jeanine

Assymetry, or symetrical appearance, is mentioned specifically in the Womens Health and Cancer Rights Act. Implants are not cosmetic just because more than one breast is involved. A plan is required to pay for both breast implants following a mastectomy (single or double) if a double implant is necessary to produce a symetrical appearance.

No offense, but I won't even consider spending time on the phone with someone who is speaking to me in less than perfect English. That tells me the company has off-shored their labor. They can off-shore their product as well since I won't be purchasing it. Nothing turns me off more than someone mangling my name--although my son had a pretty funny comeback when someone asked for Je nine. (J 9). He told him J 9 wasn't here but Jeleven was.

I held off on responding until I did because there are so many issues and things that scream "wrong" that I couldn't begin to address them all. What is the point of taking--in your original post--the same amount of money that was being paid in premiums and dumping it into a fund that the employer administers until the money runs out? The employer certainly won't be saving any money. The only result would be that the employees have lousy coverage and run the risk of incurring huge amount of medical expense. I'm not even going to comment further on the age thing. Why not take premium money, ask the carrier for a high deductible plan (which should be cheaper), and split the remaining amount between the employees in the form of an HRA? At least then your employees would not be out of luck for any catastrophic claims. Something doesn't seem right.

Why would any provider negotiate a discount with a plan of this size? Where's the incentive? I also don't understand the statement that older employees would have more in their pot than younger employees. Is the difference because of the age of the employee or the length of service of the employee?

I'm not recommending it, I'm just saying that it's possible. Namealreadyinuse gave a perfect example of when a retro amendment would be useful. You would also have to go back and and correct your claims processing system, especially if an enrollee could have benefitted from it. I don't know what the poster had in mind so we're missing a critical item from the discussion. If they intend to cut a benefit retroactively, my opinion is don't even consider it. Make the change effective at least 60 days from now and give notice before you enforce.

You can sign the amendment with an earlier effective date. However, you need to give participants 60 days prior notice of the change. If the amendment is more beneficial, I don't see a problem except maybe with your stop-loss carrier but if you try to cut or terminate a benefit retroactively and someone had relied on it, you're asking for trouble. I'd also be careful that your retroactive amendment was not directed at any specific enrollee's medical condition.

No, the massive pile of money bags crowded them out.

If the plan wants to add a benefit they can ask the insurer to add it. The insurer will then adjust the premium. However, they can't ask the insurer to not provide a state-mandated benefit nor provide a benefit prohibited by the state. Your response raises another issue in states (such as Ohio) who have amended their Constitutions to provide that no benefits inur to same-sex marital partners. So, in that case, we could not file a policy that defined "spouse" any different than what the state Constitution defines it as. We could of course agree to provide domestic partner benefits and adjust the premiums accordingly (if necessary.)

Here's how I understand it. ERISA plan sponsors have the ability to provide whatever benefits they want, within very limited federal law. Once they establish a health plan, they have to decide how they are going to pay for benefits. They can self-fund or they can purchase insurance. The state in which they are located is going to determine what type of insurance (and benefits) they can purchase. Although this isn't the case in the original posting let me give an example to explain my view. Company has a health plan. They purchase an insurance policy that doesn't doesn't cover grandchildren born to unmarried minor dependents. Company promises coverage, perhaps because of union contract. The plan states it covers, insurance policy states it doesn't. Plan still must offer coverage but insurer doesn't. In this case I would say the plan is on the hook and must self-fund. Is there conflict? Of course. However, that doesn't change the terms of the insurance policy that the plan purchased.

GBurns is correct. The health plan owns the data, not the employer. The employer is the plan sponsor but the plan is a separate legal entity. Chances are, employees of the employer work for the health plan. However, the health plan employees can't just give PHI to anyone. The health plan would have to be amended so that it is allowed to give PHI to the employer for certain settlor functions. As a TPA, we have every Self-funded plan declare to us who is the named Plan Administrator and any other person who they consider to be employees of the Plan. We give PHI only to the Plan Administrator or these designees. HIPAA was specifically written to protect employees from employers using PHI to make employment-related decisions.

All kidding aside, some states have laws that allow jails/prisons to bill a prisoner's health insurer for services received as an inmate. This saves the state or county money. The county or state could conceivably pay the COBRA premium if it makes financial sense to do so.

Most enrollees do not want to pay cash then wait to be reimbursed by the HRA or HSA account. I can see your point of applying the non-negotiated amount to the deductible but we are checking to make sure that it is actually for something that would count against the deductible. Additionally, many of these accounts are only funded for a small amount of money. Why wouldn't the enrollee want to save as much of the account money as possible by having it debited by a negotiated amount rather than a higher amount?

