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Health plan with different requirements for eligibility?


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I have a client who has a radiology practice, and offers medical benefits to all employees and radiologists, but they need to work the equivalent of 30 hours per week to be eligible for the benefits.  It is only one class.  They have a radiologist who’s dropping to 65% working time.  She is currently on medical benefits and wants to stay on.  Can they create a class that would allow “radiologists only” to be eligible for benefits if they work at least 60% of the time (24 hours per week or more).  I think the answer is yes, but does that in your opinion create a potential discrimination problem?  Any other issues?  Thanks

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Are they self-insured?  If not, I don't believe the ACA nondiscrimination rules for insured plans have kicked in yet, but then that raises the question of who is imposing the 30-hour requirement?  The employer or the insurance carrier?   

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ERISAgeek111, before your client assumes that the radiologist would not be eligible based on the health plan's 30-hours eligibility condition, might the plan's administrator consider how the employer or service recipient counts hours and consider whether the plan's measure is wider?

While I don't know your client's facts, I can imagine that a medical professional who works only 24 hours in patient-facing medical procedures and care might work another six (or more) hours in activities that count as service for the relevant employer or service recipient.  (Of course, much depends on the particular plan's provisions and definitions.)

 

Peter Gulia PC

Fiduciary Guidance Counsel

Philadelphia, Pennsylvania

215-732-1552

Peter@FiduciaryGuidanceCounsel.com

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If it's the practice that is imposing the 30-hour requirement, they might also consider scaling that back for everybody and say setting it at say 20 hours?  Obviously I don't know your particular facts and number of part-time employees but we had a similar case and were able to convince the practice that expanding coverage for all wasn't likely to increase costs significantly and avoided some expense and questionable creative classifcations while giving them ability to play up more generous HR policy.

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Remember that, for a self-insured plan, discrimination in favor of HCEs is not prohibited.  It just has a tax consequence for the HCEs.  Thus, the answer to the original question about whether you can have a different eligibility rule for a different group is yes. 

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