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As an employer, I sponsor a group health plan for my employees. Am I a covered entity under HIPAA?

Covered entities under HIPAA are health care clearinghouses, certain health care providers, and health plans. A "group health plan" is one type of health plan and is a covered entity (except for self-administered plans with fewer than 50 participants). The group health plan is considered to be a separate legal entity from the employer or other parties that sponsor the group health plan. Neither employers nor other group health plan sponsors are defined as covered entities under HIPAA. Thus, the Privacy Rule does not directly regulate employers or other plan sponsors that are not HIPAA covered entities. However, the Privacy Rule does control the conditions under which the group health plan can share protected health information with the employer or plan sponsor when the information is necessary for the plan sponsor to perform certain administrative functions on behalf of the group health plan. See 45 CFR 164.504(f) . Among these conditions is receipt of a certification from the employer or plan sponsor that the health information will be protected as prescribed by the rule and will not be used for employment-related actions. The covered group health plan must comply with Privacy Rule requirements, though these requirements will be limited when the group health plan is fully insured. See the Answer to the FAQ "Is a fully insured health plan subject to all Privacy Rule requirements?" That question, hundreds of FAQs, and a wide range of other guidance and materials to assist covered entities in complying with HIPAA and the Privacy Rule, are available at the Department of Health and Human Services Office for Civil Rights Web site .

Date Created: 04/06/2004

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Affordable Care Act Implementation FAQs - Set 15

Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of various provisions of the Affordable Care Act.  These FAQs have been prepared jointly by the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively, the Departments).  Like previously issued FAQs (available at http://www.dol.gov/ebsa/healthreform/ and Fact Sheets & Frequently Asked Questions (FAQs) ), these FAQs answer questions from stakeholders to help people understand the law and benefit from it, as intended.

Annual Limit Waiver Expiration Date based on a Change to a Plan or Policy Year

Q1:  If a group health plan or health insurance issuer that was granted a waiver from the annual limits requirements under Public Health Service Act (PHS Act) section 2711 changes its plan year (or, in the individual market, policy year) prior to the waiver expiration date, can that change modify the expiration date of the waiver?

No.  Changing the plan year (or, in the individual market, policy year) does not change the waiver expiration date.  Annual limit waivers under PHS Act section 2711 1 were approved by HHS for the plan or policy year in effect when the plan or issuer applied for the waiver.  The same holds true for waiver extensions.  They extended the waiver based on the date of the plan or policy year in effect when the initial application was submitted.  As a result, waiver recipients that change their plan or policy years will not extend the expiration date of their waivers.

For example, if a waiver approval letter states that a waiver is granted for an April 1, 2013 plan or policy year, the waiver will expire on March 31, 2014, regardless of whether the plan or issuer later amends its plan or policy year.  That said, waiver recipients may terminate the waiver at any time prior to its approved expiration date, for example, on December 31, 2013 rather than on March 31, 2014. 

Additionally, HHS requested that each plan or issuer provide its effective dates of coverage as part of its annual limit waiver application, in part so that HHS would have a record of the waiver’s expiration date.  As noted in the Technical Instructions, 2 waiver recipients must retain all records pertaining to their waiver applications to permit HHS to conduct audits of waiver applications. If there is a discrepancy between the plan or policy year in an original application and a subsequent annual update, HHS may review the waiver to determine whether the group health plan or health insurance issuer is in compliance with HHS’s policy on annual limit waivers. 

Provider Non-Discrimination

PHS Act section 2706(a), 3 as added by the Affordable Care Act, states that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law.”  PHS Act section 2706(a) does not require “that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer,” and nothing in PHS Act section 2706(a) prevents “a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.”  Similar language is included in section 1852(b)(2) of the Social Security Act 4 and implementing HHS regulations. 5

Q2:  Will the Departments be issuing regulations addressing PHS Act section 2706(a) prior to its effective date?

No.  The statutory language of PHS Act section 2706(a) is self-implementing and the Departments do not expect to issue regulations in the near future.  PHS Act section 2706(a) is applicable to non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years (in the individual market, policy years) beginning on or after January 1, 2014. 

Until any further guidance is issued, group health plans and health insurance issuers offering group or individual coverage are expected to implement the requirements of PHS Act section 2706(a) using a good faith, reasonable interpretation of the law.  For this purpose, to the extent an item or service is a covered benefit under the plan or coverage, and consistent with reasonable medical management techniques specified under the plan with respect to the frequency, method, treatment or setting for an item or service, a plan or issuer shall not discriminate based on a provider’s license or certification, to the extent the provider is acting within the scope of the provider’s license or certification under applicable state law.  This provision does not require plans or issuers to accept all types of providers into a network.  This provision also does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations.

The Departments will work together with employers, plans, issuers, states, providers, and other stakeholders to help them come into compliance with the provider nondiscrimination provision and will work with families and individuals to help them understand the law and benefit from it as intended. 

 For questions about the provider nondiscrimination provision, including complaints regarding compliance with the statutory provision by health insurance issuers, contact your state department of insurance (contact information is available by visiting www.healthcare.gov/using-insurance/managing/consumer-help/index.html ) or the Centers for Medicare & Medicaid Services, Center for Consumer Information and Insurance Oversight at 1- 888-393- 2789.  For employment-based group health plan coverage, you also may contact the Department of Labor at www.askebsa.dol.gov or 1-866-444-3272.

