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. State law includes the following provisions:
- Group health plans must provide coverage for a dependent newborn child of participants from the moment of birth. §10-16-104
- Coverage for a hospital stay for a newborn following a normal vaginal delivery must be at least 48 hours, and 96 hours for cesarean delivery, unless attending physician and mother agree to otherwise. This does not apply to employers with less than 15 full time employees or to employers who have any number of full-time or part-time employees for not more than six consecutive months each year on a seasonal basis. §10-16-104
- Newborn benefits must cover injury or sickness, including all medically necessary care and treatment of medically diagnosed congenital defects and birth abnormalities for the first 31 days of the newborn's life, notwithstanding policy limitations and exclusions, except for conditions of cleft lip/palate and inherited enzymatic disorders, where there is no age limit. §10-16-104
- After the first 31 days of life, policy limitations and exclusions that are generally applicable under the policy may apply; except that the plan must provide medically necessary physical, occupational, and speech therapy for the care and treatment of congenital defects and birth abnormalities for covered children up to five years of age. §10-16-104
- Dependent children include the following:
- Plans must provide benefits for conditions arising from mental illness. §10-16-104
- Reimbursement for services performed for mental illness by registered professional nurses or licensed clinical social workers, licensed professional counselors, or licensed marriage and family therapists who are licensed to practice in this state must not be denied. §10-16-104
- Plans must cover treatment of biologically based mental illness. §10-16-104
- Insurers must offer optional alcoholism coverage. §10-16-104
- Plans must cover annual screening for the early detection of prostate cancer in men over 50, men over 40 who are in high-risk categories. Such coverage shall be the lesser of $65 per screening or the actual charge for the screening. §10-16-104
- Plans that provide family coverage for a family must also provide for child health supervision services up to the age of 13. §10-16-104
- Plans must cover diabetes, and include equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy if prescribed. §10-16-104
- As of January 1, 2006, if the plan covers dependents it must offer, as an option, the same dependent coverage for an unmarried child who is under 25 years of age and is not a dependent, if such child has the same legal residence as the parent or is financially dependent upon the parent. §10-16-104 (HB 1101)
- Participants have the option of an independent external review by qualified experts when they have been denied a request for coverage pursuant to their health plan's procedures for denial of benefits. §10-16-113.5
- Elderly and disabled persons who require hospitalization need to be able to "return to home" without interference from health care coverage providers, if the facility is able to provide the needed services and is willing to accept payment on the same terms as a network provider. §10-16-413.5
- Participants receive a standing referral for medically necessary treatment, to a specialist or specialized treatment center participating in the carrier's network. §10-16-705
- Coverage for autism must be provided in the same manner as for any other accident or sickness, other than mental illness. §10-16-104.5
- Discrimination on the basis of sexual orientation, HIV test, genetic testing, domestic abuse, disability, or nonprofessional participation in motorcycling, snowmobiling, off-highway vehicle riding, skiing, or snowboarding is prohibited. §10-3-1104, §10-3-1104.5, §10-3-1104.7, §10-3-1104.8
- Effective August 10, 2005, carriers must allow plan participants to assign, in writing, payments due under the policy to a licensed hospital, other licensed health care provider, and occupational therapist, or a massage therapist, for services provided to the participant that are covered under the policy. §10-16-106.7 (see House Bill 05-1165)
- Notwithstanding any provision of law to the contrary, a small employer carrier may offer and accept or reject coverage for employees' domestic partners and their dependents under a standard or basic health benefit plan. §10-16-105
- As of January 1, 2008, all group sickness and accident insurance policies, except supplemental policies covering a specified disease or other limited benefit, must provide coverage for the full cost of cervical cancer vaccination for all females for whom a vaccination is recommended by the advisory committee on immunization practices of the United States Department of Health and Human Services. §10-16-104
- As of July 1, 2009, group health plans must cover test for the early detection of colorectal cancer and polyps for asymptomatic, average risk adults who are at least 50 years old, and those of any age who are at high risk. This includes people who have a family medical history of the cancer, a prior occurrence of cancer or precursor polyps, a prior occurrence of chronic digestive diseases, or other predisposing factors. (HB 08-1410) §10-16-104
- As of July 1, 2009, small group health plan carriers may offer incentives or rewards to participants for participation in a wellness and prevention program (see also HIPAA) (HB 09-1012) (HB 10-1160 for small group health plans) §10-16-136