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ERISA (Employee Retirement Income Security Act)

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. ERISA is located in the United States Code, beginning at 29 U.S.C. §1001.

ERISA requires plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.

There have been a number of amendments to ERISA, expanding the protections available to health benefit plan participants and beneficiaries. One important amendment, the Consolidated Omnibus Budget Reconciliation Act (COBRA) provides some workers and their families with the right to continue their health coverage for a limited time after certain events, such as the loss of a job. COBRA is located in the United States Code, beginning at 29 U.S.C. §1161.

Another amendment to ERISA is the Health Insurance Portability and Accountability Act which provides important protections for working Americans and their families who might otherwise suffer discrimination in health coverage based on factors that relate to an individual's health.

Other important amendments include the Newborns' and Mothers' Health Protection Act (29 U.S.C. §1185), the Mental Health Parity Act (29 U.S.C. §1185a), the Women's Health and Cancer Rights Act (29 U.S.C. §1185b), the Affordable Care Act (42 U.S.C. §18001) and the Mental Health Parity and Addiction Equity Act (MHPAEA). The MHPAEA is located in the United States Code at 26 U.S.C. § 9812 (2017); 29 U.S.C. § 1185a (2017); Public Health Service Act, 42 U.S.C. §§ 201, 300gg-5 (2017).

In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or plans which are maintained solely to comply with applicable workers compensation, unemployment, or disability laws. ERISA also does not cover plans maintained outside the United States primarily for the benefit of nonresident aliens or unfunded excess benefit plans.

In Texas, as in all states, the Employee Retirement Income Security Act of 1974 (ERISA) governs most private industry retirement and health plans, providing federal protections for individuals in these plans. ERISA mandates that plan participants receive critical information about plan features and funding, imposes fiduciary duties on those managing plan assets, and requires grievance and appeals processes for participants. It also allows participants to sue for benefits and fiduciary breaches. Amendments to ERISA, such as COBRA, HIPAA, and others, have expanded protections, including the right to continued health coverage after job loss, non-discrimination in health coverage, and parity in mental health and addiction treatment coverage. Notably, ERISA does not apply to government or church plans, plans solely for workers compensation, unemployment, or disability compliance, plans outside the U.S. for nonresident aliens, or unfunded excess benefit plans.


Texas Statutes & Rules

Texas Insurance Code - Section 1251.001. Applicability of Certain Laws
This statute is relevant because it clarifies the applicability of state insurance laws in relation to federal laws like ERISA.

This section of the Texas Insurance Code states that certain state insurance laws do not apply to a benefit plan that is fully insured and subject to the Employee Retirement Income Security Act of 1974 (ERISA). This means that for fully insured plans covered by ERISA, state insurance regulations may be preempted by federal law.

Texas Insurance Code - Section 1551.011. Exemption for Certain Plans
This statute is relevant as it exempts certain plans from state insurance laws, which may include plans covered by ERISA.

Section 1551.011 exempts certain insurance plans from state laws that regulate insurance. This includes plans established or maintained under specific federal laws, which could encompass those governed by ERISA. The statute ensures that state insurance regulations do not conflict with federal requirements for these plans.

Texas Labor Code - Section 408.001. General Provisions Relating to Benefits
This statute is relevant because it outlines the general provisions relating to benefits, which may interact with ERISA-regulated plans.

This section of the Texas Labor Code provides general provisions for workers' compensation benefits. While ERISA sets standards for private sector retirement and health plans, workers' compensation is a separate system that provides benefits to employees who suffer work-related injuries or illnesses. ERISA does not preempt state workers' compensation laws, so this statute operates alongside federal ERISA regulations.

Texas Labor Code - Section 410.255. Representation by Attorney
This statute is relevant as it pertains to the representation by an attorney in proceedings, which could include disputes involving ERISA plans.

Section 410.255 allows a party to be represented by an attorney in any proceeding under the subtitle relating to workers' compensation. While ERISA allows participants to sue for benefits and fiduciary breaches, this state statute specifies the right to attorney representation in workers' compensation proceedings, which is a separate area of employee benefits not preempted by ERISA.

Texas Business Organizations Code - Section 22.001. Applicability to Certain Entities
This statute is relevant because it discusses the applicability of the Texas Business Organizations Code to entities, which may include those managing ERISA plans.