Coverage for Individuals Participating in Approved Clinical Trials  

In general, PHS Act section 2709(a), 6 as added by the Affordable Care Act, states that if a group health plan or health insurance issuer in the group and individual health insurance market provides coverage to a qualified individual (as defined under PHS Act section 2709(b)), then such plan or issuer: (1) may not deny the qualified individual participation in an approved clinical trial with respect to the treatment of cancer or another life-threatening disease or condition; (2) may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial; and (3) may not discriminate against the individual on the basis of the individual’s participation in the trial.

A qualified individual under PHS Act section 2709(b) is generally a participant or beneficiary who is eligible to participate in an approved clinical trial according to the trial protocol with respect to the treatment of cancer or another life-threatening disease or condition; and either: (1) the referring health care professional is a participating provider and has concluded that the individual’s participation in such trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual’s participation in such trial would be appropriate. 

Q3:  Will the Departments be issuing regulations addressing PHS Act section 2709 prior to its effective date?

No.  The statutory language of PHS Act section 2709 is self-implementing and the Departments do not expect to issue regulations in the near future.  PHS Act section 2709 is applicable to non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years (in the individual market, policy years) beginning on or after January 1, 2014.

Until any further guidance is issued, group health plans and health insurance issuers are expected to implement the requirements of PHS Act section 2709 using a good faith, reasonable interpretation of the law.  The Departments will work together with employers, plans, issuers, states, providers, and other stakeholders to help them come into compliance with the law and will work with families and individuals to help them understand the coverage for clinical trials provision and benefit from it as intended.  

For questions about the coverage for clinical trials provision, including complaints regarding compliance with the statutory provision by health insurance issuers, contact your state department of insurance (contact information is available by visiting www.healthcare.gov/using-insurance/managing/consumer-help/index.html ) or the Centers for Medicare & Medicaid Services, Center for Consumer Information and Insurance Oversight at 1- 888-393- 2789.  For employment-based group health plan coverage, you also may contact the Department of Labor at www.askebsa.dol.gov or 1-866-444-3272. 

Transparency Reporting

Under section 1311(e)(3) of the Affordable Care Act, as implemented by regulations at 45 CFR 155.1040(a) and 156.220, health insurance issuers seeking certification of a health plan as a qualified health plan (QHP) must make accurate and timely disclosures of certain information to the appropriate Health Insurance Marketplace (also known as Exchange), the Secretary of HHS, and the state insurance commissioner, and make it available to the public.  Section 2715A of the PHS Act, 7 as added by the Affordable Care Act, extends the transparency reporting provisions under section 1311(e)(3) to non-grandfathered group health plans and health insurance issuers offering group or individual coverage, except that a plan or coverage not offered through an Exchange shall only be required to submit such information to the Secretary of HHS and state insurance commissioner, and make the information public.

Q4:  When do plans and issuers have to comply with the transparency in coverage reporting requirements under section 1311(e)(3) of the Affordable Care Act and section 2715A of the PHS Act?

Section 1311(e)(3) of the Affordable Care Act, as implemented at 45 CFR 155.1040(a) and 156.220, requires QHP issuers to submit specified information to the Marketplace and other entities in a timely and accurate manner.  However, because QHP issuers will not have some of the data necessary for reporting under this requirement until during or after the first year of operation of their QHPs (e.g., QHP enrollment and disenrollment), HHS is clarifying that, in order to comply with section 1311(e)(3) as implemented at 45 CFR 155.1040(a) and 156.220, QHP issuers will begin submitting information only after QHPs have been certified as QHPs for one benefit year. 8

Similarly, because section 2715A of the PHS Act simply extends the transparency provisions set forth in section 1311(e)(3) of the Affordable Care Act to group health plans and health insurance issuers offering group and individual health insurance coverage, the Departments clarify that the reporting requirements under section 2715A of the PHS Act will become applicable to group health plans and health insurance issuers offering group and individual health insurance coverage no sooner than when the reporting requirements under section 1311(e)(3) of the Affordable Care Act become applicable.  As previously stated, the Departments will coordinate regulatory guidance on the transparency in coverage standards for coverage offered inside and outside of the Marketplaces. 9

[1]  The annual limit waiver program was established in the June 28, 2010 interim final regulations (IFR) (codified at 26 CFR 54.9815-2711T; 29 CFR 2590.715-2711; and 45 CFR 147.126) that implemented PHS Act section 2711, as amended by the Affordable Care Act.  PHS Act section 2711 generally prohibits group health plans and health insurance issuers offering group or individual health insurance coverage (other than with respect to non-grandfathered individual health plans) from imposing lifetime or annual limits on the dollar value of essential health benefits, but allows ‘‘restricted annual limits’’ with respect to essential health benefits (as defined in section 1302(b) of the Affordable Care Act) for plan years (in the individual market, policy years) beginning before January 1, 2014.  The IFR provided that these restricted annual limits may be waived by the Secretary of HHS if compliance with the IFR would result in a significant decrease in access to benefits or a significant increase in premiums.  Subregulatory guidance issued by HHS set forth the process for obtaining such a waiver.  For a listing of relevant guidance, see /cciio/Resources/Regulations-and-Guidance/index#Annual Limits .

[2]  See Technical Instructions, page 3, annual _limit_waivers_technical_instructions_update_081911-001 (PDF) . (June 17, 2011).

[3]  PHS Act section 2706(a) also is incorporated into section 715(a)(1) of the Employee Retiree Income Security Act (ERISA) and section 9815(a)(1) of the Internal Revenue Code (the Code).  Accordingly, the Departments have concurrent jurisdiction over the implementation of PHS Act section 2706(a).

