Form M300 Mewa Coverage Requirements 760
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4MEWA Coverage Requirements
760 IAC 1-68-4, 760 IAC 1-68-16, IC 27-1-34-9 and PPACA
This checklist must be submitted with any health form filing(s) for Multiple Employer Welfare Arrangement (MEWA).
Please attach a completed checklist to each form filing.
MEWA Name:
Plan Name:
Contact Name:
Email:
Phone:
Instructions:
The checklist contains specific requirements/provisions and certifications that the MEWA must acknowledge with
particular laws, regulations and bulletins. When providing the completed checklist, the MEWA is expected to address
each checklist line item in the columns as follows:
Provide the specific location(s) in the document provided which addresses the requirement, or
Provide an explanation as to why the MEWA believes the item is not applicable.
All checklist line items require a response. Failure to provide fully completed checklist may result in a delay of regulatory
approval.
Location in
Requirement
IDOI use
Document
(note page #)
760 IAC 1-68-4(g) The initial enrollment period for employees meeting the
participation criteria must be at least thirty-one (31) days. If dependent coverage is
offered, the dependent's open enrollment must also comply with this time period.
760 IAC 1-68-4 (h) A MEWA may establish a waiting period during which a new
employee is not eligible for coverage in accordance with the plan document.
760 IAC 1-68-4 (j) A MEWA shall provide that the benefits applicable to an individual
or family member shall be payable with respect to a newly born or adopted child of
an insured. The coverage shall:
(1) consist of coverage of injury or sickness, including the necessary care and
treatment of medically diagnosed congenital defects and birth abnormalities; and
(2) include, but not be limited to, benefits for inpatient or outpatient expenses
arising from medical and dental treatment (including orthodontic and oral surgery
treatment) involved in the management of birth defects known as cleft lip and
cleft palate. If payment of a specific premium or fee is required to provide
coverage for a child, the policy or contract may require that notification of the
birth or adoption and payment of the required premium or fee must be furnished
to the MEWA within thirty-one (31) days after the date of birth or adoption in
order to have continuous coverage beyond the thirty-one (31) day period.
760 IAC 1-68-4 (k) Coverage offered by the MEWA shall comply with the following:
(1) The federal Women's Health and Cancer Rights Act.
(2) The federal Mental Health Parity Act.
(3) The federal Pregnancy Discrimination Act.
760 IAC 1-68-4(m) The MEWA shall provide coverage for the following:
(1) The medically necessary treatment for diabetes, including medically
necessary supplies and equipment as ordered in
writing by a:
(A) physician licensed under IC 25-22.5; or
(B) podiatrist licensed under IC 25-29; subject to general provisions of the
health benefit plan.
(2) At least one (1) prostate specific antigen test annually for an insured who is:
Form M300
Ver. 1.0
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