Important Benefit Notices
Continuation of Coverage (COBRA)
Federal law requires that most group health plans, including the plans the Town of Wilbraham offers its employees, give employees and their families the opportunity to continue their health care coverage through COBRA continuation coverage when there’s a “qualifying event” that would result in a loss of coverage under an employer’s plan; for instance, end of employment, reduction in hours of employment, death of employee, divorce or legal separation, entitlement to Medicare or loss of dependent child status.
For more information, please review the Department of Labor COBRA Fact Sheet (PDF).
Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage options for you and your family through the Health Insurance Marketplace, Medicaid or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage.
You should compare your other coverage options with COBRA continuation coverage and choose the coverage that is best for you. For example, if you move to other coverage, you may pay more out of pocket than you would under COBRA because the new coverage may impose a new deductible.
The Patient Protection and Affordable Care Act (PPACA)
The Massachusetts Health Exchange
The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums and cost-sharing reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance and co-payments) right away, and you can see what your premium, deductibles and out-of-pocket costs will be before you make a decision to enroll.
The Town as your employer is required under §1512 of the ACA (which creates 29 U.S.C. 218b), to provide you the information contained in this Notice (PDF). You may or may not qualify for health insurance through the Health Connector.
Annual Limits on Essential Health Benefits (ACA)
Starting in 2014, the Affordable Care Act prohibits annual dollar limits, which are the total benefits an insurance company will pay in a year while an individual is enrolled in a particular health insurance plan. For more information, please visit the Center for Consumer Information and Insurance Oversight. If you are offered coverage by your employer that is considered “affordable” and meets a “minimum value” standard according to federal definitions (see notice below), you most likely will not qualify for the subsidized coverage offered through the Health Connector described in this notice. However, it may still be helpful for you to read and understand the information included here. Please ask for more information if you have any questions.
To find out more about enrolling in the Marketplace, such as when the next open enrollment period will be and what you need to know about qualifying events and special enrollment periods, visit HealthCare.gov or visit HealthConnector Getting Started Guide.
Coverage for Clinical Trial Participants
Group health plans must cover certain clinical trial costs. They may not limit, deny, or require additional conditions on coverage of routine patient costs for services and items furnished in connection with the trial, and may not discriminate against individuals who participate in qualified clinical trials.
For more information on the coverage requirements, please visit Clinical Trials Under the Affordable Care Act (PDF).
Dependent Coverage to Age 26
All Town of Wilbraham health plans offer coverage for dependent children to age 26 (coverage ends on the last day of the month during which the child reaches age 26). The child is not required to live with the parent, and is eligible even if employed and being offered insurance through his/her own employer. If the child is a daughter, her pregnancy and delivery are covered; however, the grandchild will not be covered under the grandparents’ family plan.
For more information, please visit HealthCare.gov for health coverage for children under 26.
Out-of-Pocket Maximums/Cost Sharing (ACA)
Beginning with plan years renewing on or after January 1, 2014, all group health plans are required to include out-of-pocket maximums. All medical and pharmacy benefits must be applied to the out-of-pocket maximum. of no more than $6,350 for individuals, and $12,700 for families.
In 2014, all medical cost sharing must be applied to the out-of-pocket maximum. In 2015, all medical and pharmacy benefits must be applied to the out-of-pocket maximum. It is a limit to what you must pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, co-payments or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for non-essential health benefits.
For 2019 the out of pocket maximum for an individual will be $7,900 and $15,800 for a family.
Pre-existing Condition Exclusions (ACA)
Beginning with plan years renewing on or after January 1, 2014, group health plans cannot impose any pre-existing conditions exclusions, regardless of age.
Health Insurance Portability and Accountabilty Act (HIPAA)
HIPAA Special Enrollment Rules
If you are declining enrollment for yourself and/or your dependents or spouse because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in the Town’s plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. To request special enrollment or obtain more information, contact Gloria Congram, Benefits Administrator, at (413) 596-2800, Ext. 102, or meet her during office hours at Town all.
For more information, please visit HIPAA Frequently asked Questions.
Medicaid and Children's Health Insurance Program (CHIP)
Through the Marketplace, you will also learn if you qualify for premium assistance or free coverage from Medicaid (in Massachusetts, the program is known as MassHealth), or the Children's Health Insurance Program (CHIP).
Employees who turn 65 are not required to enroll in Medicare until they retire from active service.
Massachusetts General Laws Chapter 32B, Section 18A requires that a retiree, spouse or dependent insured or eligible to be insured by a town, city, county or district under this Chapter (if enrolled in Medicare Part A), shall enroll in Medicare B and a Medicare health plan. If a retiree does not submit the information required by the Town, the retiree shall no longer be eligible for the retiree’s existing health coverage. The governmental unit may, from time to time, request from a retiree, a retiree’s spouse or a retiree’s dependent, proof certified by the federal government of eligibility or ineligibility for Medicare Part A and Part B coverage. Different parts of Medicare cover different services. You may hear about four parts of Medicare: Part A, Part B, Part C and Part D.
Original Medicare, which is administered directly by the federal government (and is the way most people get their Medicare), has two parts:
1. Part A (Hospital Insurance) covers most medically necessary hospital, skilled nursing facility, home health and hospice care. It is free if you have worked and paid Social Security taxes for at least 40 calendar quarters (10 years); you will pay a monthly premium if you have worked and paid taxes for less time.
2. Part B (Medical Insurance) covers most medically necessary doctors’ services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services. You pay a monthly premium for this coverage.
3. “Part C” Medicare is not a separate benefit. Part C is the part of Medicare policy that allows private health insurance companies to provide Medicare benefits. These Medicare private health plans, such as HMOs and PPOs, are known as Medicare Advantage plans. If you want, you can choose to get your Medicare coverage through a Medicare Advantage plan instead of Original Medicare. The Medicare Advantage plans the Town of Wilbraham offers are the BC/BS Medicare HMO Blue plan, the Health New England Secure Freedom POS plan, and the Tufts Medicare Preferred Plan. All three options include prescription drug coverage which is at least as good as Medicare D coverage
4. Part D Medicare (Prescription Drug Insurance) is the part of Medicare that provides outpatient prescription drug coverage. Part D is provided only through private insurance companies that have contracts with the government -- it is never provided directly by the government (like Original Medicare is). If you want Part D, you must choose Part D coverage that works with your Medicare health benefits. If you have Original Medicare, choose a stand-alone Part D plan.
Women's Health and Cancer Rights Act (WHCRA)
The Women’s Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998, contains protections for patients who elect breast reconstruction in connection with a mastectomy. For plan participants and beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy.
- Applies to group health plans for plan years starting on or after October 21, 1998
- Applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy
- Requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient.
Under WHCRA, mastectomy benefits must include coverage for:
- Reconstruction of the breast on which the mastectomy was performed
- Surgery and reconstruction of the other breast to produce a symmetrical appearance
- Prostheses and physical complications at all stages of mastectomy, including lymphedemas
Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.
The law also contains prohibitions against:
- Plans and issuers denying patients eligibility or continued eligibility to enroll or renew coverage under the plan to avoid the requirements of WHCRA
- Plans and issuers providing incentives to, or penalizing, physicians to induce them to provide care in a manner inconsistent with the WHCRA
Group health plans, health insurance companies and HMOs covered by the law must notify individuals of the coverage required by WHCRA upon enrollment and annually thereafter. For more information regarding your rights after a mastectomy, please visit the United States Department of Labor - Your Rights After a Mastectomy (PDF).