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 laws include the following provisions:
- The plan cannot deny, refuse to issue, refuse to renew, refuse to reissue, cancel or otherwise terminate an insurance policy or restrict coverage on any individual because that individual is, has been or may be the victim of abuse. (§33-4-20)
- If the plan covers eye exams, refractions, or the fitting of corrective lenses, it must cover the services of an optometrist. (§33-6-30)
- If the plan covers surgical procedures, it must cover the services of a dentist or chiropodist-podiatrist performing surgical procedures, or a chiropractor performing other health care services. (§33-6-30)
- If the plan covers family members, it must cover newly born children from the moment of birth, and include coverage for the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. (§33-6-32)
- The plan must cover serious mental illness the same as medical and surgical benefits. (§33-16-3a)
- Home health care coverage must be made available. (§33-16-3b)
- The plan must cover primary health care nursing services (§33-16-3e)
- Coverage for temporomandibular joint disorders and craniomandibular disorders must be made available. (§33-16-3f)
- The plan must cover rehabilitation services, unless rejected by the insured. (§33-16-3h)
- The plan must cover emergency services without preauthorization or precertification. (§33-16-3i)
- If the plan covers laboratory or X-ray services, it cannot deny coverage for colorectal cancer examinations and laboratory testing for any nonsymptomatic person 50 years of age or older, or a symptomatic person under 50 years of age, as long as the tests are performed at the direction of a person licensed to practice medicine and surgery. (§33-16-3o)
- If the plan covers prescriptions, it may not require participants to obtain the prescription drugs from a mail-order pharmacy in order to obtain benefits for the drugs. (§33-16-3q)
- The plan may not cancel or refuse to renew coverage because of diagnosis or treatment of acquired immune deficiency syndrome (AIDS). (§33-16-9)
- The plan must be construed to include payment to all health care providers including medical physicians, osteopathic physicians, podiatric physicians, chiropractic physicians, midwives and nurse practitioners. (§33-16-10)
- The plan must cover adopted children under the same terms and conditions as apply to natural, dependent children of participants and beneficiaries, irrespective of whether the adoption has become final. (§33-16-11)
- The plan must cover children of each employee without regard to the amount of child support ordered to be paid or actually paid by such employee, if any, and without regard to the fact that the employee may not have legal custody of the child or children or that the child or children may not be residing in the home of the employee. (§33-16-11)
- The plan cannot deny enrollment of a child under the health plan of the child's parent on the grounds that the child was born out of wedlock; the child is not claimed as a dependent on the parent's federal tax return; or the child does not reside with the parent or in the insurer's service area. (§33-16-11)
- The plan must cover child immunizations, without deductibles, per-visit charges, and/or copayment provisions. (§33-16-12)
- The plan must cover equipment and supplies for the treatment and/or management of diabetes for both insulin dependent and noninsulin dependent persons with diabetes and those with gestational diabetes, if medically necessary and prescribed by a licensed physician. (§33-16-16)
- Carriers must accept every small employer (2-50 employees) that applies for coverage under a health benefit plan, and must accept for enrollment in the plan every employee of the small employer, including dependents, when an employee or dependent first becomes eligible to enroll under terms of the plan. (§33-16D-4)
- Participants in managed care plans must be allowed to choose a primary care provider and change that provider after six months, allowed a standing referral to a specialist, and allowed timely referral to a choice of specialists within the plan if specialty care is warranted. (§33-25C-4)
- Managed care plans must provide access by the enrollee to a second opinion. (§33-25C-4)
- Managed care plans must, at the option of the enrollee, continue to cover services of a primary care provider whose contract with the plan or whose contract with a subcontractor is being terminated by the plan or subcontractor without cause under the terms of that contract for at least 60 days following notice of termination to the enrollees. (§33-25C-4)