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    Federal & State Mandated Benefits 


    Federal and State regulations require the District to provide certain protections to those enrolled in health plans.  More information may be garnered below.


Individuals whose coverage ended, or who were denied coverage, or who were not eligible for coverage, because the availability of dependent coverage of children ended before attainment of age 26, are eligible to enroll in District-sponsored health insurance coverage (unless or until they become eligible for other employer-sponsored health benefits other than from another parent).

To ensure compliance with the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010, the District will extend the coverage for dependent children up to age 26.  This requirement applies to qualified dependents of active employees who are eligible for District-sponsored health benefits.


The District believes that the District-sponsored health and welfare plans are "grandfathered" health plans under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Employee Benefits Security Administration, U.S. Department of Labor at 866-444-3272.  Their website has a table summarizing which protections do and do not apply to grandfathered health plans.


Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal 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 her newborn earlier than 48 hours (or 96 hours, as applicable).  In any case, health plan providers may not require that a provider obtain authorization for prescribing a hospital length of stay of less than 48 hours (or 96 hours).


Medicare prescription drug coverage (Medicare Part D) became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or EPO) that offers prescription drug coverage.  All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare.  Some plans may also offer more coverage for a higher monthly premium.

The prescription drug coverage offered through District-sponsored medical plans is creditable coverage. Creditable coverage means that, on an average for all plan participants, the Plan is expected to pay out as much as the standard Medicare Part D prescription drug coverage will pay.  It also means that if you keep the District plan’s coverage and do not enroll in a Medicare prescription plan now, you will not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.


Social Security Administration


The Health Insurance Portability and accountability Act of 1996 (HIPPA) Privacy Rule establishes national standards to protect individual’s medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.

The Rule requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records and to request corrections.

For more information, visit the Department of Health and Human Services (HHS).


A Qualified Medical Child Support Order (QMCSO) is an order or a judgment from a court or administrative body directing the provider to cover a child of a participant under the group health plan.

Federal law provides that a medical child support order must meet certain form and content requirements in order to be QMCSO.  When an order is received, each affected participant and each child (or child’s representative) covered by the order will be given notice of the receipt of the order and a copy of the plan’s procedures for determining if the order is valid.

Coverage under the plan pursuant to a QMCSO will not become effective until the Plan Administrator determines that the order is a QMCSO.


The Veterans Benefits Improvement Act of 2004 (S2486) amends the Uniformed Service Employment and Reemployment Rights Act (USERRA).  For more information, visit the United States Department of Labor.


Federal law requires group health plans to provide coverage for the following services to an individual receiving plan benefits in connection with a mastectomy:

  • Reconstruction of the breast on which the mastectomy has been performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • Prostheses and physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes)

Each group health plan must determine the manner of coverage in consultation with the attending physician and patient.  Benefits for breast reconstruction and related services must be consistent with the deductibles and coinsurance amounts that apply to other similar services covered under the plan.