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Final 1557 rules issued: it's worth paying attention to

Updated: May 21



Understanding 1557 Non-Discrimination Regulations for Group Health Plans

Today's blog delves into the final 1557 non-discrimination regulations and their implications for group health plans. The regulations have been a topic of discussion across several administrations, and now, with the release of the final rules, it's crucial for covered entities to understand how they apply, especially in the realm of group health plans.

Overview of Covered Entities


Covered entities, as defined under the 1557 rules, are those entities that receive federal financial assistance and operate within the healthcare industry. This primarily includes carriers who receive federal financial aid through programs like Medicare reimbursements. Additionally, carriers often have Administrative Services Only (ASO) arrangements, extending the scope to self-funded plans as well.

Prohibited Discrimination and Protected Classes


The crux of the 1557 regulations lies in preventing discrimination against individuals on the basis of protected classes, which include race, color, national origin, sex, age, or disability. Of particular importance is the definition of sex, encompassing various characteristics such as intersex traits, pregnancy, sexual orientation, gender identity, and sex stereotypes. The regulations explicitly prohibit exclusions or denials of claims related to these characteristics in the protected class.

Implications for Plan Coverage


For both fully insured and self-insured plans, adherence to these rules is vital. Self-insured plans, with greater autonomy over their coverage, need to exercise caution, especially when considering exclusions related to conditions like gender dysphoria. While a religious exemption may be sought for certain exclusions, close collaboration with legal counsel, particularly ERISA counsel, is recommended to ensure compliance and avoid potential litigations.

Given the litigious nature of these rules, covered entities, particularly self-funded plans, must tread carefully when excluding specific conditions or treatments. Any blanket exclusions must be thoroughly scrutinized to avoid violating the non-discrimination regulations. Moreover, there are additional notification requirements, including addressing limited English proficiency, that covered entities need to be aware of to maintain compliance.

In summary, the scrutiny and adherence to the 1557 non-discrimination regulations are paramount, especially for entities managing group health plans. Understanding the nuances of the rules, seeking legal counsel when needed, and staying abreast of any updates or challenges will be instrumental in ensuring compliance and mitigating potential risks in the ever-evolving landscape of healthcare regulations.


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