[4]  Section 1852(b)(2) of the Social Security Act provides that “A Medicare+Choice organization shall not discriminate with respect to participation, reimbursement, or indemnification as to any provider who is acting within the scope of the provider’s license or certification under applicable state law, solely on the basis of such license or certification. This paragraph shall not be construed to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan’s enrollees or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan.” 

[5]  42 CFR 422.205 provides, in part, that a “[Medicare Advantage] organization may select the practitioners that

participate in its plan provider networks.  In selecting these practitioners, an MA organization may not discriminate,

in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his or her license or certification under state law, solely on the basis of the license or certification.  If an MA organization declines to include a given provider or group of providers in its network, it must furnish written notice to the effected provider(s) of the reason for the decision.”  Section 422.205 further provides that it “does not preclude any of the following [actions] by the MA organization: (1) Refusal to grant participation to health care professionals in excess of the number necessary to meet the needs of the plan’s enrollees (except for MA private-fee-for-service plans, which may not refuse to contract on this basis); (2) Use of different reimbursement amounts for different specialties or for different practitioners in the same specialty; [and] (3) Implementation of measures designed to maintain quality and control costs consistent with its responsibilities.”

[6]  PHS Act section 2709 also is incorporated into section 715(a)(1) of ERISA and section 9815(a)(1) of the Code.  Accordingly, the Departments have concurrent jurisdiction over the implementation of PHS Act section 2709.

[7]  PHS Act section 2715A also is incorporated into section 715(a)(1) of ERISA and section 9815(a)(1) of the Code.  Accordingly, the Departments have concurrent jurisdiction over the implementation of PHS Act section 2715A.

[8]  Benefit year is defined as a calendar year for which a health plan provides coverage for health benefits.  45 CFR 155.20.

[9]  See Preamble to the Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers, 77 FR 18310, 18417 (March 27, 2012).

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group health plans may deny participation

Section 108, Division BB of the Consolidated Appropriations Act, 2021 requires the Departments of Labor, Health & Human Services and the Treasury (the “Departments”) to issue regulations under Section 2706(a) of the Public Health Service Act (the “Provision”).  The Provision bars group health plans and health insurance carriers from discriminating, with regard to participation under a plan or coverage, against any health provider that acts “within the scope of its license or certification under applicable state law.” Once issued, these rules will have important consequences for group health plans and other stakeholders.

This post reports on a recent listening session organized by the Departments that offered a forum to examine the issues and for interested parties to stake out their positions.

Section 2706(a) of the Public Health Service Act, as enacted by the Affordable Care Act, bars group health plans and health insurance carriers from discriminating, with regard to participation under a plan or coverage, against any health provider that acts “within the scope of its license or certification under applicable state law.”  Section 2706(a) is incorporated by reference into ERISA Section 715(a)(1) and Internal Revenue Code Section 9815(a)(1). As a consequence, the Departments have concurrent jurisdiction over the implementation of Provision. It is also the reason why group health plans of all stripes have a stake in the matter.

In  FAQs  issued in April 2013, the Departments said that the Provision was “self-implementing.” Regulations, in their view, were therefore unnecessary. Shortly thereafter, the lawmakers took issue with the Departments’ assessment. From S. Rep. No. 113-71 at 126 (Jul. 11, 2013):

The goal of this provision is to ensure that patients have the right to access covered health services from the full range of providers licensed and certified in their State.  The Committee is therefore concerned that the FAQ document issued by [the Departments] on April 29, 2013, advises insurers that this nondiscrimination provision allows them to exclude from participation whole categories of providers operating under a State license or certification.  In addition, the FAQ advises insurers that section 2706 allows discrimination in reimbursement rates based on broad “market considerations” rather than the more limited exception cited in the law for performance and quality measures. Section 2706 was intended to prohibit exactly these types of discrimination.  The Committee believes that insurers should be made aware of their obligation under section 2706 before their health plans begin operating in 2014.  The Committee directs HHS to work with DOL and the Department of Treasury to correct the FAQ to reflect the law and congressional intent within 30 days of enactment of this act. (Emphasis added).

The House of Representatives also questioned the Departments’ failure to act. In response, the Departments issues a revised  FAQ , which provided, in relevant part:

Q4. What is the Departments’ approach to PHS Act section 2706(a)? In light of the breadth of issues identified in the comments to the RFI, the Departments are restating their current enforcement approach to PHS Act section 2706(a).  Until further guidance is issued, the Departments will not take any enforcement action against a group health plan, or health insurance issuer offering group or individual coverage, with respect to implementing the requirements of PHS Act section 2706(a) as long as the plan or issuer is using a good faith, reasonable interpretation of the statutory provision…

The lawmakers were apparently irked by the lack of clarity on whether, or to what extent, a plan could leave out certain types of providers and still be acting under a “good faith, reasonable interpretation” of the statute.  The issue resurfaced in Section 108, Division BB of the Consolidated Appropriations Act, 2021, which requires the Departments to issue regulations under the Provision.

The Statute

Section 2706(a) of the Public Health Service Act reads as follows:

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

The rule is all of three sentences, two of which tell us what non-discrimination is  not .  The section’s normative rule bars discrimination by a group health plan against “any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.”  In writing regulations, the Departments are going to need to specify what, exactly, constitutes discrimination.  While the rule seems straightforward enough, what it means for employer-sponsored group health plans is less than clear. For example:

Can an employer exclude entire classes of providers?

Could a self-funded group health plan chose not to cover, say, chiropractic services?  The passage from the above-cited Senate report appears to think that this should not be allowed under the Provision.  But what distinguishes this reading of the rule from the establishment of a garden variety any-willing-provider requirement?  Or does this mean that, if a plan chooses to cover chiropractic services, then it must agree to contract with all licensed chiropractors in the state?  And, if so, would even this limited reading pass muster?

