A child who is adopted or placed for adoption, as defined by the statein which the adoption takes place.
A period of time that must pass before health insurance coverageprovided by an HMO (Health Maintenance Organization) becomeseffective.
If a group health plan providescoverage to you through an HMO with an affiliation period, the affiliationperiod cannot be longer than 2 months (3 months for a late enrollee) from your enrollment date, and the plan cannot impose apre-existing conditionexclusion. During the affiliation period, the plan cannot charge youpremiums, and the HMO is not required to provide benefits.
The affiliation period must run concurrently with any waiting period for coverage under the plan.
Certificate of Creditable Coverage
A written certificate issued by a group health plan or health insurance issuer(including an HMO) thatshows your prior health coverage (creditable coverage).A certificate must be issued automatically and free of charge when you losecoverage under a plan, when you are entitled to elect COBRA continuation coverage orwhen you lose COBRA continuation coverage. A certificate must also be provided freeof charge upon request while you have health coverage or within 24 months afteryour coverage ends. For more information, see Questions and Answers: Recent Changes in Health Care Law.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
COBRA is a Federal law that provides rights to temporary continuation of group health plan coverage for certain employees, retirees and family members at group rates when coverage is lost due tocertain qualifying events.
The temporary continuation of group health plan coverage available after a qualifying event to certain employees, retirees and family members who are qualified beneficiaries.
Those who are eligible may be required to pay for COBRA continuation coverage and are generally entitled to coverage for a limited period of time (from 18 months to 36 months), depending on certain circ*mstances.
An individual who is (or was) provided coverage under a group health plan that is subject to COBRA because that individual was employed by one or more persons maintaining thegroup health plan.
Health coverage you have had in the past, such as coverage under agroup health plan (including COBRA continuation coverage), an HMO, anindividual health insurance policy, Medicare or Medicaid, and this priorcoverage was not interrupted by a significant break in coverage. Thetime period of this prior coverage must be applied toward anypre-existing conditionexclusion imposed by a new health plan. Proof of your creditable coveragemay be shown by a certificate ofcreditable coverage or by other documents showing you had health coverage, such as a health insurance ID card. For more information, see Questions and Answers: Recent Changes in Health Care Law.
A list of all the medicines that will be covered by yourgroup health plan.
When referring to health coverage, this means to choose, generally in writing, to participate in agroup health plan.
Written notification that you are eligible for COBRA continuation coverage. This notice should explain how long you will have to decide whether or not to elect COBRA continuation coverage. Thegroup health plan must give you at least 60 days from thedate the notice is provided to you, or from the date your coverage ended,whichever is later, to elect COBRA continuation coverage. The election notice should explain,among many other things, how much you must pay for coverage and when and towhom the payments are due.
Any labor union or organization of any kind in which employeesparticipate and which exists for the purpose of dealing with employersconcerning an employee benefit plan (including group health plans) or other matters involving employment relationships. An employee organization can also be an employeebeneficiary association.
ERISA (Employee Retirement Income Security Act of 1974)
ERISA is a Federal law thatregulates employee benefit plans, such as group health plans, thatprivate sector employers, employee organizations (such as unions), or both, offer to employeesand their families.
The first day of coverage or, if there is awaiting period, the first day ofthe waiting period. If you enroll when first eligible for coverage, your enrollment date is generally the first day of employment. If you enroll as a late enrollee, your enrollment date is the first day of coverage.
The end of your COBRA continuation coverage because the periodof time that this coverage was available to you has lapsed, or for anyreason other than your failure to pay premiums on time or for cause (such asmaking a fraudulent claim or an intentional misrepresentation of a material factin connection with your plan). Additional reasons for exhaustion of COBRAcoverage are possible besides the time being up. You have exhausted yourCOBRA continuation coverage if the coverage ends because your employer failed to pay thepremiums on time or you no longer live or work in an HMO service area and there is no similar COBRA coverage available to you. You need not accept a conversion policy at the end of your COBRA coverage in order to exhaust your COBRA coverage.
