Your Employee Rights

You may qualify for financial assistance to help lower your monthly health insurance premium through the Health Insurance Marketplace. Eligibility for these savings depends on your household income and whether your employer offers health coverage that meets Affordable Care Act (ACA) standards.

If your employer offers health coverage that meets ACA affordability and minimum value requirements, you generally will not be eligible for a Marketplace premium tax credit and may wish to enroll in your employer’s health plan.

However, you may qualify for a Marketplace tax credit if:

• Your employer does not offer health coverage.
• Your employer’s coverage does not meet the ACA minimum value standard.
• The employee-only cost of employer coverage exceeds the affordability threshold established under federal law.

A health plan meets the minimum value standard if it pays at least 60% of the total allowed cost of covered benefits.

Before declining employer-sponsored coverage, keep in mind that employer contributions toward premiums are often excluded from federal and state taxable income. If you purchase coverage through the Marketplace instead, your premium payments are generally made on an after-tax basis and you may lose any employer contribution toward your coverage.

The Health Insurance Marketplace can help you compare coverage options, estimate costs and determine whether you qualify for premium tax credits or other financial assistance.

For more information about Marketplace coverage, eligibility requirements and online enrollment, visit:

www.HealthCare.gov

The health care law defines which employers must offer health insurance to their workers. These employers are called Applicable Large Employers, or ALEs.

A company or organization is considered an ALE if it has at least 50 full-time workers or full-time equivalent employees.

Under the law, a full-time worker is generally someone who works at least 30 hours per week.

Every employee of an Applicable Large Employer (ALE) who is eligible for insurance coverage should receive a Form 1095-C. Eligible employees who decline to participate in their employer’s health plan will still receive a 1095-C.

The form identifies:

• The employee and the employer
• Which months during the year the employee was eligible for coverage
• The cost of the lowest monthly premium the employee could have paid under the plan
• Whether the employer offered insurance coverage

If an ALE does not offer insurance coverage to its employees, the 1095-C will indicate that. Employers that do not offer coverage may be subject to financial penalties.

Form 1095-C reports the health insurance coverage that was offered to an employee by their employer. It does not provide details about who was actually enrolled in coverage.

Form 1095-B provides information about an individual’s actual health insurance coverage, including which family members were covered during the year. This form is typically issued by the insurance carrier rather than the employer.

Some employers are considered self-insured, meaning they pay employee health care claims directly instead of purchasing traditional insurance coverage from an insurance company.

For self-insured employers, the employer acts as both the employer and the health plan provider. In these situations, the employer may issue both Form 1095-B and Form 1095-C information to employees.

To simplify reporting, self-insured employers may combine the information required for both forms into a single document.

Employers that are considered Applicable Large Employers (ALEs) are required to provide Form 1095-C to eligible employees and file the information with the Internal Revenue Service (IRS).

Employees generally receive Form 1095-C each year for the previous tax year. Under normal filing requirements, forms are typically distributed by the end of January.

For example, information related to the 2025 tax year would ordinarily be provided to employees in January 2026.

Please Note: The IRS has provided an extension for the 2025 reporting year. Insurers, self-insured employers, other coverage providers and applicable large employers have until March 2, 2026 to furnish Forms 1095-B and 1095-C to individuals. This extension provides an additional 30 days beyond the original January 31, 2026 deadline.

The Children’s Health Insurance Program Reauthorization Act (CHIPRA) expanded and strengthened the Children’s Health Insurance Program (CHIP), originally created through the Balanced Budget Act of 1997. CHIP provides health coverage to eligible children in families who earn too much to qualify for Medicaid but may not have access to affordable private health insurance.

CHIPRA authorized an additional $33 billion in federal funding for children’s health coverage and was expected to help provide health insurance to millions of children who otherwise would have remained uninsured.

Together, Medicaid and CHIP have significantly reduced the number of uninsured children by:

• Expanding eligibility for low-income families
• Simplifying enrollment and renewal procedures
• Improving access to preventive and routine healthcare services
• Increasing healthcare coverage for eligible children

Despite these improvements, many eligible children remained uninsured because they were not enrolled in available programs. CHIPRA was designed to increase outreach efforts and encourage enrollment among eligible families.

The legislation was ultimately enacted in 2009 after several earlier reauthorization efforts. CHIPRA continues to serve as an important component of children’s healthcare coverage in the United States.

