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Summary of differences between federal and state regulations
Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).
Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.
The differences are called out below, and represent where the state goes beyond the federal requirements under ERISA.
State
Contact
Regulations
www.legis.state.ak.us/basis/folio.asp
(Alaska Statutes (A.S.) are in Folio, so the above link takes you to the complete body of A.S.)
Benefits, coverage
Benefits
Dental, vision, hearing: Plans, including Medicare supplement policies to the extent not prohibited by 42 U.S.C. 1395 (Social Security Act), shall offer to each plan sponsor minimum dental, vision, and hearing coverage. Coverage may be offered as a rider or in a separate policy. (Alaska Statutes §21.42.385) The covered individual may choose a service provider of his or her own choice. (Alaska Statutes §21.42.392)
Phenylketonuria: Plans shall provide coverage for the formulas necessary for the treatment of phenylketonuria.
Alaska Stat. §21.42.380, Coverage for treatment of phenylketonuria.
Diabetes: Plans that include coverage for pharmacy services shall initially and at each renewal provide coverage for the cost of treating diabetes, including medication, equipment, and supplies. Plans must include coverage for outpatient self-management training or education, and medical nutrition therapy, if diabetes treatment is prescribed by a health care provider.
Alaska Stat. §21.42.390, Coverage for treatment of diabetes.
Prostate and cervical cancer screening: Plans shall provide coverage for the costs of prostate and cervical cancer screening tests.
Alaska Stat. §21.42.395, Coverage for prostate and cervical cancer detection
Plans must cover gastric bypass surgery when the surgery is medically necessary for the treatment of obesity. (Effective July 1, 2005 – HB 1) (Alaska Stat. §21.42.410)
As of January 1, 2007, plans must provide coverage for the cost of colorectal cancer screening examinations and laboratory tests. If you provide health care insurance, you must notify each covered individual of the coverage unless such coverage already exists. The notice must be included in the health benefit handbook or be provided by written or electronic communication between employers or health plan administrators and the covered individuals. Coverage is to be provided to those who are at least 50 years ole, or less than 50 but at high risk for colorectal cancer.
Alaska Stat. §21.42.377
As of September 29, 2010, plans are to cover routine patient care costs incurred by a patient enrolled in an approved clinical trial related to cancer, including leukemia, lymphoma, and bone marrow stem cell disorders.
Alaska Stat. §21.42.415
Coverage
Spouses: Health plans providing coverage for a dependent of a covered individual shall also provide coverage for spouses from not later than the first day of the first month beginning after the date the request for enrollment is received. The insurer may require that a request for enrollment be received within 31 days of the date of marriage.
Alaska Stat. §21.42.345
Delivery: If coverage provides for the costs of childbirth, it shall also provide coverage for the costs of hospitalization or medical care following childbirth for a period of not less than 48 hours after a vaginal birth; and 96 hours after a caesarean birth.
Alaska Stat. §21.42.347
Newborns: Health plans providing coverage for a dependent of a covered individual shall also provide coverage for newborns of a covered individual from the moment of birth. Coverage includes injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
Alaska Stat. §21.42.345
Adoptees: Health plans providing coverage for a dependent of a covered individual shall also provide coverage for children adopted by a covered individual from the date of adoption; and children placed with a covered individual for adoption from the date of placement for adoption.
Alaska Stat. §21.42.345
Other children: Plans may not deny enrollment of a child under the health care insurance of the child's parent on the ground that the child:
- Was born out of wedlock;
- Is not claimed as a dependent on the parent's federal income tax return;
- Does not reside with the parent; or
- Does not reside in the health care insurer's service area.
Alaska Stat. §21.36.485
Substance abuse: If you have five or more employees, the health plan needs to provide covered employees or their dependents coverage for treatment of alcoholism or drug abuse. This does not apply if there are fewer than 20 permanent, full-time employees for each working day during each of at least 20 calendar workweeks in either the current calendar year or the preceding calendar year.
Plans providing coverage may not
- Require that a covered employee or the employee's dependent be responsible for a deductible or copayment that is different for the determination of benefits relating to treating alcoholism or drug abuse than for the determination of benefits for treating another covered illness;
- Use a different claim payment methodology in determining the benefits relating to treating alcoholism or drug abuse than that used in determining the benefits for treating another covered illness;
- Require prenotification of treatment or a second opinion unless the requirement is applicable to other covered major illnesses;
- Limit coverage by provisions of the insurance contract that are not applicable to other covered major illnesses, including provisions concerning preexisting illnesses or provisions requiring that the exact date of onset be known;
- Limit treatment services under the insurance contract to either an inpatient or outpatient service;
- Exclude from coverage the cost of medically necessary treatment, including medical or psychiatric evaluation, activity or family therapy, counseling, or prescription drugs or supplies received at an approved treatment facility; or
- Deny reimbursement for actual services rendered solely because treatment was interrupted or not completed.