Information about genes, gene products andinherited characteristics that may derive from you or a family member. Thisincludes information regarding carrier status and information derived fromlaboratory tests that identify mutations in specific genes or chromosomes,physical medical examinations, family histories and direct analysis of genes orchromosomes.
The term "gross misconduct" is not specifically defined in COBRA or in regulations under COBRA. Therefore, whether a terminated employee has engaged in "gross misconduct" that will justify a plan in not offering COBRA to that former employee and hisor her family members will depend on the specific facts and circ*mstances. Generally,it can be assumed that being fired for most ordinary reasons,such as excessive absences or generally poor performance, does notamount to "gross misconduct."
An employee benefit plan established or maintained by an employer or by anemployee organization (such as a union),or both, that provides medical care to employees and their dependents directlyor through insurance (including an HMO),reimbursem*nt or otherwise.
HMO (Health Maintenance Organization)
Legal entity consisting of participating medical providers that provide or arrange for care to be furnished to a given population group for a fixed feeper person. HMOs are used as alternatives to traditional indemnity plans.
HIPAA (Health Insurance Portability and Accountability Act)
HIPAA is a Federal law that limitspre-existing conditionexclusions, permits special enrollmentwhen certain life or work events occur, prohibits discrimination againstemployees and dependents based on their health status, and guaranteesavailability and renewability of health coverage to certain employees andindividuals.
An individual who enrolls in a grouphealth plan on a date other than either the earliest date on which coverage canbegin under the plan terms or on a specialenrollment date. Under HIPAA, a late enrollee may be subject to a maximumpre-existing conditionexclusion of up to 18 months.
Mental Health Parity Act (MHPA)
MHPA is a Federal law that requires annual or lifetime dollar limits on mental health benefits provided by a grouphealth plan to be no lower than the annual or lifetime dollar limits for medicaland surgical benefits offered by that plan. MHPA applies to employers withmore than 50 employees.
NOTE:The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. For more information on MHPAEA, see the fact sheet.
Newborns' and Mothers' Health Protection Act (Newborns' Act)
The Newborns' Act is a Federal law that prohibits grouphealth plans andinsurance companies (including HMOs) that cover hospitalization in connection with childbirth from restricting a mother's or newborn's benefits for suchhospital stays to less than 48 hours following a vagin*l delivery or 96 hours following delivery by cesarean section, unless the attending doctor, nurse midwife or otherlicensed health care provider, in consultation with the mother, discharges earlier.
The person who is responsible for the management of the plan. Theplan administrator is a person specifically designated by the terms of theplan. If the plan does not make such a designation, then theplan sponsor is generally the plan administrator.
Generally, the employer, the employee organization (such as a union), or both, that establishes ormaintains an employee benefit plan, including a group health plan.
An illness or condition that was present before anindividual's first day of coverage under a group health plan. For more information, see Questions and Answers: Recent Changes in Health Care Law.
Pre-existing Condition Exclusion
A limitation or exclusion of benefits for a condition based on thefact that you had the condition before your enrollment date in the group health plan. A pre-existing conditionexclusion may be applied to your condition only if the condition is one forwhich medical advice, diagnosis, care or treatment was recommended or receivedwithin the 6 months before your enrollment date in the plan. A pre-existing condition exclusion cannot be applied to pregnancy(regardless of whether the woman had previous coverage), or togenetic information in the absence ofa diagnosis. A pre-existing condition exclusion also cannot be applied to anewborn or a child who is adopted or placed for adoption if the child hashealth coverage within 30 days of birth, adoption or placement for adoption anddoes not later have a significantbreak in coverage. If a plan provides coverage to you through anHMO that has an affiliationperiod, the plan cannot apply a pre-existing condition exclusion. Apre-existing condition exclusion can not be longer than 12 months from yourenrollment date (18 months for a late enrollee).A pre-existing condition exclusion that is applied to you must be reduced bythe prior creditable coverage you have thatwas not interrupted by a significantbreak in coverage. You may show creditable coverage through acertificate of creditablecoverage given to you by your prior plan or insurer (including an HMO) orby other proof. The plan can apply a pre-existing condition exclusion to youonly if it has first given you written notice. If your plan has both a waiting period and a pre-existing conditionexclusion, the exclusion begins when the waiting period begins. In some states,if plan coverage is provided through an insurance policy or HMO, you may havemore protections with respect to pre-existing condition exclusions.
