availability of health insurance coverage for small employers and renewability of health insurance coverage in both the small and large group markets; and
preserves the states. role in regulating health insurance, including the states. authority to provide greater protections.

Preexisting Condition Exclusions:

The law defines a preexisting condition as one for which medical advice, diagnosis, care, or treatment was recommended or received during the 6-month period prior to an individual.s enrollment date.
Most group health plans may not exclude an individual.s preexisting medical condition from coverage for more than 12 months (18 months for late enrollees) after an individual.s enrollment date.
Under HIPAA, a new employer.s plan must give individuals credit for the length of time they had continuous health coverage , thereby reducing the 12-month exclusion period.
Individuals who have 12 months of continuous health coverage . without a break in coverage of 63 days or more . do not have to start over with a new 12-month exclusion for any preexisting conditions.

Creditable Coverage:

includes prior coverage under another group health plan, an individual health insurance policy, COBRA, Medicaid, Medicare, or a public health plan.

Certificates of Creditable Coverage:

must be provided automatically by the plan when an individual loses coverage under the plan or exhausts COBRA continuation coverage.
must be provided, if requested, before losing coverage or within 24 months of losing coverage.
may be provided through the use of a model certificate which is contained in the preamble to the regulations.

Special Enrollment Rights:

are provided for individuals who lose their coverage in certain situations.
are provided for individuals who become a new dependent through marriage, birth, adoption or placement for adoption.

Discrimination Prohibitions:

ensure that individuals are not excluded from coverage, or charged more for benefits offered by a plan or issuer, based on health status-related factors.

The Department of Labor simultaneously issued interim rules regarding new disclosure requirements under ERISA for group health plans. Under those rules, plans are now required to:

furnish a summary of a .material reduction in covered services or benefits. to covered workers within 60 days after the change has been adopted by the plan.
provide information to workers if an insurance company is used by the plan -- including an explanation of whether their benefits are guaranteed under an insurance contract or policy.
list in their plan brochure the office of the Labor Department where individuals can get assistance or information about their rights under federal law in general or HIPAA in particular.

The disclosure rules also provide guidance on the use of electronic media (e.g., E-mail) to furnish covered workers with required group health plan disclosures.

The interim rules are effective for all plans with respect to the certification requirements of HIPAA beginning June 1, 1997. However, the other HIPAA provisions are generally effective for plan years beginning after June 30, 1997.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Throughout a career, workers will face multiple job changes or even job losses. A law enacted in 1986 helps workers and their families keep their group health benefit coverage during times of job loss, reduction in the hours worked, transition between jobs and in certain other cases.

The law . the Consolidated Omnibus Budget Reconciliation Act (COBRA) . gives workers who lose their health benefits the right to choose to continue group health benefits provided by the plan of a previous employer under certain circumstances.

COBRA requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the employee.s plan would otherwise end.

Several events that can cause workers and their family members to lose group health coverage may result in the right to COBRA coverage. These include:

--voluntary or involuntary termination of the employee.s employment for reasons other than .gross misconduct.;
--reduced hours of work for the employee;
--eligibility for Medicare coverage for the employee;
--divorce or legal separation of a covered employee;
--death of a covered employee; or
--loss of status as a .dependent child. under plan rules.

Under COBRA, the affected employee or family member may qualify to keep their group health plan benefits for a set period of time, depending on the reason for losing the health coverage. The following represents a basic overview of some basic information on periods of continuation coverage:

Beneficiary	Qualifying Event	Period of Coverage
Employee Spouse Dependent child	Termination Reduced hours	18 months *
Spouse Dependent child	Employee entitled to Medicare Divorce or legal separation Death of covered employee	36 months
Dependent child	Loss of dependent status	36 months

*This 18-month period may be extended for all qualified beneficiaries if certain conditions are met in cases where a qualified beneficiary is determined to be disabled under COBRA.

However, COBRA also provides that your continuation coverage may be cut short in certain cases.

Notification Requirements:

An initial general notice must be furnished to covered employees and spouses informing them of their rights under COBRA and describing provisions of the law. COBRA information also is required to be contained in the summary plan description which participants receive.

When the plan is notified that a qualifying event has happened, it must in turn notify the covered person (s) of the right to choose continuation coverage.

COBRA allows at least 60 days from the date the covered person would lose coverage because of one of the qualifying events to inform the plan administrator that the covered person wants to elect continuation coverage.

Under COBRA, the employee or a family member has the responsibility to inform the plan of a divorce, legal separation, disability or a child losing dependent status under the plan.

Employers have a responsibility to notify the plan of the employee.s death, termination of employment or reduction in hours, or Medicare eligibility.

If covered individuals change their martial status, or their spouses have changed addresses, they should notify the plan administrator.

Premium Payments:

Qualified individuals may be required to pay the entire premium for coverage up to 102% of the cost to the plan. Premiums may be higher for persons exercising the disability provisions of COBRA. Failure to make timely payments may result in loss of coverage.

Premiums may be increased by the plan; however, premiums must be set in advance of each 12- month premium cycle.

Individuals subject to COBRA coverage are responsible for paying all costs related to deductibles, catastrophic and other benefit limits.

