GBurns

What do you mean by "not include a certain dollar amount"? Where does the money for the reimbursement come from? How does it get there? What is "URM"?

WOW!!! Are you sure of this $50,000? 15% of the premium should not be anywhere near $50,000. I have never seen or heard of 1 this high. I have also not seen a "guideline" or standard. It is usually what the traffic will bear and this is usually based on competition. Call a few agents (consultants) and see what they are doing. Many will be commission from the TPA and insurer only. How much agent (referral, placement) commissions etc do they also get from the TPA and stop loss insurer for placing the business?

Steve72, My response was really directed to oriecat, who jumped in and selectively picked a "However" that met his/her purpose of interjecting a criticism without contributing anything else to the discussion.. I do know that I omitted the part that you underlined but that was because the sole purpose of my response was to point out that he/she had missed, purposely or not, a "However" etc. I wonder why you found it necessary to respond to my omission but not to that of oriecat. Fair is fair.

There is more than 1 "However". How about: "however, to refrain from intimidating or retaliatory acts (45 CFR 164.530(g)), and from requiring an individual to waive their privacy rights (45 CFR 164.530(h))" As I suggested. let's see if there are any actual cases etc.

He does not have to speak of not rolling over unused funds. It was very clearly stated that "it could be used only when needed and wouldn't need to be funded" and that it would "reimburse employees who exceed the old deductlbe amount up to the new amount". This means that there would be NO unused funds. If there are no unused funds in the scenario, it does not need to be said that there is no rollover of unused funds, because logically, there are no unused funds. Why would he talk about something that he already stated was not possible?? Why do we need a scenario other than the 1 that we are addressing?

You omitted noticing the word "However" which would act as a qualifier and affect non covered entities. I guess that we might have to wait until someone spends the time and cites a case or instance that has the same or near facts and circumstances.

First, when an employee uses the term HIPAA, it usually is used as a "catch all" for all Privacy rules, State Federal and anything else. I do not expect accuracy from an employee who probably uses the term 1 time per year. So although the OP did state HIPAA, I took that as a "catch all" not as an exact term and did not get hung up on HIPAA. There is still State law etc. Second, I still do not see how the employer can get around HIPAA. Note the references in the below (and many other) Q&A and use of such phrases as "the Privacy Rule does control the conditions under which the group health plan can share protected health information with the employer""will not be used for employment-related actions"refrain from intimidating or retaliatory acts (45 CFR 164.530(g)), and from requiring an individual to waive their privacy rights (45 CFR 164.530(h))". There are many other Q&As that seem applicable and probably more on point including 29, 97 and others. (Highlights below are mine) HIPAA Q&A 110: Question As an employer, I sponsor a group health plan for my employees. Am I a covered entity under HIPAA? Answer Covered entities under HIPAA are health care clearinghouses, certain health care providers, and health plans. A "group health plan" is one type of health plan and is a covered entity (except for self-administered plans with fewer than 50 participants). The group health plan is considered to be a separate legal entity from the employer or other parties that sponsor the group health plan. Neither employers nor other group health plan sponsors are defined as covered entities under HIPAA. Thus, the Privacy Rule does not directly regulate employers or other plan sponsors that are not HIPAA covered entities. However, the Privacy Rule does control the conditions under which the group health plan can share protected health information with the employer or plan sponsor when the information is necessary for the plan sponsor to perform certain administrative functions on behalf of the group health plan. See 45 CFR 164.504(f). Among these conditions is receipt of a certification from the employer or plan sponsor that the health information will be protected as prescribed by the rule and will not be used for employment-related actions. The covered group health plan must comply with Privacy Rule requirements, though these requirements will be limited when the group health plan is fully insured. See the Answer to the FAQ "Is a fully insured health plan subject to all Privacy Rule requirements?" That question, hundreds of FAQs, and a wide range of other guidance and materials to assist covered entities in complying with HIPAA and the Privacy Rule, are available at the Department of Health and Human Services Office for Civil Rights website, http://www.hhs.gov/ocr/hipaa. HIPAA Q&A 147: Question I’m an employer that offers a fully insured group health plan for my employees. Is the fully insured group health plan subject to all of the Privacy Rule provisions? Answer The Privacy Rule recognizes that certain fully insured group health plans may not need to satisfy all of the requirements of the Privacy Rule since these responsibilities will be carried out by the health insurance issuer or HMO with which the group health plan has contracted for coverage of its members. In particular, a fully insured group health plan that does not create or receive protected health information other than summary health information (see definition at 45 CFR 164.504(a)) and enrollment or disenrollment information is not required to have or provide a notice of privacy practices. See 45 CFR 164.520(a)(2). Moreover, these group health plans are exempt from most of the administrative responsibilities under the Privacy Rule. See 45 CFR 164.530(k). These health plans are still required, however, to refrain from intimidating or retaliatory acts (45 CFR 164.530(g)), and from requiring an individual to waive their privacy rights (45 CFR 164.530(h)). The documentation requirements at 45 CFR 164.530(j) apply to these group health plans only to the extent of amendments, if any, made to the plan documents for the sharing of information with the plan sponsor under 45 CFR 164.504(f). Additional information about the Privacy Rule, including guidance and technical assistance materials is available through the Department of Health and Human Services Office for Civil Rights website at: http://www.hhs.gov/ocr/hipaa. ********** The information that this employer wants is detailed PHI and it will not be used for the administration of any sort of health plan. It will be used for employment related purposes and refusal to give it would garner a retaliatory action. Even if there is no refusal and no immediate retaliatory action by the employer, the PHI is still going to be used towards eventual disciplinary action and which is still employment related and not health plan related. On top of all this such detailed information is not necessary to administer the sick day program and so the detailed PHI serves absolutely no purpose.