Can an employer vary the amounts paid to a provider based on skills, geography, education and experience in addition to quality measures? 

Section 2706(a) does not say.

Can employers refuse to engage in network negotiations based on a bona fide business reason?

One would hope this is the case. It is certainly consistent with the language that does not require contracting with any willing provider.

Is the Provision really just a transparency requirement?

Might the rule be read to simply require that an employer/group health plan sponsor be able to furnish a good reason for treating providers differently?

What is the impact of the Provision on carrier networks?

Part of the carrier’s value proposition is building and curating of a network.  To the extent that the Departments read the Provision broadly, this value proposition is potentially undermined.

The Listening Session

On January 19, 2022, the Departments hosted what was billed as a “listening session” regarding provider non-discrimination under Section 2706(a) of the Public Health Service Act.  The event featured presentations by more than a dozen representatives of trade associations with an interest in the Provision, including carriers, various provider organizations, and business-oriented organizations.  While the participants in the listening session represented diverse and competing interests, there were some areas of agreement.  For example, the view that the Provision is not an “any-willing-provider” mandate was unanimous.

Not surprisingly, the session also exposed certain fault lines that divided interested parties. Providers generally urged a broad reading of the rule, i.e., an “any-licensed-provider” reading.  The problem with this approach is that one would be hard-pressed to distinguish between an any-willing-provider rule and an “any-licensed-provider” rule.  Providers would also like to see payment parity for a particular service irrespective of the provider’s license.  While such an approach would mark a radical departure from current practice, it does not appear to be prohibited based on the text of the Provision.  Group health plans, on the other hand, would prefer the status quo ante.  The problem with that is, of course, that Congress must have intended the statute to do something.  Lastly, carriers urged the Departments to protect their ability to design and monitor their networks.  While their concern is understandable, it seems that there will be some impairment of this ability, if only at the margins.  

The issues raised above invite a fundamental question: what, if anything, is left of the first sentence of Section 2706(a) of the Public Health Service Act once the second and third sentences are applied?  One presumes that Congress must have intended that there be  some  residue.  It is up to the Departments to determine the contours of that residue.  Where they come out could be enormously consequential for employer-sponsored group health plans.

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  • Definitions A - M

Group Health Insurance: What It Is, How It Works, Benefits

Julia Kagan is a financial/consumer journalist and former senior editor, personal finance, of Investopedia.

group health plans may deny participation

Thomas J Catalano is a CFP and Registered Investment Adviser with the state of South Carolina, where he launched his own financial advisory firm in 2018. Thomas' experience gives him expertise in a variety of areas including investments, retirement, insurance, and financial planning.

group health plans may deny participation

What Is a Group Health Insurance Plan?

Group Insurance health plans provide coverage to a group of members, usually comprised of company employees or members of an organization. Group health members usually receive insurance at a reduced cost because the insurer’s risk is spread across a group of policyholders. There are plans such as these in both the U.S. and Canada .

Key Takeaways

  • Group members receive insurance at a reduced cost because the insurer’s risk is spread across a group of policyholders.
  • Plans usually require at least 70% participation in the plan to be valid. 
  • Premiums are split between the organization and its members, and coverage may be extended to members' families and/or other dependents for an extra cost.
  • Employers can enjoy favorable tax benefits for offering group health insurance to their employees.

Group health insurance plans are purchased by companies and organizations and then offered to their members or employees. Plans can only be purchased by groups, which means individuals cannot purchase coverage through these plans. Plans usually require at least 70% participation in the plan to be valid. Because of the many differences—insurers, plan types, costs, and terms and conditions—between plans, no two are ever the same.

Group plans cannot be purchased by individuals and typically require at least 70% participation by group members.

Once the organization chooses a plan, group members are given the option to accept or decline coverage. In certain areas, plans may come in tiers, where insured parties have the option of taking basic coverage or advanced insurance with add-ons. The premiums are split between the organization and its members based on the plan. Health insurance coverage may also be extended to the immediate family and/or other dependents of group members for an extra cost.

The cost of group health insurance is usually much lower than individual plans because the risk is spread across a higher number of people. Simply put, this type of insurance is cheaper and more affordable than individual plans available on the market because more people buy into the plan.

The earliest known example of group coverage for health services dates to 1798, when Congress established the U.S. Marine Hospital for Navy seamen. Participation was compulsory, with deductions coming from salaries. Other examples include the mining, lumber, and railroad industries in the late 1800s, which had a vested interest in ensuring the health of its workers.

Montgomery Ward is credited with establishing the nation’s first group health insurance policy in 1910. The policy did not reimburse workers for medical expenses, but provided cash payments to workers equal to half their wages in the event of injury or illness.

The progressive political movement of the early 1900s led to several proposals to establish compulsory national health insurance. However, these proposals failed to counter opposition from doctors, who objected to uniform fee structures; labor groups, which felt their power would be weakened; and insurance companies, which feared encroachment on their business.

Employer-sponsored group health insurance grew rapidly in the 1940s as a way for employers to get around wage controls set during World War II. In 1943, the War Labor Board introduced wage caps but did not include insurance premiums as part of the cap. As such, employers were free to offer health insurance to attract and retain workers, resulting in a tripling of health insurance coverage by the end of the war.

But this failed to address the needs of retirees and other non-working adults. Federal efforts to provide coverage to those groups led to the Social Security Amendments of 1965, which laid the foundation for Medicare and Medicaid .

