U.S. Department of Labor
Health Benefits Advisor for Employers
Determining Compliance with the HIPAA Provisions in Part 7 of ERISA
Compliance with HIPAA Nondiscrimination Provisions - Benefits
Does the plan uniformly provide benefits to participants and beneficiaries, without directing any benefit restrictions at individual participants and beneficiaries based on a health factor?
A plan is not required to provide any benefits, but benefits provided must be uniformly available and any benefit restrictions must be applied uniformly to all similarly situated individuals and cannot be directed at any individual participants or beneficiaries based on a health factor. If benefit exclusions or limitations are applied only to certain individuals based on a health factor, this would violate ERISA section 702(a) and 29 CFR 2590.702(b)(2).
Examples of plan provisions that would be permissible under ERISA section 702(a) include:
- A lifetime or annual limit on all benefits,
- A lifetime or annual limit on the treatment of a particular condition,
- Limits or exclusions for certain types of treatments or drugs,
- Limitations based on medical necessity or experimental treatment, and
- Cost-sharing,
If the limit applies uniformly to all similarly situated individuals and is not directed at individual participants or beneficiaries based on a health factor.
A plan amendment applicable to all similarly situated individuals and made effective no earlier than the first day of the next plan year is not considered directed at individual participants and beneficiaries. See 29 CFR 2590.702(b)(2)(i)(C).