jsb But does your scenario require the stating of the medical condition and the treatment like calcu does?

What would be the benefit of an HRA over a standard simple section 105 MERP? There was no expressed desire to fund for other than incurred expenses, no pre funding and therefore no possibility of rollover of unused funds.

For the members, for the employees of the members or for the employees of the association?

This should have some bearing: http://www.aishealth.com/GNOW/091205.html#gnowone A Google search should also bring up articles that also have this negative opinion on wellness and other programs. Some would opine that your proposed program offers "first dollar" coverage and wellness type coverages, which would be affected by this comparability rule.

The reimbursement of the deductible should be done through a MERP and be separate from the section 125 Cafeteria Plan.

How do the health center and health center employees get paid? Is a claim submitted to an insurance company, claims administrator or anyone else for payment for the services or treatment given to the employee?

calcu, I should have asked this initially. Why does the employer need the note? Is it for an STD benefit, sick days, or what?

Check your state small group health plan laws. They determine whether it is employer provided, the mandated coverage and the premium payment structure etc. Under the IRC employer provided benefits have to meet various criteria in order to be not taxable. Fail and the benefits are taxable. What do you think happens to the tax benefits in a disallowed plan?

Good suggestion. "Do it for $X or else....". I don't know about the 401(a) but How non-standard can the SPD for a 403(b) be, even if it is an ERISA plan? $11,000 makes me think that this law firm either sees the client as a "sucker" with deep pockets or have no idea what is appropriate which could occur if this is not something that they have done before. I wonder what others who used other law firms have paid?

I have never been a supporter of seminars or large classes especially for beginners. If I were you I would start self studying using either the EBIA manuals or the BNA Portfolios. I also do not think that you should be restricted to Cafeteria Plans, per se, but also cover health plans (and possibly other areas)as inseparable components. IMHO, seminars attendees need more than basic knowledge to gain anything meaningful.

I don't think that there is anything that prevents the insurer from giving coverage, but coverage is not the issue. The issues are taxation of premium, taxation of benefits, eligibility, mandate and regulation (these 3 mainly from state small group laws etc) and EEOC and state labor and civil rights laws.

If paid directly by the employer outside the Cafeteria Plan, does that not make the premiums taxable income to the employee?

That is providing that it is the employer making the decision and not the Plan itself, the Claims Administrator or the insurer. But that raises the question of whether the employer can force the employee to disclose information, especially when that information is not necessary neither is it being used for health or health plan purposes? Isn't it rather rare that an employer does the claims administration in an STD Plan? Most that I see are either insured or administered by a Third Party (if self insured), but even then I cannot recall there not being a Plan. With a Plan shouldn't that remove the employer from being in a position to access the PHI, since it has no use to the employer because there is no employer decision or administration?

I have been out of this for a while, so I am wodering what causes you to think that this might haoppen? Was there some recent law change that I missed?

The state rules etc might require that it be treated or characterized as a Group Plan. This is even potentially more so if the employer falls under the state Small Group Health Plan rules. There are also state insurance rules regarding List Billing which might also be applicable.

What about Proposed Treas Regs 1.125-1 Q&A19 ? This sales is already known to be highly compensated, so what happens if they employ other sales people who are in this same class but are not highly compensated? Aside from the HC issue, What do you think would be the case in this scenario: There were 3 employees in a class, 1 Hispanic, 1 White and 1 Black. Each gets a separately negotiated health subsidy. 1 of these indiviudals decides that the other 2 were treated better and offered better for racial or other Title VII regulated reasons. It turns out that all had made a compromise that was 10% better than initial offer but since each initial offer was different each ended with a different result. Do you see where this employer has exposed themself to a discrimination lawsuit and a valid EEOC and state labor and civil rights investigations and possible action?

In the OP it stated "the reason for the visit". I take that to mean that this employer wants to know the medical condition. IMHO that is PHI under HIPAA. The employer did not just want to know whether the person could work or not they asked for details.

jhall, I do not see a problem if this is the ONLY salesperson that this employer has and will have. Creating a separate "class" for salespersons and giving this "class' different benefits than the other employees is allowed. Any other person in this "class" is similarly situated and should get the same unless a "sub class" can be created.