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. Ohio laws contain the following provisions:
- No chronic disease or chronic physical condition may be excluded from coverage except by name or specific description.
- If the plan provides for reimbursement for services, it may not deny reimbursement for the services of those licensed to provide osteopathy, optometry, chiropractic, podiatry, nurse-midwife, psychologies, and dentist services.
- Plans must cover outpatient kidney dialysis if inpatient treatment is covered.
- Newborns are covered from the moment of birth.
- Handicapped dependents are covered notwithstanding age.
- Plans must cover outpatient mental illnesses if inpatient treatment is covered.
- Plans must cover alcoholism.
- Adopted children are covered on the same basis as other dependents upon placement with employee.
- Plans must include benefits for child health supervision services from the moment of birth until age nine.
- If the plan covers prescriptions, it must include drugs approved by the FDA on the basis that the drug has not been approved by the FDA for the treatment of the particular indication for which the drug has been prescribed, provided the drug has been recognized as safe and effective for treatment of that indication.
- Plans must cover emergency services without regard to the day or time the emergency services are rendered, or to whether prior authorization was obtained.
- Refusing to insure or limiting coverage solely because of blindness or partial blindness is prohibited.
- Political subdivisions may establish and maintain a health savings account program, which may be a part of a self-insurance program. (§9.883)
- Both the federal government, through the Affordable Care Act, and the stategovernment, through the budget that was passed in July of 2009, passed legislation allowing older age children to remain covered under their parents’ coverage. The federaland statelaws are not exactly the same. The federallaw requires plans to extend the eligibility age for dependents to age 26. Under statelaw, the employee must be allowed to pay for extending coverage for their child until the child turns 28. (§3923.24)