Benefits of a Group Health Insurance Plan

The primary advantage of a group plan is that it spreads risk across a pool of insured individuals. This benefits the group members by keeping premiums low, and insurers can better manage risk when they have a clearer idea of who they are covering. Insurers can exert even greater control over costs through health maintenance organizations (HMOs), in which providers contract with insurers to provide care to members.

The HMO model tends to keep costs low, at the cost of restrictions on the flexibility of care afforded to individuals. Preferred provider organizations (PPOs) offer the patient a greater choice of doctors and easier access to specialists but tend to charge higher premiums than HMOs.

The percent of the U.S. population covered by employer-provided group health insurance in 2021.

The vast majority of group health insurance plans are employer-sponsored benefit plans. It is possible, however, to purchase group coverage through an association or other organizations. Examples of such plans include those offered by the American Association of Retired Persons (AARP), the Freelancers Union, and wholesale membership clubs.

Not everyone is covered by a group health insurance plan. For many decades, these uninsured people were forced to bear the cost of healthcare on their own. But that has changed.

Government-sponsored health plans are an option for those left out of employer-sponsored group health insurance. The Affordable Care Act (ACA) adopted in 2010 created a marketplace for health insurance that provides coverage to 16.3 million people as of the 2022-2023 open enrollment season.

After the passage of the ACA, taxpayers were required to show they had health insurance coverage or qualified for an exemption, or else they were required to pay a penalty described as a “shared responsibility payment.” This mandated payment was eliminated with the passage of the Tax Cuts and Jobs Act beginning in the 2019 tax year.

United Healthcare, a division of UnitedHealth Group (UHC), is one of the nation's largest health insurers. It offers a buffet of group health insurance options for all types of businesses. Include are medical plans and specialty, supplemental plans, such as dental, vision, and pharmacy.

United Healthcare offers plans under the federally-sponsored Small Business Health Options (SHOP) program, a provision of the Affordable Care Act. In most states, employers must have 50 or fewer full-time employees, although some states allow for as many as 100 employees. Businesses that pay at least 50% of the insurance premium qualify for a 50% tax credit.

Midsize businesses, with between 51 and 2,999 employees, have various options available, including bundles. Large businesses, with 3,000 or more employees, qualify as national accounts, which have more services and healthcare features, including the ability to customize plan offerings.

What Is a Group Health Plan?

Group health plans are employer- or group-sponsored plans that provide healthcare to members and their families. The most common type of group health plan is group health insurance, which is health insurance extended to members, such as employees of a company or members of an organization.

What Is a Group Health Cooperative?

A group health cooperative, also known as mutual insurance, is a health insurance plan owned by the insured members . Insurance is offered at a reduced cost, and what they collect from members is based on claims paid. The cost of care is spread out across the insured population.

How Many Employees Do You Need to Qualify for Group Health Insurance?

Many group health insurers offer plans to companies with one or more employees. The type of plans available, however, may vary according to the size of the business . For example, United Healthcare provides various plans for small businesses with 1-50 employees, midsize businesses with 51-2,999, and large employers with 3,000 or more employees.

What Are Group Health Insurance Benefits?

Group health insurance plans offer medical coverage to members of an organization or employees of a company. They may also provide supplemental health plans—such as dental, vision, and pharmacy—separately or as a bundle. Risk is spread across the insured population, which allows the insurer to charge low premiums. And members enjoy low-cost insurance, which protects them from unexpected costs arising from medical events.

How Much Does Group Health Insurance Cost?

The average group health insurance policy costs roughly $7,400 annually for an individual, with the employee paying 17% of the premium. For family coverage, the average cost was about $21,000 per year, with the employee paying 27% of the premium.

Group health insurance plans are one of the most affordable types of health insurance plans available. Because risk is spread among insured persons, premiums are considerably lower than traditional individual health insurance plans. This is possible because the insurer assumes less risk as more people participate in the plan. For employees who ordinarily would not be able to afford individual health insurance, it is an attractive benefit.

U.S. Bureau of Labor Statistics, Monthly Labor Review. “ The Development and Growth of Employer-Provided Health Insurance ,” Pages 3-4.

Marilyn J. Field and Harold T. Shapiro. “ Employment and Health Benefits: A Connection at Risk ,” Chapter 2.

National Archives. “ Medicare and Medicaid Act (1965) .”

Kaiser Family Foundation. " Health Insurance Coverage for the Total Population ."

U.S. Department of Health and Human Services. “ Biden-Harris Administration Announces Record-Breaking 16.3 Million People Signed Up for Health Care Coverage in ACA Marketplaces During 2022-2023 Open Enrollment Season .”

Internal Revenue Service. “ Individual Shared Responsibility Provision .”

United HealthCare Services. “ Small Business Health Options Program (SHOP) .”

Kaiser Family Foundation. “ 2020 Employer Health Benefits Survey .”

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Employee Benefits Compliance

How can’t you discriminate let me count the ways.

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There are so many different types of nondiscrimination rules, employers are often confused when various governmental agencies issue nondiscrimination rules. For example:

  • HHS recently issued nondiscrimination rules implementing ACA section 1557 and requiring health programs that receive financial assistance from HHS to cover transgender medical services.
  • Two days later the EEOC published nondiscrimination rules on Wellness plans , the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA).
  • Employers have been waiting since 2011 for the IRS to issue nondiscrimination rules for insured group health plans. The ACA says these should be similar to existing IRC section 105(h) nondiscrimination rules that apply to self-insured group health plans.

