GBurns

Note the state law requirement that it has to be authorized in writing.

I think that PLR200146011 should give you some insight. There should be a COBRA rate already calculated by the Claims or Plan Administrator which you can adjust to calculate the imputed premium. You should engage both an actuary and legal advice. Things might have changed since 2001. I noted that a cite is Rev Rul. 61-146. This is the same Rev Ruling that is cited in Notice 2013-54 regarding "Employer Payment Plans" which are no longer available. You should get legal advice to see if this is applicable to your case.

What year was the TAM issued? Which division or region was this TAM issued in? What are the references that you came across? I am surprised that you found references which indicated that the TAM exists, but did not give the number.

To "audit" claims without a specific purpose would be futile. I advise that you decide what it is that you want to accomplish by this "audit" so that you can determine who you choose based on their experience etc in that particular area of claims auditing.

I think that you should explain further the problems that you see, especially those relate to the nondiscrimination rules. As far as I know, the controlled group rules only apply in that the companies have to offer the same sort of benefits at each company within the group. It does not mean exact but type of benefits.

Who told you that the policy from the marketplace was undoable, by which I think you mean that it cannot be cancelled? Do you have health coverage from your employer? What does the FSA cover? Where did you see that you cannot have an FSA and a marketplace policy?

That the PEO is large or is a public company is irrelevant and distracts your thinking. I do not think that there has ever been a case where the PEO is the common law employer. What benefit is being provided through this MEP? While the IRS has issued guidance regarding 401(k) s and MEP, I do not recall that health benefits could be allowed through a MEP but had to be through a MEWA.

As far as I have been told by a number of legal people at a number of state DOI s, the insurer can rescind coverage and seek restitution. It is insurance fraud. Under most state small group health insurance law, the reimbursement etc causes the arrangement to be subject to the state small group health laws, which in some cases do affect the employer. Also, since the DOL has often and long opined that in many cases, the actions by the employer would have caused the arrangement to be treated as a group health plan and to fall under ERISA and HIPAA, there could and should be action against the employer.

Zane changes its position often and on many issues has been or is wrong. Anyone who feels that they should follow much of what is posted there, should get competent legal advice. Additionally, many states small group/employer health insurance laws restrict or prohibit the reimbursement to the employee, in any manner. Also the individual health applications of the insurance carriers also prohibit or restrict the reimbursement. So between IRS Notice 2013-54 and state small group laws and the insurance application, it seems difficult to do especially in small groups (up to 100 lives).

If the PEO uses a self insured plan that multiple employers (like your company) must adopt., I would think that you have a MEWA, which raises a whole nother set of issues. While I understand your concern with the COBRA rates, you have a bigger issue that should eventually come back and bite you. I do not think that it is allowable that the health insurer should be "offering an equivalent coverage policy" , the coverage should be the same as before at the rate of 102%. There might be a leeway where COBRA could be a little more than 102%, but that rate whatever it is should have been disclosed long ago. If I were you, I would be checking with BOTH you state DOI and the DOL regarding the MEWA arrangement. I would also check the state insurance law regarding the state version of COBRA and continuation of coverage, especially since you most likely fall under your state small group/employer health insurance laws. By the way, What state are you I? Hopefully, one of our COBRA experts will see your post and chime in.

How can there be a Northern Cali solution by the Blues to a nationwide problem? What is the nationwide problem?

You should be looking at the Plan Document not the SPD. I think that in this case, since your husband is 67, entitlement and eligibility for Medicare would be the same thing. "Enrolled" might be relevant.

I cannot give you a cite, but the authorization itself give personally identifiable information about the health activities of the participant and therefore should be protected. It could tell what sort of medical practitioner or specialist is being seen etc.

Since the wording which explained that a pre-taxed premium is not reimbursable, was not clear to you, I suggest that you use Google and do search using terms like "double dipping health plan" and " Rev Rul 2002-3" so that you get other wording which should make it clearer to you. By the way, being treated as one employer is irrelevant.

See Revenue Ruling 2002-3 and IRS Notice 2013-54. Premiums that are pre-taxed were never reimbursable.

State health insurance laws regulate the conditions under which insurance can be sold. Typical wording in many states is: " 743.734 Group health benefit plans subject to provisions of specified laws; exemptions. (1) Every health benefit plan shall be subject to the provisions of ORS 743.733 to 743.737, if the plan provides health benefits covering one or more employees of a small employer and if any one of the following conditions is met: (a) Any portion of the premium or benefits is paid by a small employer or any eligible employee is reimbursed, whether through wage adjustments or otherwise, by a small employer for any portion of the health benefit plan premium; or (b) The health benefit plan is treated by the employer or any of the eligible employees as part of a plan or program for the purposes of section 106, section 125 or section 162 of the Internal Revenue Code of 1986, as amended. What being further subjected to state insurance laws mean, is state specific. ERISA preemption is not an issue since the state does not regulate the reimbursement plan itself.

Since this is a small group state small group/employer health insurance laws may be applicable.

Isn't this where it started? You initially posted "Company offers two carriers for medical coverage. Each one has about 60 employees signed up. The sum just reached over 100 for 1st time as of 12/31/11 so the question is if there is a need for a 2012 5500." KJohnson pointed out. " But two group health contracts that offered the same type of benefit might be a single plan even if not "wrapped"" along with other observations. So I wondered How you rationalized that you have 2 different plans if both are medical, which would mean that they are offering the same type of benefit.

None of the replies conditioned anything on employee count. Why do you?

What sort of coverage is provided by these voluntary supplemental policies?

I have not done any enrollments for quite a while, but when last I looked the only way to do enrollments without a broker was via a web portal. However. the web portals might not be free. Additionally, do you have anyone who can do what the broker did? Do you know what the broker did and how it was done? Historically, as proven by the Spitzer lawsuits, other than getting the rate schedules filed with the state DOI and knowing how to adjust filed rates to produce premiums, you most likely will not know whether or not writing agent/broker etc commissions are being charged even if there is no broker. I suggest that you negotiate with your broker, otherwise you could be cutting off your nose just to spite your face, as they say. By the way, What proof do you have that commissions were really carved out?

I am wondering why it is referred to as a MEWA and also about the wording used by the poster. I get the feeling that there is much more that was not disclosed.

I have not seen or heard of this. I would have asked the receptionist to give me the exact cite.

I think Allstate WSD, Aflac, Colonial, Golden Rule and Transamerica all have them.

Specified disease, Cancer and other Supplemental Plans are not subject to the EHB requirement and are, in general, exempted from ACA. The supplements do not require primary health insurance but ACA does unless you are exempted. However, there are available ACA compliant "skinny plans" in some states that will provide Minimum Effective Coverage that might satisfy your need. That should have been Minimum Essential Coverage.