AutismNews.Net
Discrimination in Health Plan Benefit Plans
The Department of Labor has instituted disability
nondiscrimination
regulations which may apply to those with "health factors." The
regulations
are
complex;
for example, they would prohibit a plan from refusing to enroll
participants
with a disability into the general medical benefits plan, but the
regulations
would not prohibit the exclusion of benefits for the treatment of
that disability itself, so long as the exclusion applied to all members
of the plan
equally. Similarly, limits one type of therapy which apply to all
illnesses
would still be legal. However, a plan cannot modify its
rules in response to a particular person's claims. See 29 CFR sec.
2590.702 (full text)
The regulations apply to both employees and their dependents.
The basic rule is as follows:
(b) Prohibited discrimination in rules
for eligibility--(1) In general--
(i) A
group health plan, ..., may not establish any rule for eligibility ...of any individual to enroll for benefits
under the terms of the plan or group
health insurance coverage that discriminates based on any health factor that relates to that individual or a
dependent of that individual.
(ii) For purposes of this section, rules
for eligibility include, but are not limited to, rules relating
to--
(A) Enrollment;
(B) The effective date of coverage;
(C) Waiting (or affiliation) periods;
(D) Late and special enrollment;
(E) Eligibility for benefit packages (including rules for individuals
to change their selection among benefit packages);
(F) Benefits (including rules relating to covered benefits, benefit
restrictions, and cost-sharing mechanisms such as coinsurance,
copayments, and deductibles);
(G) Continued eligibility; and
(H) Terminating coverage (including disenrollment) of any individual
under the plan.
Exceptions
This rule is subject to the provisions of
paragraph (b)(2) of this section (explaining how this rule applies to
benefits),
paragraph (b)(3) of this section (allowing plans to impose certain
preexisting condition exclusions),
paragraph (d) of this section (containing rules for establishing groups
of similarly situated individuals),
paragraph (e) of this section (relating to nonconfinement,
actively-at-work, and other service requirements),
paragraph (f) of this section (relating to bona fide wellness
programs), and
paragraph (g) of this section (permitting favorable treatment of
individuals with adverse health factors).
(c) Prohibited discrimination in
premiums or contributions--
(1) In general--(i) A group health plan, ... may not require an
individual, as a condition of enrollment or continued enrollment under
the plan or group health insurance coverage, to pay a premium or
contribution that is greater than the premium or contribution for a
similarly situated individual enrolled in the plan or group
health insurance coverag...based on any health factor that relates to
the individual or a dependent of the individual.
Definition of Health Factor
(a) Health factors. (1) The term health factor means, in relation to an
individual, any of the following health status-related factors:
(i) Health status;
(ii) Medical condition (including both physical and mental illnesses),
as defined in Sec. 2590.701-2;
(iii) Claims experience;
(iv) Receipt of health care;
(v) Medical history;
(vi) Genetic information, as defined in Sec. 2590.701-2;
(vii) Evidence of insurability; or
(viii) Disability.
A plan is not required to provide
coverage which would benefit a person with a disability.
The regulation states:
"(b)(2) Application to benefits--(i) General rule--
(A) Under this section,
a group
health plan ... is not required to
provide coverage for any particular benefit to any group of
similarly situated individuals.
(B) However, benefits provided under a plan ...
must be uniformly available to all
similarly situated individuals... Likewise,
any restriction on a benefit or benefits
must apply uniformly to all similarly situated individuals and
must not be directed at individual participants or beneficiaries based
on any health factor of the participants or beneficiaries ...
Thus, for example, a plan or issuer may
- limit or exclude benefits in relation to a specific disease or
condition,
- limit or exclude benefits for certain types of treatments or
drugs, or
- limit or exclude benefits based on a determination of whether the
benefits are experimental or not medically necessary,
but only if the benefit limitation or exclusion
- applies uniformly to all similarly situated individuals and
- is not directed at individual participants or beneficiaries based
on any health factor of the participants or beneficiaries.
In addition, a plan or issuer may
impose annual, lifetime, or other limits on benefits and may require
the satisfaction of a deductible, copayment, coinsurance, or other
cost-sharing requirement in order to obtain a benefit if the limit or
cost-sharing requirement applies uniformly to all similarly situated
individuals and is not directed at individual participants or
beneficiaries based on any health factor of the participants or
beneficiaries. ...
(Whether any plan provision or practice with respect to benefits
complies with this paragraph (b)(2)(i) does not affect whether the
provision or practice is permitted under any other provision of the
Act, the Americans with Disabilities Act, or any other law, whether
State or federal.)
(C) For purposes of this paragraph (b)(2)(i), a plan amendment
applicable to all individuals in one or more groups of similarly
situated individuals under the plan and made effective no earlier than
the first day of the first plan year after the amendment is adopted is
not considered to be directed at any individual participants or
beneficiaries."
For the actual text of the regulation click 29 CFR sec.
2590.702
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