jeanine

I see you are registered in NJ. I don't know about NJ case law, but in Ohio even a subpoena is insufficient to turn over confidential information in a civil case. We would insist on a court order. However, your post states the atty general is requesting info. Is this a criminal investigation? There are generally different standards of proof and/or evidence in criminal cases vs. civil cases, so a short answer would be yes, there probably is a difference between the atty general's office request and a private atty. I must give you my standard advice--run it by an atty, especially one licensed in NJ if that is the office this is coming from.

I agree with Patricia that the language is unacceptable, however I got the impression that Damien worked for a TPA and could not change the language w/o the plan's consent. I see self-fundeds wanting to do things like this all the time. In my experience, they most often have not run it by an attorney. Telling them to run it by an attorney and/or restate the hold harmless provision does 2 things: Either the plan gives up on its 'shenanigans", or it does run it by an attorney who tells them its illegal. We don't look like the bad guy and we aren't the ones offering legal advice. If they insisted on continuing to press the issue (and no one has yet) then we would determine if we wanted to drop them as a client.

Have they had their attorney look over that language? Ask for that in writing and double check your administrative services only (ASO) agreement with them for iron-clad hold harmless clauses. Of course they can say what ever they want in their plan as a self-funded plan. Just make sure you are adequately protected so you can be dismissed out of any lawsuits.

Help! Can anyone point me in the direction of some good, easy to understand explanation of the HIPAA administrative simplification requirements? I would prefer a seminar, but printed material is OK too. I have been asked to do an overview of this and set up a plan for one division of our organization. However, the structure of this organization leads to many difficulties. I work for a TPA that is under the corporate umbrella of a health care foundation. Other entities beside the TPA are a hospital, 2 licensed insurance companies, an HMO, a federal HMO, a Medicare plus choice program, provider network, etc. I'm pretty sure some divisions of the foundation have started their own independent analysis and corporate culture does little to encourage coordination among the departments.

Very good comments on this topic, however the thought of annual max makes me a little uneasy. I do compliance at a TPA and share an office with our pharmacy benefits manager. Some of our plans are extremely stingy in their annual max. Perhaps I would feel better about this if there were some sort of catastrophic coverage provision for those persons with multiple expensive treatments. Is there any prohibition on treating Rx coverage as a separate coverage and charging accordingly? Of course, if it is option only you would have adverse selection in those optioning in. I don't know if you could make it part of an unseverable package and still charge an additional premium.

I was in fact concerned about the new HIPAA privacy regulations and how it affects this disclosure. Until those regulations are fully implemented, we have decided to double check our administration agreements (checked out OK with a hold harmless clause) and to reiterate this clause on correspondence to the company. We are also only turning over upon written request from this point forward, something I can't guarantee we did at all times in the past.

Although Phil is probably correct on this, we would still offer COBRA to the ex-spouse. Why? Well for the first thing we are always afraid that we may have done something even the slightest bit incorrectly in administering some company's COBRA and we don't want to be a named defendant in the COBRA update we receive. A little while ago, we undertook a mass mailing to all employees and spouses for another COBRA Initial Notification that was updated to include COBRA 2000 information. Unless you have excellent control and documentation that all employees and spouses have received a notification of COBRA rights, I would hesitate to decline COBRA to the ex-spouse. All she has to do is claim that she never had notice of her duties and rights to receive COBRA coverage. As I said, we are probably a little too cautious.

A while back someone questioned a situation where the plan administrator was receiving EOB's and opening them before sending to the enrollee. I have a situation that is somwwhat similar. We are a TPA. Sometimes our self-fundeds ask us to provide special reports, such as a pharmacy analysis, to track drugs that might be overutilized or look for ways to cut cost by a formulary or 3-tier payor system. I advised the rep not to turn over this information until all names and socials were redacted. Since we assume all administrative functions by contract I don't think the Plan Administrator has any legitimate reason to know who receives what and for what diagnosis. Same thing with claims--they should just get the cost without need to know diagnosis of particular enrollee. Am I overreacting here? Although I don't think this is per se illegal, it certainly seems actionable under a few federal laws. One response I have gotten here is that we have the self-funded client sign a "holds harmless" provision in the general admin contract but I think that is useless. I am looking for suggestions on how to limit our liability as a TPA if someone turns over this kind of information at the insistence of the company. Do we have any way to protect ourself or at least limit our liability?

None of our self-funded plans or insured product plans drop a spouse or child from coverage simply because they are not domiciled together. In fact, we consider the COBRA qualifying event to be the entering of the divorce degree. We would question any spouse atttempting to remove a spouse from coverage under these circumstances. As Kip has also noted, you need to consider whether state law allows a plan to drop a child because they are not living in the home. I thought that OBRA '93 forbid plans from using residency (of child) as an eligibility exclusion, and forbid eligibility exclusions based on out-of -wedlock children and children who are not claimed as dependents on the employees federal tax form.

When calculating the premium for the 12 month determination period, what does the self-funded client base its cost decision on? Can the plan base its calculations on speculation of future claims (such as knowing a very sick employee has just elected COBRA) or must the premium be based on the previous 12 month experience? I have a feeling that this is very wrong but I can't find the exact language to tell me so. Also, as far as being able to change the rate during the determination period, I see 3 express situations when this can be done. In other words, the Plan does not get a free pass every 12 months to raise rates. Is this correct?

Any thoughts on this situation? Wife loses coverage through divorce. Unaware of her right to receive COBRA coverage, wife enrolls in own employer sponsored plan that has greatly reduced benefits. Wife is hospitalized 40 days after losing first coverage, when she returns home she finds notice to elect coverage. She wants to elect COBRA coverage from first source for several reasons, one being that coverage is superior. May she disenroll from her employer's coverage (enrolled only 2 weeks ago) and enroll in COBRA from her former spouse's plan? She is still within the election period. Our thought is to let her elect COBRA as she has medical needs and would benefit from the higher level of coverage under the COBRA plan.