Alaska Statutes §21.42.365
Referrals: If your organization has an HMO, enrollees must be offered a point-of-service plan option that would allow a covered person to receive covered services from an out-of-network health care provider without obtaining a referral or prior authorization from the HMO. The point-of-service plan option may require that enrollees pay a higher deductible or copayment and higher premium for the plan.
Alaska Stat. §21.86.078
Practitioners
Chiropractors: Plan participants may use the services of a licensed chiropractor of their choosing and may not be required to obtain the prior approval of their health maintenance organization, a gatekeeper, or primary care physician.
Alaska Stat. §21.86.075
Acupuncturists: Plans may offer coverage for services of a licensed acupuncturist if the plan covers acupuncture treatment by a health care provider.
Alaska Stat. §21.42.353
Optometrists: Plans that provide reimbursement for a service must provide for reimbursement to a person covered under the plan who had the service performed by an optometrist.
Alaska Stat. §21.42.363
Nurse midwives: If the plan provides for furnishing services required of a physician in the care of women during pregnancy, childbirth, and the period after childbirth, the plan shall also provide that an advanced, certified nurse practitioner may furnish those same services instead of a physician.
Alaska Stat. §21.42.355
Discrimination: Unfair discrimination is prohibited against a person who provides a service covered under a group health insurance policy that extends coverage on an expense incurred basis, or under a group service or indemnity type contract issued by a health maintenance organization or a nonprofit corporation, if the service is within the scope of the provider's occupational license. Here, "provider" means a state licensed physician, physician assistant, dentist, osteopath, optometrist, chiropractor, nurse midwife, advanced nurse practitioner, naturopath, physical therapist, occupational therapist, marital and family therapist, psychologist, psychological associate, licensed clinical social worker, or certified direct-entry midwife.
Alaska Stat. §21.36.090
There are exceptions to the discrimination provisions, including rewards under a wellness program, as long as the program meets the following requirements, which track with the federal HIPAA nondiscrimination provisions:
- The program is reasonably designed to promote health or prevent disease;
- Individuals have an opportunity to qualify for the reward at least once per year;
- The reward is available for all similarly situated individuals;
- The program has alternative standards for individuals who are unable to obtain the reward because of a health factor;
- Alternative standards are available for individuals who are unable to participate in a reward program because of a health condition;
- The insurer provides information explaining the standard for achieving the reward and discloses the alternative standards; and
- The total rewards for all wellness programs under the policy do not exceed 20 percent of the cost of coverage.
Alaska Stat. §21.36.110
Effective 10/3/09, health care insurers may not discriminate based on genetic information per the federal Genetic Information Nondiscrimination Act.
Alaska Stat. §21.36.480
NOTE: See also HIPAA for discrimination.
Employer’s failure to make payments
If an employer agrees with an employee or group of employees to make payment to a medical, health, hospital, welfare fund or such other fund for the benefit of the employees, or has entered into a collective bargaining agreement providing for the payments, but fails to make the payments when due, a lien is created in favor of each affected employee on the earnings of the employer and on all property of the employer used in the operation of the employer's business to the extent of the money, plus penalties due to be paid on the employee's behalf to qualify the employee for participation in the fund and for expenses incurred by the employee for which the employee would have been entitled to reimbursement under the fund if the required payments had been made.
Alaska Stat. §23.10.047
Effective 1/1/2012, insurers are required to submit rate filings for health care insurance plans, both individual and group, except for large employer rates if exempted by the director by regulation, at least 45 days before the effective date of the premium rate. Health care insurance plans do not include “excepted benefits” policies; therefore, the rate filing requirements do not apply to these policies. The division has been informed by the U.S., Department of Health and Human Services Center for Medicare & Medicaid Services (CMS) that effective January 1, 2012 Alaska is deemed to have an effective rate review program. This is part of the Affordable Care Act (ACA) provisions.
Alaska Stat. §21.54.015
See HB 164
Effective 1/1/2013, insurers are required to cover autism spectrum disorders for individuals under 21 years of age. Small employers with 20 or fewer employees are excepted. Small employers with 21-25 employees may be excepted if they demonstrate to the Director of Insurance by actual claims experience over any consecutive 12-month period, that compliance increased the premiums by three or more percent.
Alaska Stat. §21.42.397
See SB 74 (CH 63)
Effective 9/11/16, insurers must provide coverage for mental health benefits provided through telehealth and may not require that prior in-person contact occur between a health care provider and a patient before payment is made for covered services.
Alaska Stat. 21.42.422 (HB 234)
Effective 1/1/17, if a plan provides coverage for anti-cancer medications that are injected or intravenously administered, the plan may not require a higher copayment, deductible, or coinsurance for a patient-administered medication than it does for a healthcare provider administered medication.
Alaska Stat. 21.42.430 (SB 142)
Federal
Contact
Employee Benefits Security Administration (EBSA)
Regulations
29 CFR chapter XXV (Parts 2509 – 2590)