Medicaid and the Children’s Health Insurance Program (CHIP) are the primary public health coverage programs that help provide affordable healthcare for children in low-income families.

Medicaid is the nation’s largest health coverage program for children and provides healthcare benefits to eligible low-income individuals and families. CHIP was created to complement Medicaid by providing coverage for uninsured children whose families earn too much to qualify for Medicaid but may not be able to afford private health insurance.

Today, millions of children receive healthcare coverage through these programs:

• Approximately 29 million children are enrolled in Medicaid.
• Approximately 7 million children are enrolled in CHIP.
• Many states provide coverage for children in families with incomes at or above 200% of the Federal Poverty Level (FPL).

Both Medicaid and CHIP are funded through a partnership between federal and state governments. While the federal government helps fund both programs, CHIP generally receives a higher federal matching rate than Medicaid.

Together, Medicaid and CHIP play a critical role in improving access to preventive care, routine medical services and healthcare coverage for millions of children across the United States.

The Children’s Health Insurance Program Reauthorization Act (CHIPRA) introduced several initiatives designed to help states enroll more eligible children in Medicaid and CHIP while improving access to healthcare services for low-income families.

Bonus Payments for States

CHIPRA provides financial incentives to states that successfully increase enrollment of eligible low-income children in Medicaid. States may qualify for bonus payments when enrollment exceeds established target levels.

To receive bonus funding, states must implement a number of eligibility simplification measures, such as:

• 12-month continuous eligibility
• Elimination of certain asset tests
• Removal of in-person interview requirements
• Combined Medicaid and CHIP applications
• Simplified renewal processes
• Presumptive eligibility programs
• Express Lane eligibility procedures
• Premium assistance programs

Contingency Fund

CHIPRA established a contingency fund to help states cover additional CHIP costs when enrollment grows beyond expected levels and program spending exceeds available state allotments.

Outreach and Enrollment Support

The legislation also provides funding to help states identify and enroll eligible children who may not already be participating in Medicaid or CHIP. CHIPRA includes:

• Federal outreach grant funding to support enrollment efforts
• Enhanced funding for translation and interpretation services
• Programs designed to improve access for diverse and underserved populations

Together, these initiatives help expand healthcare coverage, simplify enrollment and improve access to care for millions of children and families.

The Children’s Health Insurance Program Reauthorization Act (CHIPRA) continues CHIP as a federally supported program that helps states provide health coverage to eligible children. Funding is distributed through annual state allotments, with states receiving enhanced federal matching funds for CHIP expenditures.

State Funding and Allotments

Under CHIPRA, states continue to receive annual CHIP funding allotments. The legislation updated the funding formula to better reflect actual and projected program spending, while also accounting for inflation and child population growth.

Key funding improvements include:

• Annual state allotments based on spending needs and enrollment trends.
• Adjustments for inflation and child population growth.
• Revisions to allotment calculations to better match state healthcare needs.
• More timely use of allocated federal funds.

Federal Funding

CHIPRA increased funding for children’s healthcare coverage through Medicaid and CHIP by approximately $33 billion over baseline funding levels. The additional funding was supported primarily through increases in federal tobacco excise taxes.

Contingency Fund

CHIPRA established a contingency fund to assist states whose CHIP enrollment and expenditures exceed their annual allotments due to increased participation by eligible children.

Outreach and Enrollment Funding

To help identify and enroll eligible children, CHIPRA also provides:

• Federal outreach grants to support enrollment efforts.
• Enhanced funding for translation and interpretation services.
• Resources to improve access for underserved populations and communities.

These financing provisions help ensure that states have the resources needed to expand healthcare coverage and improve access to care for eligible children and families.

Children

CHIPRA 2009 was designed primarily to expand healthcare coverage for children. The Congressional Budget Office (CBO) estimated that millions of additional children would gain coverage through Medicaid and CHIP, including many who were previously uninsured.

States continue to have flexibility in setting eligibility levels for children, subject to federal guidelines and funding requirements. CHIPRA also supported efforts to increase enrollment among children who were already eligible but not participating in available programs.

Pregnant Women and Adults

CHIPRA created new options for states to provide healthcare coverage for pregnant women. The legislation also established guidelines regarding adult coverage under CHIP and provided transition options for states that had previously extended CHIP coverage to certain adult populations.

