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Feedback on Provider Listing requirement of SPDs


Guest joebellis
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Guest joebellis

I have reviewed information on all of the "Big 5" on the new content requirments for health plan SPDs. Each of them has failed to address the "provider listing" requirement.

I have contacted the DOL with question and requested an answer by phone " a complete provider listing is required as part of or an attachment to the SPD".

However can not find anything in writing to that effect.

I need to provide info to client regarding this. One client is one the of "Big 5".

Any help?

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It’s my understanding that the SPD need only state that a complete listing of providers is available and where that listing is available. Unless you want to have to update the listing periodically I don’t think publishing it in an SPD makes much sense, but then again I’m not positive that the DOL would agree with me.

I am rewriting our SPDs and I am going to tell participants that they can get the listing from BCBS, our HR department or on the web. We have one PPO plan that has 491 pages of providers. I’m sure not going to publish this information in the SPD.

If I was going to consult an organization on the DOL requirements I’d consult an ERISA attorney. In lieu of that I’m going to rely on good faith logic.

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Guest joebellis

Thanks for the info.

Here is a summary of what I referring to:

The Department of Labor (DOL) has revised the rules for what must be included in summary plan descriptions (SPDs). The new DOL requirements must be implemented by the start of the second plan year beginning on or after January 22, 2001. Thus, for calendar-year plans, the compliance date is January 1, 2003. However, the guidance also includes certain so-called clarifications of old rules that DOL says should currently be reflected in SPDs.

Of immediate interest to employers are those clarifications. Employers should consider whether existing SPDs fall somewhat short of the level of detail now spelled out in the final rule.

For example, the DOL says that group health plan SPDs are required to fully describe the coverage provided for, among other things, existing and new drugs, medical tests, devices, and procedures. DOL indicated that an SPD need not list each and every covered drug, test, device, or procedure, but it must adequately inform participants whether and under what circumstances benefits will be provided, and tell participants how to get additional information about coverage for specific medical expenses. During the review period of the ruling, employers concerned that the requirement to disclose additional detail about group health plans might entail frequent SPD amendments, as drugs and procedures are added to, or dropped from, the plan. The DOL rejected that criticism, pointing out that now, as before, the difficulty can be resolved if employers issue a Summary of Material Modifications statement covering plan changes.

The final regulations also "clarify" that a network provider list must accompany a group health plan SPD, as opposed to merely being available on request. The network provider list may be part of the SPD or may be furnished as a document that accompanies the plan's SPD, provided that the summary plan description contains a general description of the provider network and provided further that the SPD contains a statement that provider lists are furnished automatically, without charge, as a separate document.

Another clarification broadens the required disclosure of events that may result in disqualification, ineligibility, denial, loss, or forfeiture of benefits ? particularly regarding plan amendment and termination. This would also include subrogation or reimbursement, and other plan provisions that may eliminate, reduce, offset, or otherwise adversely affect benefits. Any fees that plans charge participants or participant accounts must also be disclosed.

Looking ahead to new changes in the rules that, for calendar-year plans, must be reflected by January 1, 2003, the DOL has repealed the SPD exception for federally qualified HMOs. Thus, plans will need to provide information in their SPDs about HMO eligibility, funding, benefits, and claims procedures. DOL reaffirmed that a plan administrator may issue different SPDs to different classes of participants, and emphasized that participation in an HMO, PPO, or other plan option would constitute a different participant class. Thus, employees not eligible for a particular plan option (for example, an HMO not covering their geographic area) need not be given information about it if an employer adopts that distribution approach.

The final regulations also require additional disclosure in the SPD about claims processing procedures. In addition, the regulations provide new model statements addressing ERISA rights and PBGC coverage.

Employers should review their SPDs in light of the final regulations. All ERISA pension and welfare plans are affected, and the "clarification" provisions in particular require immediate attention.

Employers who are considering electronic delivery of plan communications may see the final regulations as a reason to take a new look at how they deal with furnishing and updating their SPDs. The regulations do not specifically address distribution by electronic media, however they do offer guidelines for determining if an employer has satisfied the requirements for delivery of the SPD through electronic media.

Electronic delivery of the SPD, to the participant who has the ability to access at their worksite the furnished documents in electronic form; and has the opportunity at their worksite location to readily convert furnished documents from electronic form to paper form without charge to the participant, will meet the statutory requirements if:

1. Appropriate and necessary measures have been taken to ensure that the system for furnishing documents results in actual receipt by participants of transmitted information and documents, through use of return-receipt electronic mail feature or confirmation of receipt of transmitted information;

2. Electronically delivered documents are prepared and furnished in a manner consistent with the applicable style, format and content requirements;

3. Each participant is provided notice, through electronic means or in writing, informing the participant of the documents to be furnished electronically, the significance of the documents and the participant?s right to request and receive, free of charge, a paper copy of each such document; and

4. Upon request of any participant, the administrator furnishes, free of charge, a paper copy of any document delivered to the participant through electronic media.

The following is the language from the regulation - 29 CFR 2520.102.3

Composition of provider network if a separate document is not provided, or

General description of the provider network and a statement that: Provider lists are furnished without charge as a separate document on enrollment in the plan and upon your request.

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Isn’t it obvious that the Feds want to make it so expensive and difficult for employers to comply with their idealistic rules? They wont be satisfied until they force the country into a national health and welfare state like Europe and Canada.

I am still going to do a good faith effort to comply. Some of what they want employers to do is warranted. Some if it is paternalistic and and unreasonable. The only time you really need a comprehensive SPD is to protect your back side in court. 99% of plan participants don't ever consult an SPD. They just get their care and then worry about coverage.

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Guest joebellis

Attached is an annotated copy fo the regulation. Highlighting the Provider Lisiting requirement.

Would appreciate your take on it.

Thanks

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Joe:

That section that says essentially that an employer may provide the provider listing separately from the SPD provided the SPD references that it is available is what I’ve been talking about. I wouldn’t thank that a DOL moron, assuming there are some morons there working there, would even expect an SPD to have 500 pages of providers published in its text. If they do expect it I’d like to ague the point with them.

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Guest joebellis

The person that I spoke with at the DOL in the Office of Regulations ans Intrepretations said that a full provider listing was the intent of the regulation.

Then proceeded to read to me from page 70228 of the Federal Register the following:

The Department continues to believe, however, that, unlike schedules and listings of specific benefits that may be furnished upon request, complete listings of network providers should be furnished automatically to each participant and beneficiary. The Department believes that, where the availability of specific medical services or benefits under a plan may depend in whole or in part on knowing the specific service provider from whom services may be obtained, the selection of a service provider becomes a particularly significant benefit decision.

The Department believes that, under such circumstances, participants and beneficiaries will be in the best position to evaluate and assess their medical provider options when they can review a complete listing of the providers available to them under the terms of the plan, rather than having to inquire on a service-by-service or provider-by provide basis. For this reason, the Department is retaining the requirement that detailed provider lists be furnished automatically, without charge, to participants. The Department recognizes, however, that requiring all providers to be listed in an SPD may undermine the usefulness of SPDs as a disclosure document. The Department, therefore, is also retaining the proposed provision in paragraph (j)(3) permitting the network provider listings to be furnished in a separate document, provided that the SPD contains a general description of the provider network and, as noted, that provider lists are furnished automatically, without charge.

Last night I am across the attached document from Mercer.

Thanks for the feedback

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