Six federal health plan rules, and how to check each one against your plan.
ERISA sections 701 and following add federal rules to employer health plans on enrollment, hospital stays, mastectomy coverage, genetic information, mental health parity and student leave. This checklist shows what each rule asks of the plan and which notice or plan item to look for.
Six Requirements, Six Checklists.
General information, not legal or tax advice. Each checklist cites the statute or regulation it relies on.
Special Enrollment and Health Factors
The 30-day and 60-day windows, the notice at first offer and the ban on health-based eligibility and premiums.
Newborns’ Act Hospital Stays
The 48 and 96 hour floors and the summary plan description statement.
Mastectomy Reconstruction Coverage
What the plan must cover after a mastectomy and the notice at enrollment and each year.
Genetic Information Rules
The limits on genetic tests, genetic information requests and genetic-based premiums.
Mental Health Parity
A short checklist that points to our full parity guides.
Student Leave of Absence
One year of protected coverage for a student on medically necessary leave.
How Part 7 Fits Together.
Part 7 of Title I of ERISA begins at section 701, 29 U.S.C. 1181. It applies to the group health plan itself, and it speaks to employers through what the plan documents say and what participants are told. Some of the duties fall on the insurer as well. The six checklists linked above take one requirement each. They are written from the statute and the regulations, not from any agency worksheet.
Part 7 has exceptions. Under ERISA section 732, 29 U.S.C. 1191a, the requirements do not apply to a plan that has fewer than two participants who are current employees on the first day of the plan year, and they do not apply to excepted benefits described in section 1191b(c)(1). Other excepted benefits escape only when they are offered under a separate policy or otherwise are not an integral part of the plan. The text of 1191a(a) leaves out sections 1185 and 1185o, so the Newborns’ Act is not covered by the small plan exception.
Part 7 also contains provisions this checklist does not cover. We chose the six that most often turn up in employer plan documents and enrollment kits. Use these pages as a cross-check, then read the full guides on the topics that matter to your group.
Notice And Plan Document Items.
This table lists the notice or plan item to look for under each rule. Where the rule has no notice of its own, the table says so. Ask your carrier or administrator for each item by name and note the date it was last issued.
| Requirement | Statute | Notice or plan item to find | Where it comes from |
|---|---|---|---|
| Special Enrollment | ERISA 701(f) | A notice of special enrollment rights, given at or before the time an employee is first offered the chance to enroll | 29 CFR 2590.701-6(c) |
| Health Factors | ERISA 702(a), (b) | Eligibility, waiting period and contribution terms that do not vary by health status. We found no separate notice in the statute. | 29 U.S.C. 1182 |
| Newborns and Mothers | ERISA 711 | A summary plan description statement on hospital length of stay for childbirth | 29 U.S.C. 1185(d); 29 CFR 2520.102-3(u) |
| Mastectomy Coverage | ERISA 713 | Written notice on enrollment and every year after that | 29 U.S.C. 1185b(a) |
| Genetic Information | ERISA 702(c), (d) | Forms, health questionnaires and plan rules that do not ask for genetic tests or genetic information when the statute bars it | 29 U.S.C. 1182(c), (d) |
| Mental Health Parity | ERISA 712 | Medical necessity criteria and denial reasons available on request; a documented comparison for nonquantitative limits | 29 U.S.C. 1185a(a)(4), (a)(8) |
| Student Leave | ERISA 714 | A description of the continued coverage rule inside any notice about the certification needed for student status | 29 U.S.C. 1185c(c) |
How To Run The Checklist.
- Pull the current plan document, the summary plan description, the enrollment kit and any carrier certificate or booklet.
- Open one child checklist at a time and mark each item as found, missing or not applicable.
- For every notice, write down who sends it, when it goes out and where you keep proof of delivery.
- Send the gaps to the carrier or administrator in one list, and keep their reply with the plan file.
- Add the notice dates to your plan-year calendar so they repeat.
Common Misreadings.
- Assuming the carrier handles everything. Many carriers supply notice language, but the duty sits with the plan.
- Treating a rule as met because nobody has complained. Several of these rules turn on what the plan terms say, not on a claim.
- Skipping the exceptions test. Check the small plan and excepted benefit rules before you conclude a rule applies, and remember the Newborns’ Act is carved out of the small plan exception.
- Applying state rules by habit. Insured coverage in Michigan can also be subject to state insurance law, and we do not summarize it here.
Related Rules And Tools.
HIPAA for Employers
The wider HIPAA picture for employer health plans.
Special Enrollment Deadline Calculator
Work out a special enrollment window from the qualifying date.
ERISA Compliance for Michigan Employers
The broader ERISA duties that sit around Part 7.
A Compliance Calendar for Your Plan Year
A plan-year view of the dates that matter.
Laws And Sources
29 U.S.C. 1181 (ERISA 701): Subsection (f) sets the special enrollment periods for loss of other coverage, new dependents and Medicaid or CHIP changes.
29 U.S.C. 1182 (ERISA 702): Health status rules for eligibility and premiums, plus the genetic information rules in subsections (a)(1)(F), (b)(3), (c) and (d).
29 U.S.C. 1185 (ERISA 711): Standards relating to benefits for mothers and newborns, including the notice rule in subsection (d).
29 U.S.C. 1185a (ERISA 712): Parity in mental health and substance use disorder benefits.
29 U.S.C. 1185b (ERISA 713): Required coverage for reconstructive surgery following mastectomies, with the enrollment and annual notice.
29 U.S.C. 1185c (ERISA 714): Coverage of dependent students on medically necessary leave of absence.
29 U.S.C. 1191a (ERISA 732): Exceptions for small plans and excepted benefits.
29 CFR 2590.701-6: Special enrollment periods, including the notice of special enrollment in paragraph (c).
29 CFR 2590.702: Defines the health factors and applies the rule to eligibility, benefits and premium contributions.
29 CFR 2590.702-1: Additional requirements prohibiting discrimination based on genetic information.
29 CFR 2590.711: Standards relating to benefits for mothers and newborns.
29 CFR 2590.712: Parity in mental health and substance use disorder benefits.
29 CFR 2520.102-3: Contents of the summary plan description; paragraph (u) covers the hospital length of stay statement.
General information, not legal or tax advice.
Quick Answers.
Brief answers on how the six requirements fit together, each linked to the fuller page.
What is ERISA Part 7?
It is the part of ERISA, starting at section 701 and codified from 29 U.S.C. 1181, that sets federal rules for group health plans. This checklist covers six of them: special enrollment and health factor rules, the Newborns’ Act, mastectomy coverage, genetic information, mental health parity and student leave.
Does Part 7 apply to every group health plan?
No. Section 732 of ERISA, 29 U.S.C. 1191a, exempts a plan with fewer than two participants who are current employees on the first day of the plan year, and it exempts excepted benefits. The same text leaves the Newborns’ Act outside the small plan exception.
Where do the notices come from, the carrier or the employer?
The statute puts the duty on the group health plan and, for some rules, the insurer too. Many carriers supply the language, but the plan sponsor still has to confirm that the notice reached participants. Ask your carrier or administrator for the exact document and date.
Which of these rules require a notice every year?
Of the six, we verified an annual notice only for mastectomy coverage under ERISA 713, 29 U.S.C. 1185b(a). Special enrollment and hospital stay notices are tied to enrollment and the summary plan description.
Who should we ask to confirm our plan meets these rules?
Start with your carrier or administrator for the plan documents and notices, then your ERISA counsel for legal conclusions. We review the documents with you and flag gaps, but we do not give legal advice.
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