Workers. Right to Health Plan Information
(ERISA, Proposed Claims Procedures, and SPD Regulation)

The Employee Retirement Income Security Act (ERISA) governs approximately 2.6 million health benefit plans sponsored by private sector employers nationwide. These plans provide a wide range of medical, surgical, hospital and other health care benefits to some 122 million Americans.

Under ERISA, workers and their families are entitled to receive a summary plan description describing the benefits offered by the plan, how they qualify for benefits and procedures for filing benefit claims. This plan document also explains the process under which individuals appeal denials of benefits.

Currently, group health plans have up to 90 days to respond to original claims for benefits from workers and their beneficiaries. Individuals then have at least 60 days to appeal denied claims.

Plans must consider and respond to appeals of denied claims within 60 days and provide a written explanation of the reason for the denial.

Dramatic changes have occurred in recent years in the nature and delivery of health benefits. Claims procedures are particularly important to persons covered by private-sector employment-based health plans because benefit disputes can affect the delivery of health care services.

On September 9, 1998, the Department proposed rules to improve the internal claims process of group health plans and to clarify disclosure requirements applicable to health benefit information under ERISA.

Proposed Claims Procedure Regulation:

The department.s proposed claims procedure regulation would strengthen the benefit claims and appeal process for all ERISA-covered employee pension and welfare benefit plans. Some of the major provisions of the proposal are described below.

The proposal would establish shorter time limits for making health benefit claim decisions:

For urgent care claims, as soon as possible, but not later than 72 hours for an initial decision and no later than 72 hours for appeals;
For non-urgent health care claims, within a reasonable period of time, but no later than 15 days for the initial decision and no later than 30 days for appeals.

The proposal would require plans to provide participants with more information about the plan.s claims procedures and more timely information about the claims decision when a claim has been denied.

The proposal would provide that appeals must be decided by a party who is neither the initial claim reviewer nor a subordinate of the initial claim reviewer and, for decisions based on medical judgments, the reviewer of a denied health care claim must consult with a medical professional.

The proposal would ensure that claimants have access to judicial review when plans fail to establish or to follow claims procedures that comply with the new rules.

The proposal would require that all ERISA-covered health plans, including plans that provide benefits through federally qualified HMOs, comply with the new claims procedure rules.

Proposed Summary Plan Description Regulation
and Interim Amendment of NMHPA Disclosure Rule:

The proposed regulation and a separate interim rule would update and clarify certain SPD content requirements for ERISA-covered employee benefit plans.

The proposed SPD content regulation would:

Provide that health plan SPDs must describe: (i) any cost-sharing provisions, including premiums, deductibles, coinsurance and copayment amounts for which the participant or beneficiary will be responsible; (ii) any annual or lifetime caps or other limits on benefits under the plan; (iii) the extent to which preventive services are covered under the plan; (iv) whether, and under what circumstances, existing and new drugs are covered under the plan; (v) whether, and under what circumstances, coverage is provided for medical tests, devices and procedures; (vi) provisions governing the use of network providers, the composition of the provider network and whether, and under what circumstances, coverage is provided for out-of-network services; (vii) any conditions or limits on the selection of primary care providers or providers of speciality medical care; (viii) any conditions or limits applicable to obtaining emergency medical care; and (ix) any provisions requiring preauthorizations or utilization review as a condition to obtaining a benefit or service under the plan.

Make clear that pension and welfare benefit plan SPDs must describe, among other things, their procedures related to qualified domestic relations orders (QDROs) and qualified medical child support orders (QMCSOs), the plan sponsor.s authority to terminate the plan or eliminate benefits under the plan, COBRA continuation rights, and must include updated information on Pension Benefit Guaranty Corporation (PBGC) coverage and ERISA rights.

Repeal the limited exemption with respect to SPDs of health plans providing benefits through qualified health maintenance organizations (HMOs). The proposal would result in health plans that provide benefits through a federally qualified HMO having to comply with the improved SPD disclosure rule being proposed for other health plans.

The Department issued an interim rule on April 8, 1997, that required ERISA group health plans that provide maternity or newborn infant coverage to distribute a notice regarding the Newborns. Act rules on length of hospital stays following childbirth.

Under the interim rule, group health plans were required to include the Newborns. Act notice in a summary of material modifications (SMM) or updated SPD not later than 60 days after the first day of the first plan year beginning on or after January 1, 1998.

On September 9, 1998, the Department amended the interim rule to clarify that the notice must explain that the mother.s or newborn.s attending provider, after consulting with the mother, can authorize a shorter stay than the 48 or 96 hour periods described in the Newborns. Act.

Administrators of group health plans must include this improved disclosure notice in the first SMM or updated SPD that is required to be furnished following the November 9, 1998 effective date of the amendment.

The Department provided sample language in the interim rule that group health plans could include in their SPDs or an SMM to satisfy this disclosure requirement.

Resources

For more detailed information, contact the Labor Department.s Pension and Welfare Benefits Administration.s toll-free publications hotline at 1-800-998-7542 for copies of:

.Questions and Answers: Recent Changes in Health Care Law,. with supplements.

.Health Benefits Under the Consolidated Omnibus Budget Reconciliation Act.

.Pension & Health Coverage . . . Questions & Answers for Dislocated Workers.

Or visit our website at www.dol.gov/dol/pwba. If you have specific questions about these laws or your right to benefits, contact a PWBA field office near you: