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Americans with Disabilities Act - Title I

Employee Health Plans

 

Covered Entities

Title I of the Americans with Disabilities Act of 1990 (P.L. 101-336) applies to covered entities . Covered entities are private employers, state and local governments, employment agencies, labor unions, and joint labor management committees with 15 or more employees.

Guidelines for Employee Health Plans

Title I permits disability-based distinctions in employer health plans as long as covered entities do not use them as subterfuges (ploys or deceptions) to evade Title I requirements. A covered entity cannot make decisions based on concerns about the impact of an individual's disability or his/her dependent's disability on the covered entity's health plan. A covered entity must provide employees with disabilities equal access to the health benefits it provides to employees without disabilities.

Disability-based Distinctions

A disability-based distinction singles out a particular disability, a discrete group of disabilities, disability in general, or a single procedure or treatment of a particular disability or discrete group of disabilities. Examples of illegal, disability-based distinctions include the following:

• Coverage limits on the treatment of any pre-existing blood disorders, if the plan does not exclude other pre-existing conditions; and
• Exclusion of a drug used only to treat AIDS. Examples of permissible, non-disability-based distinctions include the following:
• Different levels of coverage for physical conditions and mental/nervous conditions; _ Different levels of coverage for vision care and medical care;
• Pre-existing condition clauses;
• Coverage limits on medical procedures that are not exclusively, or nearly exclusively used in treating a particular disability (e.g., limits on the number of x-rays the plan will pay for); and
• Lifetime or annual caps on plan benefits.

Permissible Disability-based Distinctions

Title I permits health plans to make a disability-based distinction as long as it is not a subterfuge. A distinction is not a subterfuge when it is justified by the risks or costs associated with the disability. Determining whether a disability-based distinction is permissible is a case-by-case process. Examples of permissible disability-based distinctions include the following:

• A cap on a particular catastrophic disability if the health plan treats all similarly catastrophic conditions the same way;
• A disability-based distinction based on legitimate actuarial data or actual or reasonably anticipated experience, and that the health plan treats conditions with comparable actuarial data and/or experience in the same fashion;
• A disability-based distinction for the treatment of a discrete group of disabilities would have been so expensive as to cause the plan to become insolvent;
• A disability-based distinction to prevent a drastic alteration in the scope of coverage or level of benefits provided to all employees; and
• Exclusion of a particular treatment because it can prove that the treatment does not have any medical value.