Health Tradition is required to meet state and federal regulations for health maintenance
organizations. Among those are the Health Insurance Portability and Accountability
Act (HIPAA) and Employee Retirement Income Security Act (ERISA). Health Tradition
is also accountable to the Office of the Commissioner of Insurance for the State
of Wisconsin for compliance with state regulations.
Health Insurance Portability and Accountability Act
HIPAA is a federal law designed to reform the insurance market and simplify healthcare
administrative processes by setting standards for submission of electronic bills,
electronic payments and checking referrals and authorizations electronically. The
law also provides for protection of patient information from inappropriate use or
disclosure. These standards do not limit a provider from using a patient’s
information when providing appropriate treatment, sending information to insurance
companies for reimbursement or using information for quality control or operational
improvement.
Employee Retirement Income Security Act
ERISA is a federal law that sets minimum standards for most voluntarily established
pension and health plans in private industry to provide protection for individuals
in these plans. ERISA requires plans to provide plan information to participants,
provide fiduciary responsibility, have formal grievance and appeals processes and
gives participants the right to sue for benefits and breaches of fiduciary duty.
Women’s Health and Cancer Rights Act
On October 21, 1998, President Clinton signed into law the Women’s Health and Cancer Rights Act
of 1998. Under this legislation, group health plans that provide coverage for mastectomies also
are required to cover reconstructive surgery and breast prosthesis (such as implants) following
a mastectomy.
Under this law, members of Health Tradition Health Plan receive coverage for the following
mastectomy-related procedures:
- Reconstruction of the breast on which the mastectomy was performed
- Surgery and reconstruction of the unaffected breast to produce a symmetrical appearance
- Breast prosthesis (artificial substitute)
- Treatment for physical complications of all stages of the mastectomy, including lymphedema
For questions regarding this information, please contact Health Tradition Customer Service at 1-877-832-1823
Office of the Commissioner of Insurance
The Office of the Commissioner of Insurance (OCI) for the state of Wisconsin was
created by the legislature in 1871. The original intent of OCI has not changed drastically
over the years. In 1871, OCI was vested with broad powers to ensure that the insurance
industry responsibly and adequately met the insurance needs of Wisconsin citizens.
Today, OCI's mission is to lead the way in informing and protecting the public and
responding to its insurance needs.