leevena

Thanks for filling in the missing information.

True, it grew out of the fraud and abuse that was occurring in the benefit industry, with participants being left without benefits. I started my career in 1982, so I was not in the industry at the time of passage, but it may have just been easier to include the "non-retirement" plans as opposed to writing a new law for them.

Good question. Most of ERISA does apply to retirement plans, but there is some impact on group health plans, dental, fsa, HRA's, life, disability, etc.. For these plans ERISA places requirements around employer responsibilities for communication of plan information to participants, fiduciary responsibility for plan assets, need for an appeals/grievance process, and it gives participants the right to sue. There are some group health plans not subject to to ERISA, including; church, voluntary plans, and (sit down for this one) government plans. The good news for most employers, much of this is done by the carrier because so many of the plans are fully-insured. For self-funded, the employer does need to check a little closer.

Brian Gilmore, as a side note, it is great to have you on this site. I have found your insights/knowledge to be very helpful.

See the 1999 Final Regs in Federal Registry.

Coleboy, could you be a little more specific about the type(s) of plans you administer? I have gone back and forth on this, but considering you have at least one support person, it does appear that the load is not too great.

Cate, I may be a little confused so I apologize ahead of time. Is this a situation where a parent/subscriber has dependent coverage (an adult child) and the subscriber does not know if the dependent is on their plan? If so, how can the parent/subscriber not know who is on their plan? Thanks.

I am a little confused, are the 2 employees still on your medical plan? Your first sentence states the employees are currently covered by your medical plan. Your last sentence states you never offered them COBRA, which would only occur is they were leaving the medical plan. COBRA is for employees who lose medical coverage. If the are on disability and still covered by the medical plan, you will need to offer them COBRA when they have a qualifying event and exit the medical plan.

This is now getting more complicated, and we are lacking details to give you any definitive answers. Is an employer allowed to give employees money in exchange for opting out? Yes. Can it be in varying amounts based on a different coverage level? Yes. Is there an affordability issue? Probably not because people opting out of their plan is not a cause for affordability. Affordability is determined by determining the cost of the group plan in relation to the employees income. Part A triggered if 95% opt out? Again, probably not. As long as employer offers it makes no difference. Employer hit with A and B if the only way...probably not. Could you please be a little more forthcoming with the reason why you are asking these questions? Based on your first post I assumed you were asking for yourself because your employer is now making this available. Your last post has questions that go beyond. Thanks.

No issues. This is a strategy used by many employers.

My gut is telling me that there is more to this than we are being told.

Loch 1, if you don’t mind me asking, but what is the big deal? According to your first post they added 7 days to the 45 days. What is it about the 7 days? Also, what was the exact reason given?

Yes it may be legal. See the link below for more info. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-disability-benefits.pdf

The DOL allows expenses to be paid by; the employer, the plan, or both. This should also be included in the plan documents.

So, what is your answer?

Sorry, saw this after other responses. Key is that the employee does not actually lose group coverage because COBRA is an extension of coverage.

Rule of thumb, cobra coverage is the same as when an active employee, with exceptions for; HIPPA qualifying events, plan network, such as HMO, not available in your geography, and Open Enrollment. Should check with employer to learn more.

There is insufficient information here, suggest you discuss with counsel. From an arms length, it does appear as if you may have a plan that is subject to ERISA, but it depends on how the plan is structured. If it is an informal plan then it may be subject to state regulation, and if you have a multi-state organization there may be multiple state regulations to consider. If it is a formal plan, it tends to be ERISA regulated. But keep in mind, I do not know enough, just some thoughts for you to consider.

Belgarth and Chaz are correct. Surveys have shown upwards of 70% of large groups have utilized passive enrollments, for all benefits. This number has dropped over recent years, somewhere around 50%. That being said, it is up to the employer to decide how they will handle this, and place it in plan docs.

Self funded plans are not subject to the Essential Health Benefit requirements. If a self funded plan does offer an Essential Health Benefit, then it may not cap the benefit. There is no standard definition of infertility services. Essential Health Benefits can differ from state to state depending on what is used as a definition. So, there is no way to to give you an answer to your question because there is not sufficient information here. But, I would go to the plan administrator for their opinion.

I agree with acm. Presumably, the employer has decided upon a certain dollar amount per category ( single, family, etc.) of employee. It is up to each employee how to design their plan.

Catsby, there is more to this issue than ACA. Telemedicine can be impacted by ACA, ERISA, and COBRA. There may even be state law issues to deal with, but I am not an expert on each state. Generally speaking, when a telemedicine program is integrated into the group plan these issues are satisfied because of its inclusion in the plan. When offered as a stand-alone it is viewed as a separate plan and the employer needs to satisfy ERISA requirements, create a separate COBRA process, and abide by ACA. Abiding by ERISA and COBRA is not very difficult, nor expensive. The ACA excepted benefit piece may be because of the requirements. To meet this threshold, the plan must; not provide significant medical care benefits, not be coordinated with the group plan, be cost free to the participants, and does not have any cost sharing.

Thank you. So if I understand correctly, if the copay is waived, it is actually the provider who is giving up revenue, not the plan.

I do not believe that a premium reduction would be subject to the MLLR. In such a scenario, there is not monies returned to group. I am unfamiliar with rebates for fully insured groups that are not classified as MLRR. Could these rebates be for level-funded plans? If so, there are some rules around those refund of surplus claim dollars.

Scooter. Do you know what happens to the waived amounts? Does the carrier need to pay the provider the waived copay, or does the provider eat it? Thanks