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COBRA – The Consolidated Omnibus Budget Reconciliation Act (COBRA) was passed in 1986 to provide certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates.

ERISA  The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that governs employee health and pension plans in the private industry. By establishing standards and requirements with which the plan sponsors must comply, ERISA strives to protect the participants of those plans.

HIPAA  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) places certain requirements on group health plan sponsors and insurers in the areas of portability and privacy/security.

FMLA  The Family and Medical Leave Act of 1993 (FMLA) provides certain employees with up to 12 work weeks of unpaid, job-protected leave a year, and requires group health benefits to be maintained during the leave as if the employees continued work instead of taking leave. HR managers often name FMLA issues as their top headache.

Medicare Part D  Group health plans and individual health insurance policies that offer prescription drug coverage to Medicare-eligible individuals must comply with the following requirements:

  • Disclosure Notice to the Centers for Medicare and Medicaid Services (CMS)
  • Disclosure Notice to Medicare Part D Eligible Individuals

Form 5500  Certain employee benefit plans subject to ERISA are required to file an annual report with the federal government. The Form 5500 and its related schedules satisfy that requirement.

Cafeteria Plans  An Internal Revenue Code Section 125 Cafeteria Plan is a method of allowing employees to pay for qualified benefits on a 
pre-tax basis. In its simplest form, it is a premium only plan, which allows employees to pay for health insurance premiums before tax. In its most complicated form, an employer may offer employees flex credits to select among various benefits or a cash-out option.

Reimbursement Accounts  The following arrangements are available in a group environment to reimburse employees and dependents for qualified medical expenses.

Flexible Spending Arrangement (FSA) – A Flexible Spending Arrangement (FSA) is typically funded by pre-tax employee contributions through a Section 125 Cafeteria Plan. An employer may also choose to contribute to employee accounts.

Health Savings Account (HSA) – A Health Savings Account (HSA) may be funded by either employee or employer contributions, or both. Employee contributions may be paid pre-tax through a Section 125 Cafeteria Plan or post-tax. Post-tax contributions would be eligible as an above-the-line deduction on the individual's personal tax return.

Health Reimbursement Arrangement (HRA) – A Health Reimbursement Arrangement (HRA) is funded completely by employer contributions. An HRA may not be funded directly or indirectly by employee contributions.

Retirement Plans  Employer-sponsored retirement plans have become a necessity for any employer looking for a competitive advantage when hiring new staff, and a valuable way to reward profitability and hard work.

401(k) – Easily the most popular retirement plan, a 401(k) plan can be implemented by companies of all sizes, from sole proprietors and self-employed individuals to large, publically traded firms. 401(k) plans can be customized to include a wide variety of employer contributions, such as a match or profit-sharing contributions.

403(b) – A 403(b) plan functions in much of the same manner as a 401(k) plan, with the exception of who is able to participate in the plan. A 403(b) plan designed for employees of public schools, employees of certain tax-exempt organizations through IRS Code 501(c)(3), and certain ministers. The investments in a 403(b) plan are generally in the form of annuity contracts or mutual funds.


Complications of Pregnancy, Childbirth and the Puerperium: Includes vaginal and cesarean deliveries and

complications of pregnancy, such as ectopic and molar pregnancies. Puerperium refers to 42 days following

childbirth and expulsion of the placenta. Refers to the mother only.


Conditions Influencing Health Status: This includes post-surgical states, organ / tissue transplants, artificial limbs

and replacements. Examples include knee replacements and kidney transplant status.


Conditions in the Perinatal Period: Perinatal refers to the period beginning after the 28th week of gestation and

ending 28 days after birth. Problems can include hemorrhage, digestive disorders, respiratory distress

syndrome and disorders relating to short gestation and unspecified low birth weight.


Congenital Anomalies: Includes the treatment of any condition present at birth. This includes Spina Bifida, cleft

palate, Down's Syndrome, heart disease, kidney displacement & polycystic kidney disease.


Diseases of the Blood and Blood Forming Organs: Includes any problems associated with white or red blood cells,

platelets or plasma. An example includes Anemia, a deficiency in red blood cells.


Diseases of the Circulatory System: Includes problems with the heart, blood vessels and circulation. Some common

diagnoses include Coronary Artery Disease, cardiovascular disease, and stroke.


