DOL Self-Compliance Checklist for HIPAA and Other Health Care Laws

Posted by Mark Holloway on July 24, 2012 | Be the First to Comment

The DOL has posted on its website a 38-page self-compliance checklist that covers several of the major laws that apply to employer group health plans.  The Self-Compliance Tool is located at http://www.dol.gov/ebsa/pdf/CAGAppA.pdf

The checklist includes questions on compliance with:

  • Pre-Existing Condition Exclusions (11 questions);
  • Certificates of Creditable Coverage (5 questions);
  • HIPAA Special Enrollment  (5 questions);
  • HIPAA Nondiscrimination (7 questions);
  • Wellness Programs (5 questions);
  • HMO Affiliation Periods (1 question);
  •  Multiple Employer Welfare  Arrangement Guaranteed Renewability (1 question);
  • Mental Health Parity Act and Mental Health Parity and Addiction Equity Act  (8 questions);
  • Newborns’ and Mothers’ Health Protection Act (4 questions);
  • Womens’ Health and Cancer Rights Act (WHCRA) (4 questions);
  • Genetic Information Nondiscrimination Act (GINA) (4 questions); and
  • Michelle’s Law (2 questions).

For example, Section 1(A) of the checklist notes that if a plan imposes a preexisting condition exclusion period, the plan must comply with the rules set out in the section.  The section defines a preexisting condition exclusion and then asks the following questions:

  • Does the plan comply with the 6-month look back rule?
  • Does the plan comply with HIPAA’s 12-month or 18-month look-forward rule?
  • Does the plan offset the length of its preexisting condition exclusion by an individual’s creditable coverage?
  • Does the plan comply with HIPAA by not imposing a preexisting condition exclusion with respect to genetic information?
  • Does the plan comply with HIPAA by not imposing an impermissible preexisting condition exclusion on newborns?
  • Does the plan comply with HIPAA by not imposing an impermissible preexisting condition exclusion on adopted children or children placed for adoption?
  • Does the plan comply with HIPAA by not imposing a preexisting condition exclusion on pregnancy?
  • Does the plan provide adequate and timely general notices of preexisting condition exclusions?
  • Does the plan provide adequate and timely individual notices of preexisting condition exclusions?
  • Does the plan comply with the requirements relating to determination of individuals’ creditable coverage?
  • If the plan determines that an individual does not have the creditable coverage claimed, and the plan wants to modify an initial determination of creditable coverage, does the plan comply with the rules  relating to reconsideration?

The Labor Department explains each question in detail.  If you answer “No” to any of the questions above, the group health plan is in violation of the HIPAA provisions on preexisting condition exclusions.

You may want to take the Self-Compliance Test to determine whether your group health plan is in compliance with these various laws.  If you have any questions about the Self-Compliance Tool or about the results of the test, feel free to contact your Lockton account team representative. 

 

 

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