Legal Immigrants

CHIPRA gave states the option to provide Medicaid and CHIP coverage to eligible legal immigrant children and pregnant women without requiring a five-year waiting period. Coverage eligibility remained limited to individuals who met federal and state program requirements.

Undocumented immigrants remained ineligible for CHIP coverage under the legislation.

Citizenship Verification

CHIPRA updated citizenship verification procedures by allowing states to use electronic data matching with the Social Security Administration (SSA) to verify citizenship and eligibility information. This streamlined enrollment while maintaining program integrity.

Overall, CHIPRA expanded opportunities for children and certain other eligible populations to obtain healthcare coverage while simplifying enrollment and eligibility verification processes.

Benefits

CHIPRA expanded and enhanced healthcare benefits available through the Children’s Health Insurance Program (CHIP), with a particular focus on improving access to dental and behavioral health services.

• Requires CHIP plans to include dental coverage that meets established benefit standards.
• Allows states to offer supplemental dental-only coverage for eligible children who have health insurance without dental benefits.
• Supports dental health education and public awareness efforts.
• Promotes reporting and monitoring of dental access and quality measures.
• Requires states to make participating dental provider information available to families.
• Encourages mental health and substance use disorder benefit parity when those services are included in CHIP plans.
• Includes provisions designed to reduce barriers to premium assistance programs.

Access, Data and Quality Improvements

CHIPRA introduced several initiatives to improve healthcare access, strengthen program oversight and enhance the quality of care provided to children enrolled in Medicaid and CHIP.

• Established the Medicaid and CHIP Payment and Access Commission (MACPAC) to review program access and payment policies and provide recommendations to Congress.
• Provided funding for child health quality improvement initiatives.
• Supported the development of healthcare quality measures and electronic health records.
• Created demonstration projects focused on improving healthcare quality and addressing childhood obesity.
• Encouraged the use of health information technology to improve care coordination and outcomes.
• Funded efforts to improve state-level data on children’s health coverage and access to care.
• Required federal evaluation of CHIP program performance and effectiveness.

Together, these provisions were designed to improve healthcare services, expand access to important benefits and strengthen the overall quality of care available to children and families participating in Medicaid and CHIP.

CHIPRA strengthened children’s healthcare coverage by providing states with additional funding, enrollment incentives and tools designed to make it easier for eligible children and families to obtain health insurance through Medicaid and CHIP.

The legislation supports coverage expansion by:

• Providing increased federal funding for children’s health programs.
• Offering incentives to states that successfully enroll eligible low-income children.
• Simplifying enrollment and renewal processes.
• Supporting outreach efforts to identify and enroll eligible families.
• Helping states manage growing demand for children’s healthcare coverage.

CHIPRA also provides states with greater certainty regarding federal funding levels, helping them maintain coverage during periods of economic uncertainty and increased healthcare needs.

As economic conditions change, programs such as Medicaid and CHIP continue to play an important role in providing healthcare coverage for children whose families may lose employer-sponsored insurance or experience financial hardship.

While CHIPRA significantly expanded access to healthcare coverage for children, ongoing efforts to improve enrollment, outreach and healthcare access remain important to ensuring that eligible children receive the care and coverage they need.

CHIP and Medicaid continue to serve as critical resources in improving health outcomes and reducing the number of uninsured children across the United States.

The Family and Medical Leave Act (FMLA) allows eligible employees to take unpaid, job-protected leave for certain family and medical reasons. Qualifying leave may be taken for:

• The birth of a child and care of the newborn child.
• The placement of a child with the employee for adoption or foster care.
• The care of a spouse, child or parent with a serious health condition.
• The employee’s own serious health condition that makes them unable to perform the essential functions of their job.

FMLA leave helps eligible employees balance work and family responsibilities while maintaining job protection and continued access to certain benefits during their approved leave period.

The Family and Medical Leave Act (FMLA) provides special leave provisions for eligible employees who have family members serving in the military.

Eligible employees with a spouse, son, daughter or parent who is on active duty or has been called to active duty in the National Guard or Reserves may use up to 12 weeks of FMLA leave to address certain qualifying military-related needs.

Qualifying exigencies may include:

• Attending military ceremonies and events
• Arranging alternative childcare
• Addressing financial or legal matters
• Participating in counseling sessions
• Attending post-deployment briefings and reintegration activities

In addition, FMLA provides a special military caregiver leave that allows eligible employees to take up to 26 weeks of leave during a single 12-month period to care for a covered service member with a serious injury or illness.