In theory,that is what we would do. I'm not sure how the split in the bill would actually work though. However, all of our plans have a preexisting condition exclusion. Assuming no coverage at the time of hospitalization, the only way this condition could be covered is if there was a prior coverage no more than 63 days and there was enough creditable coverage for the pre-ex time. (I believe it is 6 months). In any case we would not cover the entire stay.

Our insured product plans have to be approved by the Ohio Department of Insurance. We have contract language that states that if you are hospitalized at the time coverage should take effect, coverage is effective immediately (to comply with HIPAA) but any previous insurance coverage is responsible for care until discharge. The reverse is also stated so that we are responsible even if you obtain other coverage for the hospital stay not to exceed 365 days. If the other coverage becomes exhausted before discharge, we then start paying. I'm not sure if this is Ohio law or not but it seems to me we had some help from ODI in getting this language straightened out.

Try calling the Pa. state department of insurance. One other very useful site I recommend is www.insure.com. I think there are links to state insurace sites on it. There is also a good forum for questions on all types of insurance, including health care insurance.

You don't give your background, and I'm going to assume you are asking in response to a particular situation involving a specific plan. First of all, any Pa. law regarding well-baby and well-woman exams only applies to plans that the state of Pa. may regulate. If the plan is a true insurance plan subject to state insurance law, then the law if it exists, can regulate the plan. Check on the internet if your state has an official state website. If it does, it will probably provide links to state law in codified form. From this site, you should be able to access specific provisions of the law by typing in key phrases. Be aware, however, if you are trying to find out if your plan must comply with any state laws, you must first find out if it is subject to state law. Plans provided by an employer who self-funds (pays all costs from the company's assets instead of buying an insurance policy)are exempt from state law by ERISA. ERISA does not require plans to offer well-baby or well-woman care. With more details on what and why you are asking, you may get a more detailed response than what I have been able to give you.

I would really appreciate some guidance in this area. We were told by an ERISA attorney that self-funded health benefits plans maintained by a division of a municipality (in this case a school board, but question applies to city maintaining a plan as well) were exempt from the disclosure requirements of ERISA section 1. Because of this, they did not have to issue SPD's to their enrollees. What I don't know is this: are they also exempt from other ERISA requirements?? If so, are they regulated under any state insurance laws such as mandatory benefits, or as in Ohio, a law that sets up a mandated review process? Any insights or leads to where I might find additional information would be greatly appreciated.

I see at least 3 major problems with what you are proposing. If your plan is an insured product plan, state law probably prohibits you from offering coverage to some and not others. (depends on your state). If you are self-funding the plan, you can't discriminate amongst similarly situated individuals, however you may be able to offer a plan to just salaried personnel as opposed to hourly. Third, federal law known as HIPAA forbids you to require enrollees to pay a different contribution based on any health related status. Many states have similar laws which would apply if the plan was insurance. If you are determined to apply these rules you have suggested, I suggest you consult an attorney who is familar with health benefits law.

I believe it is now $110 a day.

Is the plan self-funded or an insured product benefit? If it is self-funded, ERISA does not let you discriminate against similarly situated individuals. You could have a plan that just compensated the partners and not hourlies, or you could have a lesser benefit for full time vs part time. To my knowledge, this kind of classification does not include classifying persons by age for medical benefits. If this is offered through an insurance plan, check with state law. In Ohio, a small business (under 50 employees I think) may not offer insurance to some employees without offering it to all, regardless of whether it is management vs. hourly.

We would of course let her add the baby through the addition of family coverage but only on the same plan she has for herself, the high option. If there is an open enrollment period when the enrollees can change from high to low, as is our case, she could change herself and the baby's coverage at that time.

Thanks for all the input and site suggestions. I will let you know as I get any more details from DOL and the results of their visit. In the meantime, I am still open to suggestions.

Kirk, We are the TPA. I am not sure if the subpoenas are so we can turn our client plans over to DOL or if they are for something else. Also, we administer plans for companies that buy our insured product line (actually another corporation but TPA and insurance company have same parent company). This is the area that worries me most. I have someone here who seems to think that they are off limits to the DOL because it is "insurance" and state law regulates. Even though it is insurance I am sure that DOL has jurisdiction to inspect based on the fact that they are ERISA plans. Comments anyone?

I am hoping to get some advice from anyone who has survived a DOL audit. Firm is a TPA, servicing self-funded and insured product employee health and welfare benefits plans. We have been told that DOL will arrive in about 5 weeks, subpoena in hand. Will we receive more information before the audit as to what specifically they want us to produce? If not, is there a reasonable time we may ask for in order to produce the documents? We have no idea yet whether they are auditing firm as a supplier of services to plans or if they are auditing a specific plan. Personal experience or reference to guidelines would be extremely appreciated.

At this point I think I would call United Healthcare. If United also provides the COBRA administration for your employer, they should be able to give you the most accurate advice as to whether your coverage will be portable. I understand your reluctance in not wanting your employer to find out you are thinking of leaving but I would be reasonably sure that a call to the health plan would not tip them off.

Check the new COBRA 2000 regulations available from numerous websites on Benefitslink. You may have to go back a few weeks or months. The new regs. say that as long as an employer offers a benefits program that the employee can utilize, they must be given the COBRA option. Two examples are most often given. 1)Plan is a PPO; employee can use any provider and pay the out of network difference; 2)Plan offers both an HMO and PPO; employee must be allowed to switch from HMO to PPO if this enables employee to participate in plan.