Why are there so many different types of nondiscrimination rules? Because different laws prohibit discrimination based on various factors, and different regulatory agencies administer the various laws and issue regulations to limit or prohibit discrimination in that particular area.  For example, tax laws (administered by the Internal Revenue Service) prohibit benefits discrimination in favor of “highly-compensated” employees.  Employment laws (administered by the Dept. of Labor and the EEOC) prohibit discrimination based on race, religion, national origin, gender, pregnancy, gender identification, and disability.   HIPAA prohibits health plans from discriminating based on health status factors, and the Mental Health Parity and Addiction Equity Act (MHPAEA) prohibits discrimination (in terms of payment and coverage) against mental health and substance use disorder services.

In some cases several different nondiscrimination law apply (wellness programs, for example), and regulations issued by different agencies may be inconsistent. Thus, it is important to understand ALL the nondiscrimination rules that apply.

This article explains different types of nondiscrimination rules that apply for benefits, compensation and employment; what laws contain these rules; and which government agencies have jurisdiction over the various laws.

The following matrix summarizes the various types of benefits and prohibited discrimination, and the effects of discriminating. Additional information is provided following the matrix.

Additional Details on the Various Types of Nondiscrimination Rules Listed Above  

The Internal Revenue Code (Code) includes numerous sections that prohibit employee benefit plans from discriminating in favor of higher-paid employees and against lower-paid employees or the “rank-and-file” employees.  Specifically, these Code sections prohibit discrimination in favor of highly compensated “employees,” “individuals” or “participants” (HCEs, HCIs or HCPs) or in favor of “key” employees (the most highly paid).  These terms are defined below. The reason the Code prohibits discrimination in favor of highly-paid individuals is because certain benefits receive favorable tax treatment (because Congress wants to encourage employers to provide these benefits to employees),  so from a public policy perspective these benefits should be available to most or all employees, not predominantly just to the highly-paid.

The Affordable Care Act (ACA) also includes various nondiscrimination provisions.

  • Insured plans cannot discriminate in favor of highly compensated employees and against non-highly compensated employees.  (PHSA 2716)
  • Nondiscrimination against patients in clinical trials: A plan or issuer may not deny a qualified individual the right to participate in a clinical trial and may not limit or impose additional conditions on the coverage of routine patient costs for any items or services furnished in connection with participation in an approved clinical trial.
  • Market Reforms – Health plans and insurers cannot discriminate against any health care provider acting within the scope of his/her license or certification under applicable state law.  (PHSA 2706)

The Employee Retirement Income Security Act (ERISA) did not initially include nondiscrimination provisions, but it has been amended to include nondiscrimination provisions under HIPAA, the MHPAEA, the ACA.   Thus, ERISA now prohibits discrimination based on health status factors, mental health, nondiscrimination provisions in the ACA (listed above).  ERISA is administered by the Employee Benefits Security Administration (EBSA) of the DOL.

The Health Insurance Portability and Accountability Act (HIPAA) prohibits discrimination based on “health status factors.”  Adverse “health status” factors or conditions could be pre-existing conditions, chronic diseases, genetic or hereditary health conditions, or any type of injury or illness, such as cancer or AIDS, prior claims, hospital or facility confinement, not actively-at-work, or disability.  HIPAA prohibits plans and insurers from charging higher prices to, or refusing to cover, or excluding certain benefits for people who have adverse health factors such as those listed above.  The “wellness program” rules provide a limited exception to the HIPAA health status factor nondiscrimination rules, so long as specific criteria are met.  That is, under a wellness program (a program of “health promotion and disease prevention”), an employer can charge higher premiums or cost-sharing (such as copayments, deductibles or coinsurance) to employees who do not participate or do not meet certain outcomes or “reasonable alternative standards.” The allowable discrimination is that the employer can charge such employees an additional 30% for their group health plan premiums (50% for tobacco cessation programs).  Wellness programs also must comply with other federal nondiscrimination rules listed below, such as the ADA and GINA.  Rewards/ penalties under tobacco cessation programs subject to the ADA are limited to 30% of the total self-only health plan premium (not 50% as HIPAA would allow).

The Mental Health Parity and Addiction Equity Act (MHPAEA ) requires that a group health plan’s coverage of and payment for mental health and substance use disorder (MH/SUD) benefits must be in “parity” with the plan’s coverage of and payment for medical and surgical benefits. Specifically, the MHPAEA requires that:

  • the financial requirements and quantitative treatment limitations  (QTLs) that apply to MH/SUD benefits cannot be any more restrictive than the “predominant” financial requirements and QTLs that apply to “substantially all” medical/ surgical benefits under the plan; and
  • for non-quantitative treatment limitations (NQTLs), the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits cannot be more restrictive than those that apply to medical/surgical benefits.  For example, preauthorization requirements applied to MH/SUD services cannot be more restrictive than those applied to medical/surgical services.

The MHPAEA also requires parity in any aggregate lifetime or annual dollar limits on MH/SUD and medical/surgical benefits; however, these types of limits no longer apply to most types of benefits since the Affordable Care Act prohibits plans form imposing such limits on benefits that are “essential health benefits”(EHBs).

The MHPAEA is administered jointly by the Employee Benefits Security Administration (EBSA) of the Department of Labor (DOL); Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS); and the Internal Revenue Service (IRS), Department of the Treasury.

The Equal Employment Opportunity Commission (EEOC) enforces federal laws that make it illegal to discriminate against a job applicant or an employee because of the person’s race, color, religion, sex (including pregnancy, gender identity, transgender status and sexual orientation), national origin, age (40 or older), disability or genetic information. These laws also prohibit retaliation against a person because the person complained about discrimination, filed a charge of discrimination, or participated in an employment discrimination investigation or lawsuit.

