State and federal regulations for health insurance

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), Employee Retirement Income Security Act (ERISA) and the Patient Protection and Affordable Care Act. Health Tradition is also accountable to the Office of the Commissioner of Insurance for the State of Wisconsin for compliance with state regulations.

Health Care Reform

Health Care Reform, sometimes referred to as “ObamaCare” is officially known as PPACA – Patient Protection and Affordable Care Act, or simply the Affordable Care Act. It has many provisions, becoming effective on different dates between 2010 and 2018.

Most of the newly mandated benefits have always been covered by Health Tradition plans.

Health Tradition Health Plan is committed to meet or exceed the provisions of all insurance laws on or before the effective dates. You may have already 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. Implementation of some new provisions has been delayed by either the federal government or the Wisconsin Office of the Commissioner of Insurance (OCI). Health Tradition Health Plan will continue to keep you informed if any changes will impact you or your current coverage.

Become knowledgeable about health reform

This new law is anything but simple, and the amount of information available can be overwhelming. Due to multiple political perspectives, information you hear can be distorted or misleading. To ease your search for reliable information, we have provided these links to official information on Health Care Reform.

Links to reliable information

Independent health information resource

The Henry J. Kaiser Family Foundation


Department of Health and Human Services (HHS) – Health Care Reform Website

National Association of Insurance Commissioners (NAIC) – Health Care Reform Website


Wisconsin Officer of the Commissioner of Insurance (OCI)

Fact Sheet on HealthCare Reform for Wisconsin Residents  

For Employers

Department of Labor Health Care Reform Website

IRS Tax Credits Website

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.