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San Joaquin Health Care 2004 JPA Handbook

HIPAA Rights
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a group health plan’s pre-existing condition limitation period for medical care benefits cannot exceed certain statutory maximums (generally, 12 months), and credit must be given towards meeting this period for the individual’s prior coverage under certain types of health plans (including COBRA coverage) so long as there has been no lapse of coverage of more than 63 days (not counting waiting periods), all as set forth in the provisions enacted by HIPAA. The maximum exclusion period is reduced by a participant’s or dependent’s prior health coverage. Each participant or dependent is entitled to a certificate that will show evidence of his or her prior health coverage. If a person buys health insurance other than through an Employer group health plan, a certificate of prior coverage may help the person obtain coverage without a pre-existing condition exclusion (contact your state insurance department for further information). You have the right to receive a certificate of prior health coverage as of July 1, 1996. You may need to provide other documentation for earlier periods of health care coverage.
If for some reason you do not receive a Certificate of Creditable Coverage when your SJJPA coverage terminates, please contact Legacy Enterprises immediately by calling 209-957-3185 or 800-232-3185. Immediately by calling 209-957-3185 or 800-232-3185.

NEWBORNS’ AND MOTHERS’ HEALTH
PROTECTION ACT OF 1996
Effective for plan years beginning on or after January 1, 1998, the Newborns’ and Mothers’ Health Protection Act of 1996 prevents group health plans and insurers from restricting benefits for any hospital length of stay in connection with childbirth for the mother or the newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending physician, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and insurance companies may not, under federal law, require that a physician obtain authorization for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Women’s Health and Cancer Rights Act of 1998
Effective for plan years beginning on or after October 21, 1998, the Women’s Health and Cancer Rights Act of 1998 requires that group health plans and health insurance companies providing benefits for a mastectomy must also provide, in connection with the mastectomy, coverage for (i) reconstruction of the breast on which the mastectomy has been performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and, (iii) prostheses and physical complications of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and co-insurance provisions that are appropriate and consistent with other benefits under the Plan.

Qualified Medical Child Support Orders
A qualified medical child support order (QMCSO) is an order issued by a domestic relations court (or certain administrative agencies) that orders a group health plan to provide health coverage to a child of a participant in the plan in connection with a divorce or family support proceeding. The Plan has adopted procedures for reviewing medical child support orders in order to determine if they are QMCSOs. Participants and their beneficiaries can obtain, without charge, a copy of the Plan’s QMCSO procedures from the Plan Administrator.


©2006 Legacy Consulting Insurance Services, Inc.
811 W Fremont Street
SUITE B
Stockton, CA 95203
Phone: (209) 546-0402 ~ Fax: (209)546-0824
San Joaquin JPA Handbook 2004