The laws apply to all types of work situations, including hiring, firing, promotions, harassment, training, wages, and benefits. For additional information, see the EEOC website at https://www.eeoc.gov/laws/statutes/ .

The laws enforced by the EEOC include:

  • Title I of the Americans with Disabilities Act of 1990 (ADA) This law makes it illegal to discriminate against a qualified person with a disability in regard to compensation or other terms and conditions of employment, including “fringe benefits available by virtue of employment, whether or not administered by the covered entity.”  The ADA generally prohibits employers from making disability-related inquiries or requiring medical examinations unless needed to determine ability to perform the essential functions of the job. It does include an exception for voluntary employee health programs, including many workplace wellness programs. The ADA also requires employers to “reasonably accommodate” the known physical or mental limitations of an “otherwise qualified individual with a disability” who is an applicant or employee, unless doing so would impose an “undue hardship” on the employer’s business. The ADA applies to employers in the private sector and in state and local governments.
  • The Genetic Information Nondiscrimination Act of 2008 (GINA) ( Effective –  11-21-09).  This law makes it illegal to discriminate against employees or applicants because of genetic information. Genetic information includes information about an individual’s genetic tests and the genetic tests of an individual’s family members, as well as information about any disease, disorder or condition of an individual’s family members (i.e. an individual’s family medical history).
  • The Age Discrimination in Employment Act of 1967 (ADEA) This law protects people who are 40 or older from discrimination because of age.
  • Title VII of the Civil Rights Act of 1964 (Title VII) This law makes it illegal to discriminate against someone on the basis of race, color, religion, national origin, or sex. The law also requires that employers reasonably accommodate applicants’ and employees’ sincerely held religious practices, unless doing so would impose an undue hardship on the operation of the employer’s business.
  • The Pregnancy Discrimination Act This law amended Title VII to make it illegal to discriminate against a woman because of pregnancy, childbirth, or a medical condition related to pregnancy or childbirth.
  • The Equal Pay Act of 1963 (EPA) This law makes it illegal to pay different wages to men and women if they perform equal work in the same workplace.
  • Sections 501 and 505 of the Rehabilitation Act of 1973 This law makes it illegal to discriminate against a qualified person with a disability in the federal government. The law also requires that employers reasonably accommodate the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or employee, unless doing so would impose an undue hardship on the operation of the employer’s business.
  • Sections 102 and 103 of the Civil Rights Act of 1991 Among other things, this law amends Title VII and the ADA to permit jury trials and compensatory and punitive damage awards in intentional discrimination cases.

Additionally, state employment laws also prohibit employers from discriminating in terms and conditions of employment (including leave and benefits terms) based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age (40 or older), disability or genetic information. An example of a state law would be the California Fair Employment and Housing Act (FEHA).

So the next time someone says a certain action or benefit plan provision would be discriminatory, ask them just what nondiscrimination law they believe it would violate.

Excellent article, thank you for the detailed information.

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US denies involvement in Kremlin drone attack and says Moscow lacks strength to mount large attacks – as it happened

After Moscow accuses US of being behind Kremlin drone attack, White House says: ‘We had nothing to do with this’. This live blog is closed

  • 4 May 2023 Summary
  • 4 May 2023 Moscow's forces lack the strength to mount large-scale attacks, says US intelligence chief
  • 4 May 2023 US denies involvement in claimed Kremlin drone attack
  • 4 May 2023 Summary of the day so far …
  • 4 May 2023 Moscow blames Washington for Kremlin drone incident
  • 4 May 2023 Zelenskiy on ICC visit: 'We all want to see a different Vladimir here in The Hague'
  • 4 May 2023 Zelenskiy to have meeting at ICC in The Hague
  • 4 May 2023 Drones hitting Odesa had 'for Moscow' and 'for the Kremlin' scrawled on them
  • 4 May 2023 Zelenskiy denies Moscow claim of Kremlin drone attack
  • 4 May 2023 No casualties in Kyiv in Thursday morning attack
  • 4 May 2023 'All clear' in Kyiv - city officials
  • 4 May 2023 Oil refinery fire extinguished
  • 4 May 2023 Zelenskiy has arrived in the Netherlands – local media
  • 4 May 2023 Russia 'likely staged' Kremlin drone attack, says Institute for the Study of War
  • 4 May 2023 Explosions reported in Zaporizhzhia
  • 4 May 2023 Black Sea oil refinery ablaze in Russia
  • 4 May 2023 Russian oil refinery on fire – Ukraine armed forces
  • 4 May 2023 US embassy in Kyiv warns US citizens of 'ongoing heightened threat of missile attacks'
  • 4 May 2023 Ukraine Armed Forces report explosions in Odesa, Kramatorsk and Sloviansk
  • 4 May 2023 Air raid sirens sound in several regions as explosions reported in Odesa
  • 4 May 2023 Opening summary

A still image from video said to show alleged Ukrainian drone attack on Kremlin

US denies involvement in claimed Kremlin drone attack

The White House denies any involvement in an alleged drone attack on the Kremlin, with the spokesperson for its national security council, John Kirby , telling MSNBC:

We had nothing to do with this.

We reported earlier that the Kremlin’s spokesperson Dmitry Peskov had made the unsubstantiated claim the US was behind the incident. He said Russia knows “decisions about such terrorist attacks are taken in Washington” and that Kyiv “just implements these decisions”.

He added that “Washington is definitely behind this attack, we are aware of this,” though he offered no evidence to back up his claims.

Kirby said:

Peskov is just lying there, pure and simple.

He reiterated that Washington does not support or condone attacks by Ukraine outside its borders.