A covered service member is a current member of the Armed Forces, including members of the National Guard or Reserves, who has sustained a serious injury or illness in the line of duty while serving on active duty.

These provisions help military families manage important responsibilities and provide support during periods of military service and recovery.

To be eligible for leave under the Family and Medical Leave Act (FMLA), an employee must meet all of the following requirements:

• Have worked for the employer for a total of at least 12 months.
• Have worked at least 1,250 hours during the 12 months immediately preceding the start of the leave.
• Work at a location where the employer has at least 50 employees within a 75-mile radius in the United States or its territories.

The required 12 months of employment do not have to be consecutive. In most cases, however, periods of employment before a break in service of seven years or more are not counted toward FMLA eligibility.

An exception may apply when the break in service is due to the employee’s fulfillment of military obligations in the National Guard or Reserve.

Employees who meet these requirements may be eligible for job-protected leave under FMLA for qualifying family and medical reasons.

Employees requesting leave under the Family and Medical Leave Act (FMLA) may be required to provide medical certification supporting the need for leave.

Certification of Health Care Provider forms are available through your employer and on the U.S. Department of Labor website.

A separate Certification of Health Care Provider form must be completed for each medical condition for which FMLA leave is being requested.

Employers may designate a qualified individual to review and verify medical certifications, including:

• Healthcare providers
• Human resources professionals
• Leave administrators
• Management officials

The employer may authenticate, review and request clarification of the medical certification when necessary, consistent with FMLA regulations and privacy requirements.

In certain situations, an employer may require a second or third medical opinion regarding the employee’s serious health condition. Any required second or third opinion is provided at the employer’s expense.

Timely and complete medical certification helps ensure that leave requests are processed accurately and in compliance with FMLA requirements.

Employees on approved Family and Medical Leave Act (FMLA) leave may continue their health insurance coverage under the same terms and conditions that applied while actively working.

Employees remain responsible for paying their share of any required health insurance premiums during their leave. If an employee fails to make the required premium payments, the employer may terminate health insurance coverage in accordance with FMLA regulations.

Before coverage can be canceled, the employer must:

• Provide a minimum grace period of 30 days for premium payment.
• Send written notice of the pending cancellation at least 15 days before coverage will end.

If coverage is terminated due to nonpayment, the employee’s health insurance must be reinstated upon return to work without requiring a waiting period, new enrollment or evidence of insurability.

FMLA regulations ensure that eligible employees who return from approved leave can resume their health benefits under the same conditions that existed prior to their leave.

Under the Family and Medical Leave Act (FMLA), employers may choose the method used to determine the applicable 12-month period during which employees are entitled to FMLA leave.

Many employers use a rolling 12-month period measured backward from the date an employee begins FMLA leave. Under this method, the employer looks back 12 months from the date leave is requested and calculates how much FMLA leave has already been used during that period.

The rolling-year method helps ensure that employees receive their entitled leave while preventing the stacking of multiple 12-week leave periods within a short timeframe.

Employers should clearly communicate the method used to calculate the 12-month FMLA period and apply it consistently to all eligible employees.

Employees requesting leave under the Family and Medical Leave Act (FMLA) are responsible for providing timely notice to their employer when the need for leave arises.

When the need for FMLA leave is foreseeable, employees must provide at least 30 days’ advance notice before the leave is expected to begin.

If 30 days’ notice is not possible, employees must notify their employer as soon as practicable and generally follow the employer’s normal call-in and leave reporting procedures.

Employers may require that leave requests related to a serious health condition affecting the employee or an eligible family member be supported by a completed Certification of Health Care Provider form.

Medical certification helps verify the need for leave and ensures that FMLA requests are administered consistently and in compliance with federal regulations.

During approved Family and Medical Leave Act (FMLA) leave, employers are required to maintain an employee’s group health insurance coverage under the same terms and conditions that would have applied if the employee had continued working.

While FMLA requires continuation of health insurance benefits, it does not require employers to continue all non-health benefits during the leave period. The administration of non-health benefits may vary according to the employer’s policies and benefit plan provisions.

Upon returning from FMLA leave, employees must have all eligible benefits restored to the same status they held before the leave began.