I feel silly for even asking this, but what do the numbers mean on Revenue rulings? For example, IRS 2002-45. Does this mean that this is the 45th revenue ruling issued by the IRS in 2002?

We're an insurance company and a TPA (2 separate affiliated companies). The TPA administers the HRA through a separate Administrative Services Only agreement because the HRA is a separate, self-funded health plan. We couple the HDHP with the HRA for several reasons. The claims are submitted directly to the HDHP first where network discounts are applied. This also allows us to accurately track the deductible for the HDHP since (sometimes) the HRA will pay for expenses that are not covered under the HDHP. In addition, in order to make the providers happy, we allow the enrollee to assign the benefits under the HRA to the provider so that the provider is paid quickly.

I'll concede on Part A but not Part B.

Kirk, Sorry, I did not mean to come off so forceful in my response. I didn't want to get too detailed either but we have reviewed the whole concept of "carve-outs" under just about any conceivable proposal. Our general answer from counsel is that these are pretty much impermissable when the enrollee is an active employee. Retirees are another issue. We have analyzed this with ERISA, ADEA, and ADA in mind. If you require the person to enroll in Medicare they have to pay the Medicare premium. The employer can't subsidize the premium. I think this leads to fairness issues.

You can always try your luck purchasing off the street but the best time to do it is earlier in the day. Right before gametime will probably cost you as much as the ticket service. If all else fails (and even if it doesn't) take the family for a Fenway tour. I don't remember if this is limited to certain days but it is limited to mornings. It's pretty cheap and you get to sit in the dugouts and walk the warning track to the Green Monster!

The 30 month COB only applies if the person enrolls in Medicare. You can not force an active employee to enroll in Medicare to receive benefits under your plan. 42 CFR 411.102(a)--A group health plan of any size (i) may not take into account the ESRD-based Medicare eligibility or entitlement of any individual who is covered or seeks to be covered under the plan; and (ii) may not differentiate in the benefits it provides between individuals with ESRD and other individuals covered under the plan, on the basis of the existence of ESRD, or the need for dialysis, or in any other manner.

If the plan has a COB provision it has every right to pend claims based on receiving COB information.

Send your "P" a COB letter informing that all claims are pended until completion of COB (you may have already done this and this is why you have the divorce decree). Then P should send the divorce decree to X's plan and ask if it is satisfactory as a QMCSO. If not, P must go back to court and get a QMCSO and send to X's employer. At that point, X will be forced to cover the children as long as certain conditions are met. X's plan administrator can add them to coverage and withhold premium contributions even if X objects pursuant to a valid QMCSO.

Health plans, health care providers, and health care clearinghouses are covered entities. HIPAA limits how they can use or disclose individually identifiable protected health information that they have in their possession by virtue of the fact they are a health plan or a provider. They can't divulge any information to you (as in your example of wanting to assist your friend) without your friend's authorization. The SSA can't disclose to you either without your relative's authorization, nor can they disclose information to the uncle. However, no one, including the SSA or any health care provider can stop a non-covered entity from telling them something. Whether they believe it or not is another story.

HIPAA applies to Covered Entities and their Business Associates. The uncle is neither.

I think the information is PHI even as you describe it in number 1. However, the individual isn't a covered entity plus it's his/her own PHI. They can disclose it to whoever they want. If the plan administrator were to call the insurance company they shouldn't be able to get the information from the insurer without an authorization. This is the approach we have taken with our clients. In a way, we are forcing them to be "hands-off" PHI unless they can demonstrate that they have fully complied with HIPAA. Most are more than happy to receive only enrollment/disenrollment and summary information so that they do not have to comply with all of the other requirements. A plan administrator--or more likely in the scenario you have described, the HR person--would not be able to discuss this with us without an authorization.

Why not fire the employee? If the employer doesn't want to cover domestic partner benefits because the arrangement violates church doctrine, why have they employed them in the first place? Before anyone criticizes me for this statement, let me say I don't necessarily agree with doing this, but this is how one church in particular usually deals with these issues.

I know next to nothing about DCAP's except that it is a way to pay for dependent care expenses. If a company wants to institute a DCAP are there any rules as far as pro-rating contributions? By this I mean company plans to begin offering under their cafeteria plan beginning 3/1/05. Can the employee withhold the maximum annual amount contributing January and February retroactively and submitting dependent care expenses from January and February? Thanks for any replies.