We’ve been clear with them publicly and we’ve been clear with them privately that we do not encourage nor do we enable them to strike outside Ukraine.

Here’s a summary of the day’s main events:

Russian forces in Ukraine are so degraded they cannot mount any significant offensive moves and are focused for now on consolidating control of occupied territory, the US intelligence chief said. Avril Haines said Putin’s strategy is likely to be to prolong the conflict until western support for Kyiv wanes.

The White House denied any involvement in an alleged drone attack on the Kremlin. The spokesperson for its National Security Council John Kirby told MSNBC: “We had nothing to do with this.”

Moscow has accused Kyiv of attempting a drone strike on the Kremlin with the aim of killing the Russian president, Vladimir Putin . The Kremlin said two drones had been used in the attack but were disabled by Russian defences. In a statement on its website, the Kremlin said it considered the attack a planned terrorist act and an attempt on the life of the president of the Russian Federation.

Kremlin spokesperson Dmitry Peskov blamed the US for the attack, saying “decisions about such terrorist attacks are taken in Washington” and that Kyiv “just implements these decisions”. He said “Washington is definitely behind this attack, we are aware of this.”

Zelenskiy denied Ukraine was responsible. “We don’t attack Putin, or Moscow, we fight on our territory,” he said. The US secretary of state, Antony Blinken, said the US could not confirm Russian reports that Ukraine targeted Putin.

Vladimir Putin must be brought to justice for his war in Ukraine , Volodymyr Zelenskiy said on Thursday during a visit to The Hague, where the international criminal court (ICC) is based. “We all want to see a different Vladimir here in the Hague, the one who deserves to be sanctioned for his criminal actions here, in the capital of international law,” Zelenskiy said in a speech. “I’m sure we will see that happen when we win,” he said, adding: “Whoever brings war must receive judgment.”

Ukrainian air defences said they downed 18 out of 24 kamikaze drones that Russia launched in a pre-dawn attack on Thursday. In a statement, Kyiv city administration said that all missiles and drones targeting the Ukrainian capital for the third time in four days, have been destroyed. No casualties were reported.

The US embassy in Ukraine has warned US citizens in the country of that there is an “ongoing heightened threat of missile attacks, including in Kyiv and Kyiv oblast”. It said, “In light of the recent uptick in strikes across Ukraine and inflammatory rhetoric from Moscow, the Department of State cautions US citizens of an ongoing heightened threat of missile attacks, including in Kyiv and Kyiv oblast.”

Russian emergency services extinguished a fire at a large oil refinery in Russia two hours after it was hit in a drone attack, Tass news agency reported early on Thursday. TASS said the incident occurred at the Ilsky refinery near the Black Sea port of Novorossiysk in the Krasnodar region, and that four drones were used. A day earlier, a fuel depot further to the west caught on fire near a bridge linking Russia’s mainland with the occupied Crimea peninsula.

Residents of the key southern Ukrainian city of Kherson were stocking up on food and water after another night of heavy Russian shelling and before an announced 56-hour curfew due to begin on Friday evening. A number said they planned to stay indoors before the curfew and planned closure of the city, adding that they had slept in their clothes or gone to shelters because of the intensity of the Russian attack.

Finland has received a diplomatic note from Russia complaining over vandalism at a Russian consulate on the demilitarised Aland island located in the Baltic Sea between Finland and Sweden, the Finnish foreign ministry said on Thursday.

Zelenskiy handed out watches to wounded Ukrainian soldiers at a Dutch military base on Thursday as part of his surprise visit to the Netherlands, Reuters reports.

The Ukrainian president earlier met the king and prime minister and called for a new international tribunal to be set up in The Hague to try Russia’s leadership for the crime of aggression over its invasion of Ukraine .

In his visit to the military base in Soesterberg, near Utrecht, the president met a handful of soldiers who are undergoing rehabilitation treatment in the Netherlands after suffering severe wounds in fighting against Russian forces.

A US envoy has welcomed an upcoming trip by a senior Brazilian official to Ukraine , but said any negotiations should not “reward” Russia, AFP reports.

Closing a trip to Brazil, Linda Thomas-Greenfield , the US ambassador to the United Nations, said officials affirmed “their commitment to addressing this issue from both sides”.

We’re not telling Brazil not to engage on peace. What we have said is that engagement has to take Ukraine into account and it cannot be a negotiation based on rewarding Russia for taking Ukraine territory during their unprovoked war.

Brazil has sought to chart a balanced path on the Ukraine war, condemning the invasion but not sending weapons to Ukraine or joining sanctions on Russia .

The Brazilian president, Luiz Inacio Lula da Silva , irritated the United States by saying on a visit to China last month that Washington was partly responsible for the war through its billions of dollars in weapons shipments to Ukraine.

Lula later said he opposed the invasion but favoured peace negotiations and would send to Ukraine a senior aide, Celso Amorim , whom Thomas-Greenfield met earlier Thursday at the presidential palace.

US intelligence officials are still trying to determine who was behind the drone incident at the Kremlin, and are exploring various possibilities – including a false flag operation by Russia or that a fringe group with sympathies for Ukraine could have been involved, the Associated Press reports, citing a US official.

But the official, who spoke on the condition of anonymity to discuss the sensitive matter, said intelligence officials don’t yet have any definitive answers. The official added that the Biden administration “certainly would not support the strike against Mr Putin”.

Zelenskiy’s top advisor, Mykhailo Podolyak , has claimed Russia had “staged” the alleged drone attack. He cited the delay in Russian state media reporting it and “simultaneous video from different angles” that appeared to show the aftermath of the alleged attack.

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