If a lapse in coverage occurs during the leave period, the employer may not:

• Require new evidence of insurability.
• Impose new waiting periods.
• Exclude coverage for medical conditions that arose while the employee was on FMLA leave and not covered by the plan.

These protections help ensure that employees returning from approved FMLA leave can resume their benefits without penalty or loss of coverage.

FMLA does not require the continuation of non-health benefits during leave. However, when an employee returns to work, all benefits must be restored to their previous status.

If a lapse in coverage occurs during FMLA leave, the employer cannot require current evidence of insurability or exclude coverage for conditions that arose while the employee was on FMLA leave and not covered by the plan.

If an employer chooses to continue health coverage during unpaid FMLA leave by paying the employee’s share of the premium, and the employee does not return to work at the end of the leave, the employer may recover the premiums paid.

This may include both the employer’s share and the employee’s share of group health coverage premiums paid during the unpaid FMLA leave period.

The Mental Health Parity and Addiction Equity Act (MHPAEA) helps ensure that mental health and substance use disorder benefits are provided on terms comparable to medical and surgical benefits under a group health plan.

• Financial requirements such as deductibles, copayments and coinsurance for mental health benefits cannot be more restrictive than those that apply to substantially all medical and surgical benefits.
• Financial requirements and treatment limitations for substance use disorder benefits cannot be more restrictive than those that apply to substantially all medical and surgical benefits.
• Mental health and substance use disorder benefits may not be subject to separate cost-sharing requirements or treatment limitations that apply only to those benefits.
• If a health plan provides out-of-network medical and surgical benefits, it must also provide out-of-network mental health benefits.
• If a health plan provides out-of-network medical and surgical benefits, it must also provide out-of-network substance use disorder benefits.
• Plan participants may request information regarding medical necessity criteria and the reasons for any denial of mental health or substance use disorder benefits.
• Existing parity protections related to annual and lifetime dollar limits continue to apply and are extended to substance use disorder benefits.

MHPAEA promotes equal access to behavioral health care by requiring that mental health and substance use disorder benefits be administered in a manner comparable to medical and surgical benefits.

Under the Newborns’ and Mothers’ Health Protection Act (NMHPA), health plans generally may not restrict benefits for a hospital stay related to childbirth to less than 48 hours following a vaginal delivery or 96 hours following a cesarean section.

If the baby is delivered in the hospital, the applicable time period begins at the time of delivery—not at the time the mother was admitted to the hospital.

For example, if a mother is admitted to the hospital at 10:00 p.m. and gives birth at 6:00 a.m. the following day, the 48-hour or 96-hour period begins at 6:00 a.m., the time of delivery.

If the baby is delivered outside of a hospital and the mother is later admitted to a hospital in connection with childbirth, the required hospital stay period begins at the time of hospital admission.

This protection helps ensure that mothers and newborns receive an appropriate period of post-delivery care before discharge, unless an earlier discharge is approved by the attending healthcare provider in consultation with the mother.

Under the Newborns’ and Mothers’ Health Protection Act (NMHPA), a group health plan may not deny coverage for a hospital stay of up to 48 hours following a vaginal delivery or 96 hours following a cesarean section based on a determination that the stay is not medically necessary.

A mother and her newborn cannot be required to obtain prior authorization, precertification or other approval solely to receive coverage for the minimum hospital stay protections provided under federal law.

However, health plans may require participants to notify the plan of a pregnancy before a hospital admission. Advance notification may be necessary to:

• Access certain participating providers or facilities.
• Receive the highest level of plan benefits.
• Reduce potential out-of-pocket expenses.

These notification requirements cannot be used to deny coverage for the federally protected minimum hospital stay following childbirth.

No. The Newborns’ and Mothers’ Health Protection Act (NMHPA) does not require group health plans to provide maternity or childbirth coverage.

The law applies only to health plans that already provide benefits for hospital stays related to childbirth. For those plans, NMHPA establishes minimum protections regarding the length of hospital stays following delivery.

Other federal laws, including Title VII of the Civil Rights Act of 1964 and the Pregnancy Discrimination Act, may require employers to provide pregnancy-related benefits on the same basis as other medical conditions.

Questions regarding employment discrimination protections related to pregnancy should be directed to the U.S. Equal Employment Opportunity Commission (EEOC).

