leevena

Yes

Not enough information to give you an definitive answer. You should review non-discrimination rules for Sections 125 and 105. See how your plan stacks up.

If push comes to shove, the findings will always favor the employee. Having not read your documents, I am guessing at some of this. The plan adoption agreement means nothing, what does the SPD state? This is the key document.

Peter is correct. Highly unlikely the employer does not have PHI. Self funding and privacy notices are tough, but the employer is a covered entity and is required to send the notice.

You may want to hold off on the gap idea for awhile. I do not understand why your administrator will only allow 50% of deductible reimbursement. Unless I am misunderstanding your benefit plan, you are trying to limit the employee OOP, to as close to $0 as possible. Also, as mentioned earlier, this is an ERISA plan, subject to its rules. You will need plan documents, including a SPD, compliant plan design and wording, as well as being subject to section 105 non- discrimination rules. Make sure your admin is aware and capable. Lee

You may be over thinking it. Go with th high deductible plan and make sure you identify the types of expenses and the amounts of expenses you want the HRA to reimburse. Keep in mind, this is an ERISA plan, subject to all the requirements, including having written documents and fiduciary responsibilities. Penalties can add up quickly. That aside, this is easy to do.

If theKeep in mind that this is not the most efficient method of communicating, there are too many variables and unknowns. That aside, I commend your effort. If I understand your plan benefit description, it appears that your solution of funding the HRA by the increase in the max out of pocket. To start, I would want to know more about your current plan design, and more specifically, how much OOP does the enrolle actual pay? What, if any, expenses do the employees actual have? There is no deductible or copays, so it appears to be a plan so rich that there are no employee OOPs. Is this true? If that is true, and your goal is to minimize cost shifting to the employee, you will need to design the HRA to match the other plan. This is nothing more than analyzing where the Cadillac plan actual OOP expenses are. Then do your math. Do I understand the plans?

Keep in mind that this is not the most efficient method of communicating, there are too many variables and unknowns. That aside, I commend your effort. If I understand your plan benefit description, it appears that your solution of funding the HRA by the increase in the max out of pocket. To start, I would want to know more about your current plan design, and more specifically, how much OOP does the enrolle actual pay? What, if any, expenses do the employees actual have? There is no deductible or copays, so it appears to be a plan so rich that there are no employee OOPs. Is this true? If that is true, and your goal is to minimize cost shifting to the employee, you will need to design the HRA to match the other plan. This is nothing more than analyzing where the Cadillac plan actual OOP expenses are. Then do your math. Do I understand the plans?

Why do you ask?

Not enough info provided to give a definitive answer, so keep that in mind. HIPPA allowsa for different contribution levels, so I would say a 98% yes it is ok. But if the plan is self-funded, or if the premiums are run through a 125 plan, you should test for non-discrimination for both. Highly unlikely, but possible for discrimination in one of these.

Let me ask you one final question. How is it that a relatively inexperienced TPA employee has discovered this and no one else since 1974 has, including the Erisa attorney you have spoken to? You need to give up on this.

Multiple people here have told you that all of this is SOP, if you choose not to believe, so be it. You may also want to get another job.

You statement above tells us you are trying to gather as much information and insight into this before you decide what to do about it. Please expand, what is your role in this. Also, it appears to me that you are overreacting to all of this. There are 4 or 5 respondents with over 100 combined years of experience all telling you to not worry.

BetterCallSaul. I understand your concern, but am puzzled by your tone. Is there more to this story, you come across as very angry? Also, while reading this again it occurred to me that a new SPD may not be required to be delivered in this situation. If the required information of a SPD did not change there would not need to be a mandated delivery of the new SPD. The mere fact that the funding changed from fully insured to self funded does not necessarily constitute a new plan. Was there any significant reduction in benefits?

Thanks for the clarification. A couple of comments for you. 1. The funding vehichle is not relevant, both insured and self-funded plans are subject to ERISA guidelines. 2. A Summary of Benefits and Coverage document must be provided to plan participants during enrollment, this document is more likely to be read than a SPD. 3. Benefit information is provided to administrator for purposes of claim adjudication and payment. As mentioned earlier, this is standard operating procedure. I doubt if I have ever seen a SPD delivered before effective date.

I agree with Luke, this is done all the time, maybe not as late as your situation though. But as I read your post I was struck by your questioning the legitimacy of the retroactive piece of this. Is there more to this situation? I have been doing this since 1982, and cannot ever remember a SPD being signed and ready on the effective date. While not as late as this situation, they were all technically retroactive. BTW, I assume you were referring to a SPD when you said plan document.

Yes, assuming plan allows for it via eligibility definition. Being married is not relevant.

If a participant or beneficiary makes a written request for a copy of the spd, it must be furnished within 30 days. DOL penalty is $150 per day, or thereabouts, I have forgotten the exact amount.

Yes, just place it in the medical.

Yes, HRA is ok. Medicaid is secondary, so primary pays what they are obligated to pay, which could be $0.00. The provider asking for 50% up-front is not unusual with this type of benefit schedule. Provider sending to Medicaid is irrelevant. They are secondary and will coordinate with primary. Very good chance that Medicaid will pay nothing more anyway. If what you state above is true, which is a complete screw-up, then Medicaid will get their money back.

Do not see where the provider is being paid $1;600. Group plan pays first, so the employee in this situation pays the $800. I assumed the HRA is structured to reimburse all $800, so the HRA reimburses the employee their $800 out-of-pocket. Medicaid would not pay anything because the billed charges were $800 and paid in-full by the employee.

Specific information for Medicare can be found at cms.gov and for Medicaid go to Medicaid.gov. Long story short, Medicaid uses COB with all other payors. In your example the group health plan pays first, the Medicaid pays pays based on COB. Provider does not send back the $800. And yes, the HRA does pay. Hope this helps.

I think Larry Starr has a very unique, and enviable, situation. But for those who do not have the same, I believe very much in service agreements over purchase orders if the purchase order does not contain specifics. Yes it protects the firm, but it also identifies for both parties what is expected from both sides. Truth be told, I would prefer Larry’s situation over an agreement.

Yes, it is possible and is done often. There are issues of possible additional administrative issues, costs, and headaches. The actual cost should also be reviewed, sometimes it is better to split the risk, other times it is not.

Could this be a situation where the employee was given the subsidy wrongly?