Compliance

Health Tradition is required to meet state and federal regulations for health maintenance organizations. Among those are the Health Insurance Portability and Accountability Act (HIPAA) and Employee Retirement Income Security Act (ERISA). Health Tradition is also accountable to the Office of the Commissioner of Insurance for the State of Wisconsin for compliance with state regulations.

Understanding Health Care Reform

Health Care Reform, sometimes referred to as “Obama-Care” is officially known as PPACA – Patient Protection and Affordable Care Act, or simply the Affordable Care Act. This is a set of many laws; each becoming effective on different dates, gradually between 2010 and 2018. Because you are insured with Health Tradition Health Plan, most of these laws will not change your current benefit plan, or impact you in any way.  Your Health Tradition health insurance has always covered the majority of these newly mandated benefits.  As well, many of these provisions just oblige insurance companies and health care providers to report more information to the government, or to you.

Health Tradition Health Plan is committed to meet or exceed the provisions of all insurance laws, on or before the necessary effective dates.    You may have received notices of updates to your Certificate of Coverage explaining PPACA changes which became effective in 2010 and 2011 such as

  • Adult dependent coverage up to age 26, regardless of marital or student status
  • More preventative health screenings without deductibles or co-pays
  • Better coverage for certain mental health conditions
  • Clarified or required standardized language for benefits that you already had

You may also notice some minor changes to forms and statements from Health Tradition, since the law now requires all insurers to use standard templates for these forms.

Most of the PPACA requirements for 2012 are again not coverage related, or are mandates for benefits that you already have.  Health Tradition Health Plan will continue to keep you informed if any mandates will impact you or your current health insurance coverage.

This new law is anything but simple, and the amount of information available can be overwhelming. As you may know, the constitutionality and overhead costs of several mandates are generating great debates.  Due to multiple political perspectives, some information can be distorted or misleading.  At this point, the Wisconsin Office of the Commissioner of Insurance (OCI) has chosen to temporarily delay the enforcement of some of these regulations, until these controversies are sorted out.

To ease your search for reliable information, we have provided you with links to official information on Health Care Reform designed for the consumer.  We encourage you to start with the facts below, establish your own opinions, and then if so inclined, discuss your opinions with your legislators. Health Tradition Health Plan will continue to update you, as well as this list of links, as these laws evolve.

Independent Consortium of Providers

Federal

Wisconsin

For Employers

Employee Retirement Income Security Act

ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. ERISA requires plans to provide plan information to participants, provide fiduciary responsibility, have formal grievance and appeals processes and gives participants the right to sue for benefits and breaches of fiduciary duty.

Women’s Health and Cancer Rights Act

On October 21, 1998, President Clinton signed into law the Women’s Health and Cancer Rights Act of 1998. Under this legislation, group health plans that provide coverage for mastectomies also are required to cover reconstructive surgery and breast prosthesis (such as implants) following a mastectomy.

Under this law, members of Health Tradition Health Plan receive coverage for the following mastectomy-related procedures:

  • Reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the unaffected breast to produce a symmetrical appearance
  • Breast prosthesis (artificial substitute)
  • Treatment for physical complications of all stages of the mastectomy, including lymphedema

For questions regarding this information, please contact Health Tradition Customer Service at 1-877-832-1823

Office of the Commissioner of Insurance

The Office of the Commissioner of Insurance (OCI) for the state of Wisconsin was created by the legislature in 1871. The original intent of OCI has not changed drastically over the years. In 1871, OCI was vested with broad powers to ensure that the insurance industry responsibly and adequately met the insurance needs of Wisconsin citizens. Today, OCI’s mission is to lead the way in informing and protecting the public and responding to its insurance needs.