Diseases of the Digestive System: Includes the treatment of any organ or area of the body pertaining to digestion.

These areas include the mouth/teeth, esophagus, stomach, intestines, gall bladder, liver and pancreas.

Diagnoses include: Esophageal Reflux, Gastroenteritis, Appendicitis and hernias.


Diseases of the Genitourinary System: Includes problems related to the kidneys, bladder and male and female

genitalia. Common diagnoses include Hematuria, Urinary Tract Infection, Acute or Chronic Renal Failure and

Calculus of Kidney (stones).


Diseases of the Nervous System: Includes treatment for disorders of the Central and Peripheral Nervous systems.

Diagnoses include: Carpal Tunnel Syndrome, Obstructive Sleep Apnea, Epilepsy, Multiple Sclerosis,

Alzheimer's Disease and Migraine headaches.


Diseases of the Respiratory System: Includes treatment for diagnoses such as Asthma, Pneumonia, Emphysema,

Pharyngitis, Sinusitis, Bronchitis and COPD. These can be acute or chronic in nature.


Diseases of the Skin and Subcutaneous Tissue: This involves any condition relating to the skin or beneath the skin,

including hair and nails. Some conditions include Acne, Corns, Cellulitis, Psoriasis, Dermatitis and fungal



Ears and Mastoid: Includes any condition pertaining to the ear or the mastoid process. The mastoid process is the

portion of the temporal bone extending down behind the ear. Diagnoses include Otitis Media, Tinnitus,

Meniere􀀁s Disease, Hearing Loss and Labyrinthitis.


Endocrine, Nutritional and Metabolic Diseases: Endocrine disorders include those of the endocrine glands and

includes the thyroid, pituitary, pancreas, ovaries and testes. Disorders include Diabetes, thyroid disease,

Obesity, Hyperlipidemia, Cystic Fibrosis and any disease affecting the immune system.


Health Services: This includes elective surgeries, other procedures & aftercare, rehabilitation and dialysis. Specific

examples include: long-term medication use, Physical Therapy and chemotherapy.


Health Services: Reproduction and Development: Include services pertaining to the child only. For example, normal

pregnancy, post-partum care and exam or health supervision of an infant or child.

Infectious and Parasitic Diseases: Includes diseases caused by microbes outside of the body that infect and damage within the body. These diseases are recognized as communicable or transmissible. Diagnoses HIV, Hepatitis, Colitis & intestinal disruptions such as food poisoning.

Injury and Poisoning: Includes treatment for injuries to the body or for any poison ingested. Diagnoses include

sprains & strains, fractures, burns and lead poisoning. Patients are most commonly seen in the emergency room for acute conditions.

Mental Health: Refers to a group of disorders causing severe disturbances in thinking, feeling or relating. treatment of any condition that affects mood or behavior. The most common diagnoses include anxiety disorders, depressive disorders and schizophrenia.

Musculoskeletal and Connective Tissue Disease: Includes orthopedic treatment, which would involve anything to the bones, muscles, joints and soft tissue. Diagnoses: Arthritis, Tendonitis, back disorders, disc rheumatism, and scoliosis. These diagnoses are more chronic in nature.

Neoplasms: Includes any abnormal growth of cells, either benign or malignant (cancer). Though these can at any spot of the body, some of the most common forms include neoplasms of the breast, prostate, and brain. Other examples include Leukemia and Hodgkin's Disease.

Other Circumstances: This includes convalescent care and follow-ups to surgeries and examinations.

Potential Health Hazards: Personal or family history of diseases or disorders; e.g., breast cancer.

Procreative and Contraceptive Management: This includes artificial insemination, fertility testing, genetic family planning, sterilizations and contraceptive management.

Signs, Symptoms and Ill-Defined Conditions: Includes signs, symptoms, abnormal lab results and ill-defined

conditions for which no known cause can be found. For example, a patient may experience chest pain, known cause is found.

Substance Abuse: Includes behavior marked by the use of chemically active agents, such as prescription drugs, alcohol or tobacco. Cognitive, behavioral and physiological symptoms indicate that the person use of the substance.

Without Reported Diagnosis: This includes general medical examinations, gynecological exams, mammogram

screenings, preventive services, physicals and special screenings for neoplasms.