For additional information, visit:

www.eeoc.gov

The Newborns’ and Mothers’ Health Protection Act (NMHPA) applies to group health plans that provide benefits for hospital stays related to childbirth.

If an employer-sponsored health plan is self-insured (meaning the employer pays claims directly), the federal requirements of the NMHPA generally apply.

If coverage is provided through an insurance company or Health Maintenance Organization (HMO), the plan may instead be subject to applicable state laws governing maternity and newborn hospital stays.

When a state law meets certain federal standards, the state law generally applies in place of the federal NMHPA requirements. Because state requirements may differ slightly from federal rules, it is important for participants to understand which law governs their coverage.

Individuals covered under an insured health plan should contact their state’s insurance department for the most current information regarding maternity and newborn hospital stay protections and coverage requirements.

Regardless of whether federal or state law applies, eligible participants may be entitled to important protections related to hospital stays following childbirth.

An attending provider is a healthcare professional who is licensed under state law and is directly responsible for providing maternity or pediatric care to a mother or newborn child.

Depending on state licensing requirements, an attending provider may include:

• Physicians
• Nurse practitioners
• Certified nurse-midwives
• Physician assistants
• Other licensed healthcare professionals authorized to provide maternity or pediatric care

A health plan, hospital, insurance company or Health Maintenance Organization (HMO) is not considered an attending provider.

Under the Newborns’ and Mothers’ Health Protection Act (NMHPA), the attending provider works with the mother to determine the appropriate length of hospital stay following childbirth. The attending provider cannot receive financial incentives or penalties that encourage discharge of the mother or newborn earlier than the federally protected minimum hospital stay period of 48 hours following a vaginal delivery or 96 hours following a cesarean section.

These protections help ensure that healthcare decisions are based on the medical needs of the mother and newborn rather than financial considerations.

Yes. Group health plans may apply deductibles, copayments, coinsurance and other cost-sharing requirements to hospital stays related to childbirth, provided those requirements are applied consistently throughout the protected hospital stay period.

Under the Newborns’ and Mothers’ Health Protection Act (NMHPA), a plan cannot impose greater cost-sharing requirements on the latter portion of a federally protected hospital stay than it applies to the earlier portion of the stay.

For example, a plan may cover 80% of the cost of a 48-hour hospital stay and require the participant to pay the remaining 20%. However, the plan cannot cover 80% of the first 24 hours and then reduce coverage to 50% for the second 24 hours.

These protections help ensure that financial considerations do not discourage mothers and newborns from receiving the full hospital stay protections provided under federal law.

Group health plans that provide maternity or newborn infant coverage are required to inform participants and beneficiaries about their rights under the Newborns’ and Mothers’ Health Protection Act (NMHPA) and any applicable state law protections.

This information must be included in the plan’s Summary Plan Description (SPD). The SPD must describe the federal or state law requirements that apply to hospital length of stay following childbirth for both the mother and newborn child.

If a health plan operates in multiple states where different laws apply, the SPD must clearly explain:

• The federal NMHPA requirements that apply in certain locations.
• Any state laws that provide maternity and newborn hospital stay protections.
• Which requirements apply to participants based on their location and coverage.

These disclosure requirements help ensure that participants understand their rights and available protections regarding maternity and newborn hospital stays.

The Women’s Health and Cancer Rights Act (WHCRA) provides important protections for individuals who undergo a mastectomy and are covered under certain group health plans.

Whether WHCRA or a comparable state law applies to your coverage depends on the type of health plan in which you are enrolled. In general:

• Self-insured group health plans are generally subject to the federal WHCRA requirements.
• Insured group health plans and individual health insurance policies may be governed by state laws that provide similar protections.

If you are covered under an insured health plan, contact your healthcare provider or your state’s insurance department to determine whether WHCRA or applicable state law protections apply to your coverage.

Health plans may apply normal deductibles, copayments and coinsurance to reconstructive surgery related to a mastectomy, provided those cost-sharing requirements are consistent with those applied to other medical and surgical benefits under the plan.

WHCRA does not prohibit health plans or insurance carriers from negotiating payment arrangements with healthcare providers. However, the law does prohibit plans and insurers from:

• Penalizing healthcare providers for providing services required under WHCRA.
• Offering incentives that encourage providers to deliver care that is inconsistent with WHCRA protections.

These protections help ensure that healthcare decisions related to post-mastectomy care are based on medical needs and patient preferences rather than financial incentives.