Pre-existing Condition Exclusion Period
The period of time that a group health plan can legally limit your access tothe health benefits offered by that plan because of apre-existing condition. Under HIPAA, the maximum pre-existing condition exclusion period that can be applied to an individual is 12 months (18 months for late enrollees).
Generally, qualified beneficiaries include covered employees, their spouses and their dependent children who are covered under the group health plan on the day before the qualifying event. In certain cases, retired employees, their spouses and dependent children may be qualified beneficiaries. In addition, any child born to, or placed for adoption with, a covered employee during a period of COBRA continuation coverage is a qualified beneficiary.
Certain events that would ordinarily cause an individual to lose health coverage. The type ofqualifying event will determine who the qualified beneficiaries for the qualifying event are and the length of time COBRA continuation coverage is available.For more information, see Questions and Answers: Recent Changes in Health Care Law.
Generally, a significant break in coverage is a period of 63consecutive days during which you have no creditable coverage. In some states, the period is longer if your plan coverage is provided through an insurancepolicy or HMO. Days in a waitingperiod during which you had no other health coverage cannot be countedtoward determining a significant breakin coverage. For more information, see Questions and Answers: Recent Changes in Health Care Law.
Similarly Situated Non-COBRA Beneficiaries
The group of covered employees, theirspouses or dependent children who are covered under a group health plan maintainedby the employer or employee organization. This group is receiving theirbenefits under the group plan and not through COBRA continuation coverage. They are most similarly situated to the circ*mstancesof the qualified beneficiary immediatelybefore the qualifying event.
SPD (Summary Plan Description)
An important document that the plan administrator must provide to participants and beneficiaries that explains what coverage the plan offers,how the plan operates and the rights and responsibilities of participants and beneficiaries.Each SPD is different. If you need a copy of the SPD, contact your planadministrator.
The opportunity to enroll in a grouphealth plan when certain work or life events occur, regardless of the plan's regular enrollment dates. Generally,if certain conditions are met, special enrollment is available whenyou, your spouse or your dependents lose other coverage (including exhaustion ofCOBRA continuation coverage), when you marry or when you have a new child bybirth, adoption or placement for adoption. The plan must give you at least 30days--from the loss of coverage or from the date of the marriage, birth,adoption or placement for adoption--to request special enrollment. The maximumpre-existing conditionexclusion that may be applied to a person upon special enrollment is 12months (reduced by the person's prior creditable coverage). However, if enrolled within 30 days of birth, adoption or placement for adoption, children may be exempt from any pre-existing condition exclusion. A description of a plan's special enrollment rules must be given to the employee on or before the time the employee is offered the opportunity to enroll in the plan. For more information, see Questions and Answers: Recent Changes in Health Care Law
The period that must pass before an employee or dependent iseligible to enroll (becomes covered) under the terms of thegroup health plan. If the employee ordependent enrolls as a late enrollee or on aspecial enrollment date, any period beforethe late or special enrollment is not a waiting period. If a plan has a waitingperiod and a pre-existing conditionexclusion, the pre-existing condition exclusion period begins when thewaiting period begins. Days in a waiting period are not counted towardcreditable coverage unless there is othercreditable coverage during that time. You should try to maintain creditablecoverage during a waiting period to reduce any pre-existing condition exclusionthat may apply. Days in a waiting period are also not counted when determininga significant break in coverage.
Women's Health and Cancer Rights Act (WHCRA)
WHCRA is a Federal law thatprovides important protections for individuals who have undergone a mastectomy. For more information, see Your Rights After a Mastectomy: The Women's Health and Cancer Rights Act.
U.S. DEPARTMENT OF LABOR
200 Constitution Ave NW
Washington, DC 20210
1-866-4-USA-DOL
1-866-487-2365
TTY
www.dol.gov
ABOUT THE SITE
