Recent headlines have provided us with information on changing approvals of recommended vaccines. It is important to remember that news items do not immediately impact group health plan coverage. As the group health plan rules continue to evolve, longstanding legal requirements still apply. In particular, group health plan coverage for pediatric vaccines has been mandated to remain constant since May 1, 1993. The coverage of pediatric vaccines cannot be reduced below the level the plan provided as of May 1, 1993, or else the group health plan is in violation of the COBRA continuation coverage requirements. The federal COBRA continuation coverage requirements apply to group health plans of employers that employed an average of at least 20 employees on an average business day in the preceding calendar year and that are not otherwise exempted from COBRA’s requirements.
It is also important to remember that vaccination recommendations change for group health plans subject to the Patient Protection and Affordable Care Act (“PPACA”) —i.e., group health plans of employers that had 2 or more current employees on the first day of the plan year. PPACA’s preventive care mandates do not apply to certain limited benefits or “excepted benefits.” A plan does not have to adopt new recommended changes to preventive coverage until the first day of the plan year following the one-year anniversary of the recommendation’s issuance. Changes to the recommendations regarding removing an item or service must still be covered through the last day of the plan year. There is a special rule for the addition of the coronavirus vaccine, but its removal is not separately addressed.
For pediatric vaccine coverage, PPACA does not address or change the requirement to maintain the same pediatric vaccine coverage as existed in the employer’s group health plan on May 1, 1993, to avoid COBRA penalties. Group health plans separately must comply with PPACA’s preventive care mandate, and the rules for implementing changes. So, as you prepare for group health plan annual enrollment, evaluate any proposed changes under all of the applicable laws and regulations (including labor laws and contractual obligations for employers with collective bargaining agreements), as well as the human resources and employee relations consequences. Headlines do not necessarily mean immediate plan coverage changes. Before implementing a change, careful analysis of all requirements is prudent.
The opinions expressed are those of the author and do not necessarily reflect the views of the firm, its clients, or any of its or their respective affiliates. This article is for informational purposes only and does not constitute legal advice. For additional assistance please contact Greta E. Cowart or a member of the Employee Benefits & Executive Compensation (EBEC) practice.
Meet Greta
Meet GretaGreta E. Cowart has counseled employers for more than 30 years on best practices in human resources and employee relations related to benefits and executive compensation. In her practice, Greta routinely develops strategies for effective administration of claims and other disputes, including defense of grievances, and in ERISA claim litigation, while also considering applicable labor and employment laws. Greta also provides fiduciary training and review of fiduciary operations to improve the documentation of the fiduciary process.