This section of the Texas Business Organizations Code specifies the types of entities to which the code applies. While ERISA imposes fiduciary duties on plan managers, this state statute governs the general operations of business entities in Texas, which could include entities that manage ERISA plans. However, the fiduciary duties under ERISA are federal requirements and would take precedence over state law.

Federal Statutes & Rules

Employee Retirement Income Security Act of 1974 (ERISA) - 29 U.S.C. §1001 et seq.
ERISA establishes minimum standards for retirement and health plans in the private sector to protect individuals in these plans.

ERISA sets requirements for disclosure, funding, and fiduciary responsibility for private sector employee benefit plans. It mandates that plan participants receive information about plan features, funding, and management. Plan administrators are held to a fiduciary standard, meaning they must act in the best interest of the participants. ERISA also includes provisions for participants to address grievances and appeal for benefits, as well as the right to sue for benefits and fiduciary breaches.

Consolidated Omnibus Budget Reconciliation Act (COBRA) - 29 U.S.C. §1161 et seq.
COBRA is an amendment to ERISA that allows employees and their families to continue their health coverage under certain circumstances.

COBRA provides eligible employees and their beneficiaries the option to extend their health insurance coverage in the event of job loss, reduction in work hours, transition between jobs, death, divorce, and other life events. This coverage can be extended for a limited period, typically 18 to 36 months, depending on the qualifying event, and requires that participants pay the full premium.

Health Insurance Portability and Accountability Act (HIPAA) - 29 U.S.C. §1181 et seq.
HIPAA is an amendment to ERISA that addresses health insurance coverage discrimination and privacy of health information.

HIPAA provides protections against discrimination in health coverage based on health-related factors. It sets rules for pre-existing conditions, special enrollment rights, and prohibits discrimination based on health status. HIPAA also establishes standards for the privacy and security of protected health information (PHI).

Newborns' and Mothers' Health Protection Act - 29 U.S.C. §1185
This act is an amendment to ERISA that sets minimum standards for health plan coverage of mothers and newborns after childbirth.

The Newborns' and Mothers' Health Protection Act requires group health plans and health insurance issuers offering group or individual health insurance coverage to provide a minimum hospital stay for childbirth. For vaginal deliveries, a 48-hour stay is mandated, and for cesarean sections, a 96-hour stay is required, unless the mother and doctor agree to an earlier discharge.

Mental Health Parity Act - 29 U.S.C. §1185a
This act is an amendment to ERISA that requires parity in the application of aggregate lifetime and annual dollar limits on mental health benefits with those established for medical and surgical benefits.

The Mental Health Parity Act mandates that annual or lifetime dollar limits on mental health benefits are not lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer in the group market.

Women's Health and Cancer Rights Act - 29 U.S.C. §1185b
This act is an amendment to ERISA that provides protections for patients who elect breast reconstruction in connection with a mastectomy.

The Women's Health and Cancer Rights Act requires group health plans and health insurers that cover mastectomies to also cover certain reconstructive surgery and associated services, including reconstruction of the other breast to achieve symmetry, prostheses, and treatment for complications arising from a mastectomy, including lymphedema.

Affordable Care Act (ACA) - 42 U.S.C. §18001
The ACA is a comprehensive health care reform law that includes amendments to ERISA to expand health insurance coverage and consumer protections.

The ACA, among other provisions, extends dependent coverage up to age 26, prohibits pre-existing condition exclusions, mandates coverage of preventive services without cost-sharing, and implements health insurance marketplaces. It also introduces the employer mandate, requiring certain employers to offer health insurance coverage, and the individual mandate, requiring most individuals to have health insurance or face penalties (although the penalty was reduced to $0 at the federal level starting in 2019).

Mental Health Parity and Addiction Equity Act (MHPAEA) - 29 U.S.C. § 1185a
The MHPAEA is an amendment to ERISA that requires equal treatment of mental health and substance use disorder benefits and medical/surgical benefits in group health plans.

The MHPAEA mandates that financial requirements (such as co-pays and deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits. It also requires parity in out-of-network benefits and expanded disclosure requirements regarding the criteria for medical necessity determinations and the reason for any denial of reimbursement or payment for services.