Medicare offers prescription drug coverage through Medicare Part D plans. These plans are available to individuals who are eligible for Medicare and provide at least a standard level of prescription drug coverage established by Medicare.

If you are covered under an employer-sponsored prescription drug plan, it is important to know whether that coverage is considered creditable coverage. Creditable coverage means that the prescription drug coverage provided by your employer is expected to pay, on average, at least as much as standard Medicare prescription drug coverage.

Maintaining creditable coverage can help you avoid a late enrollment penalty if you later decide to enroll in a Medicare Part D prescription drug plan.

Individuals generally may enroll in a Medicare Part D plan when they first become eligible for Medicare and during the annual enrollment period each year from October 15 through December 7. Special enrollment opportunities may also be available when leaving employer-sponsored coverage.

If you enroll in a Medicare prescription drug plan while still covered under your employer’s plan, you may be able to keep both coverages. If you choose to waive or drop employer coverage, Medicare may become your sole source of prescription drug coverage.

It is important to understand that if you go 63 consecutive days or longer without creditable prescription drug coverage after becoming eligible for Medicare, you may be subject to a permanent Medicare Part D late enrollment penalty.

This penalty generally increases your monthly Medicare prescription drug premium by at least 1% for each month that you were eligible for Medicare Part D but did not maintain creditable prescription drug coverage.

You may receive a Notice of Creditable Coverage annually, when your prescription drug coverage changes, before a Medicare enrollment period, or upon request. Keep this notice with your important records, as it may be needed to verify your prescription drug coverage status in the future.

Preventive care services help detect health conditions early and support overall wellness. Many preventive services are covered at no cost when received from an in-network provider, as required by applicable healthcare regulations.

Covered preventive services for adults may include:

• Abdominal Aortic Aneurysm one-time screening for eligible men who have ever smoked
• Alcohol misuse screening and counseling
• Aspirin use counseling for certain adults
• Blood pressure screening
• Cholesterol screening for eligible adults
• Colorectal cancer screening
• Depression screening
• Type 2 diabetes screening for eligible adults
• Diet and nutrition counseling for individuals at higher risk of chronic disease
• Falls prevention interventions for adults age 65 and older
• Hepatitis B screening for individuals at increased risk
• Hepatitis C screening for adults ages 18 to 79
• HIV screening and prevention services for eligible individuals
• PrEP (Pre-Exposure Prophylaxis) medication and related services for individuals at high risk of HIV infection
• Lung cancer screening for eligible adults at high risk
• Obesity screening and counseling
• Sexually transmitted infection (STI) prevention counseling
• Statin preventive medication for eligible adults at increased cardiovascular risk
• Syphilis screening for individuals at higher risk
• Tobacco use screening and cessation support
• Tuberculosis screening for certain high-risk adults

Recommended Adult Immunizations May Include:

• Chickenpox (Varicella)
• Diphtheria
• Influenza (Flu)
• Hepatitis A
• Hepatitis B
• Herpes Zoster (Shingles)
• Human Papillomavirus (HPV)
• Measles
• Meningococcal
• Mumps
• Pertussis (Whooping Cough)
• Pneumococcal
• Rubella
• Tetanus

Coverage recommendations, eligibility requirements, frequency limits and age guidelines may vary. Consult your healthcare provider for preventive care recommendations based on your age, health status and risk factors.

Preventive care plays an important role in supporting healthy growth and development. Many preventive services for children and adolescents are covered at no cost when provided by an in-network healthcare provider.

Covered preventive services for children may include:

• Alcohol and drug use assessments for adolescents
• Autism screening at 18 and 24 months
• Behavioral assessments throughout childhood
• Bilirubin screening for newborns
• Blood pressure screening
• Blood screening for newborns
• Cervical dysplasia screening for sexually active females
• Congenital hypothyroidism screening for newborns
• Depression screening beginning routinely at age 12
• Developmental screening and surveillance
• Dyslipidemia screening for children at increased risk
• Fluoride supplements and fluoride varnish treatments
• Gonorrhea preventive medication for newborns
• Hearing screening for newborns
• Height, weight and Body Mass Index (BMI) measurements
• Hematocrit and hemoglobin screening
• Hemoglobinopathy and sickle cell screening for newborns
• Hepatitis B screening for at-risk adolescents
• HIV screening for adolescents at higher risk
• PrEP (Pre-Exposure Prophylaxis) HIV prevention medication and related services for eligible adolescents
• Iron supplements for infants at risk for anemia
• Lead screening for children at risk of exposure
• Medical history assessments throughout development
• Obesity screening and counseling
• Oral health risk assessments
• Phenylketonuria (PKU) screening for newborns
• Sexually transmitted infection (STI) prevention counseling for at-risk adolescents
• Tuberculosis (TB) testing for children at higher risk
• Vision screening
• Well-baby and well-child visits

