Notices and Disclosures
Special Rule for Maternity and Infant Coverage
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the attending provider or physician, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Special Rule for Women’s Health Coverage
The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”) requires group health plans, insurance issuers and HMOs who already provide medical and surgical benefits for mastectomy procedures to provide insurance coverage for reconstructive surgery following mastectomies. This expanded coverage includes (i) reconstruction of the breast on which the mastectomy has been performed, (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (iii) prostheses and physical complications at all stages of mastectomy, including lymphedemas. These procedures may be subject to annual deductibles and coinsurance provisions that are similar to those applying to other medical or surgical benefits provided under the Medical Benefit. For answers to specific questions regarding WHCRA benefits, contact the Plan Administrator.
The Board of Trustees recognizes that the Fund must comply with all applicable HIPAA requirements and shall take appropriate measures to do so. For example, the Plan does not contain any pre-existing exclusions; the Plan permits special enrollments and late enrollments pursuant to federal law. The Fund provides creditable coverage. The Fund must comply with HIPAA Privacy and Security laws. Lastly, the Plan must comply with HIPAA; Administrative Simplification Requirements; known as Operating Rules as applicable.
Mental Health Parity
Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, this Plan applies its terms uniformly and enforces parity between covered health care benefits and covered mental health and substance disorder benefits relating to financial cost-sharing restrictions and treatment-duration limitations. For further details, please contact the Plan Administrator.
Genetic Information Nondiscrimination Act
The plan shall comply with all requirements of the Genetic Information Nondiscrimination Act of 2008 (GINA).
Patient Protection and Affordable Care Act
The Trustees have elected “non-grandfathered” status for purposes of complying with the Patient Protection Affordable Care Act and have taken all measures in accordance therewith. For example, the Fund does not impose any lifetime or annual limits on essential health benefits nor does the Plan contain or impose any preexisting exclusions. The Plan provides preventive health services, including women’s preventative health services, as required by the PPACA. The following is a list of some of the PPACA requirements as of the date of publishing of this SPD.
Dependent Coverage to Age 26
Coverage will be provided to the Participant’s children under age twenty six (26). A child may include a son, daughter, step-child, adopted child, foster child and children named in a Qualified Medical Child Support Order, unmarried children who cannot work because of a physical or mental disability, provided the disability began before age twenty six (26). There is no requirement that a child be financially dependent upon his parents; be a student; reside with his parents; or be single.
Recommended Preventive Services
The Affordable Care Act requires the Plan to provide certain Recommended Preventive Services on an in-network basis at no cost to you and your dependents. To determine which services provided on an in-network basis are Recommended Preventive Services for which no co-payments may be charged and no cost-sharing may be imposed, please refer to the list posted on the Federal government’s Recommended Preventive Services website.
To access the Federal government’s website regarding Recommended Preventive Services, go to Healthcare.gov. Alternatively, you may contact the Plan Administrator.
Recommended Preventive Services often include certain immunizations for children and adults, such as those for:
- Diphtheria, Tetanus, Pertussis,
- Measles, Mumps Rubella,
- Meningoccoccal, and
- Human Papillomavirus.
Recommended Preventive Services also often include certain screening tests for health issues, such as:
- High blood pressure,
- Breast, cervical and colorectal cancer,
- Hepatitis B,
- Congenital hypothyroidism,
- Iron anemia, and
In addition, Recommended Preventive Services often include services included in comprehensive guidelines for infants, children, and adolescents, such as those relating to:
- Measurement (ex., length, height, weight, head circumference, BMI, blood pressure), and
- Screenings (ex., vision, hearing, autism, psychosocial/behavioral, alcohol/drug use, lead screening).
Essential Health Benefits and Plan Limits
Annual dollar limits and lifetime dollar limits do not apply to Essential Health Benefits. Essential Health Benefits include benefits, items and services that fall within the following categories:
- ambulatory patient services,
- emergency services,
- maternity and newborn care,
- mental health and substance abuse disorder services, including behavioral health treatment,
- prescription drugs,
- rehabilitative and habilitative services and devices,
- laboratory services,
- preventive and wellness services,
- chronic disease management, and
- pediatric services, including oral and vision care.
The rules regarding whether an annual or lifetime dollar limit applies to an Essential Health Benefit are complex and detailed. The restrictions and prohibitions regarding limitations in the Plan do not apply to services (even Essential Health Benefit services) which are limited by the number of visits or other criteria. For example, if a Plan provision provides that coverage for a chiropractor is limited to 20 visits, this limitation is not prohibited by the law which restricts the Plan from imposing certain annual or lifetime dollar limits.
Benefits that do not constitute Essential Health Benefits, as determined in accordance with the Plan Administrator’s good faith interpretation of the requirements of federal law and any applicable Plan provisions, may still be subject to annual and lifetime dollar limits.
If you obtain emergency services, you will not be required to obtain a prior authorization, regardless of whether services are provided in network or out of network.
The Fund does not impose more restrictive requirements or benefit limitations, including cost sharing, in or out-of-network emergency services than those imposed on in-network emergency services. This parity with respect to cost sharing applies to copayment or coinsurance rates.
The Fund does not impose any lifetime or annual limits on “essential health benefits”. However, if otherwise permitted under federal or state law, the Fund may place lifetime limits on specific benefits that are not “essential health benefits.” Essential health benefits (which are to be more precisely defined by regulatory guidance) include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Preexisting Conditions – No Exclusions or Limitations for Eligible Dependents
The Patient Protection and Affordable Care Act (PPACA) prohibits plans from imposing any preexisting condition exclusion for enrollees under the age of 19. However, our Fund prohibits any preexisting condition exclusion for all enrollees.
Limitations on Requirements Relating to Designation of Primary Care Providers
The following notice is made regarding your choice of health care professionals:
- Blue Cross Blue Shield of MA and Fallon Health Plan generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For a list of participating professionals, you may contact Blue Cross Blue Shield of MA (800-217-7878) or Fallon Health Plan (800-868-5200).
- You may designate a pediatrician as a primary care physician for a child, if that physician will accept the child as a patient.
- A female participant or beneficiary does not need a prior authorization or a referral from her primary care physician to obtain services from an in-network obstetrical or gynecological specialist. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of professionals who specialize in obstetrics or gynecology, contact Blue Cross Blue Shield of MA (1-800-217-7878) or Fallon Health Plan (1-800-868-5200).