Recommended Childhood Immunizations May Include:

• Chickenpox (Varicella)
• Diphtheria, Tetanus and Pertussis (DTaP)
• Haemophilus Influenzae Type B (Hib)
• Hepatitis A
• Hepatitis B
• Human Papillomavirus (HPV)
• Inactivated Poliovirus (Polio)
• Influenza (Flu)
• Measles
• Meningococcal
• Mumps
• Pneumococcal
• Rubella
• Rotavirus

Recommended preventive services, screenings and immunizations may vary based on a child’s age, health history and risk factors. Consult your healthcare provider for guidance regarding appropriate preventive care for your child.

Preventive healthcare services for women are designed to promote wellness, detect health conditions early and support healthy pregnancies. Many preventive services are covered at no cost when received from an in-network provider.

Pregnancy-Related Preventive Services

• Anemia screening for pregnant women
• Bacteriuria and urinary tract infection screening
• Breastfeeding support, counseling and supplies
• Breastfeeding interventions and education
• Folic acid supplementation for women who may become pregnant
• Gestational diabetes screening
• Gonorrhea screening for women at increased risk
• Hepatitis B screening at the first prenatal visit
• Maternal depression screening during well-baby visits
• Preeclampsia prevention and screening for eligible pregnant women
• Rh incompatibility screening and follow-up testing
• Syphilis screening for pregnant women and women at increased risk
• Tobacco cessation counseling and interventions for pregnant tobacco users
• Urinary tract and other infection screening

Women’s Preventive Health Services

• Annual well-woman preventive care visits
• Bone density screening for women age 65 and older, and certain younger women at risk
• BRCA genetic counseling for women at higher risk for breast cancer
• Breast cancer mammography screenings
• Breast cancer risk-reduction counseling and preventive medication discussions
• Cervical cancer screening, including Pap tests
• Chlamydia screening for younger women and those at higher risk
• Diabetes screening for women with a history of gestational diabetes
• Domestic and interpersonal violence screening and counseling
• HPV DNA testing for eligible women age 30 and older
• HIV screening and counseling
• Osteoporosis screening for eligible women
• PrEP (Pre-Exposure Prophylaxis) HIV prevention medication and related services for eligible women
• Sexually transmitted infection (STI) counseling
• Tobacco use screening and cessation interventions
• Urinary incontinence screening

Contraceptive Services

Women have access to Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures and contraceptive counseling as prescribed by a healthcare provider. Certain exemptions may apply under federal law.

Coverage requirements, eligibility criteria and screening frequency may vary based on age, medical history and individual risk factors. Consult your healthcare provider for personalized preventive care recommendations.

Michelle’s Law provides important protections for dependent college students who must take a medically necessary leave of absence from school due to a serious illness or injury. The law helps ensure continued health coverage during a difficult time when a student’s enrollment status may otherwise affect eligibility for benefits.

Under Michelle’s Law, employer-sponsored group health plans may continue coverage for an eligible dependent child who loses student status because of a medically necessary leave of absence from school.

Coverage may continue for up to 12 months, unless the dependent child would otherwise lose eligibility under the terms of the plan for another reason, such as reaching the maximum dependent age limit.

To qualify for extended coverage:

• The child must be covered under the health plan as a dependent student.
• The leave of absence or reduction in enrollment status must result from a serious illness or injury.
• The leave must be medically necessary.
• The change in student status would otherwise cause coverage to end.

The plan may require written certification from the child’s physician stating that:

• The child has a serious illness or injury.
• The leave of absence or change in enrollment status is medically necessary.

Michelle’s Law applies to both fully insured and self-insured employer-sponsored group health plans.

If your dependent child may lose eligibility due to a medically necessary leave of absence from school, contact your Human Resources department or benefits administrator for information regarding eligibility requirements, certification procedures and continuation of coverage.