jeanine

We ran into a problem just recently with our certificates of insurance which had an "actively at work" clause. We were told by the Ohio dept. of insurance that these clauses violate HIPAA unless the actively at work clause specifically does not apply if the enrollee is absent from work because of a health-status related factor. I would think that a self-funded plan could also not require this without running afoul of HIPAA. Without specific cites I believe that many federal circuit decisions (6th included) have held that SPD language trumps the Plan Document whenever an enrollee relies on any information provided through the SPD as it is their only means of finding out about the plan, absent a request to the plan administrator for a copy of the official plan document. Also, you have a bit a paternalism at work here with courts not expecting an enrollee to understand the more difficult language of a plan document.

New COBRA rates for the 12 month period are due Jan.1. Plan does not receive rates, quotes last year's rate to current COBRA enrollees and new elections. New rates arrive Jan. 25. Plan wants to retro the increase back to Jan.1, even though premiums are paid for January and in some cases 3 months in advance. My first thought is no way, but how long is the Plan tied to the rates quoted Jan.1?? May the Plan use the new rates any time during the 12 month period or are they bound (quasi-contractually) to provide COBRA at the first premium amount until a new 12 month period. Please provide citation if available...right now I'm thinking 26 USCS Section 4980B(f)(4)©applies("any applicable premium shall be made for a period of 12 months and shall be made before the beginning of such period."

You might want to try the Corbel website (www.corbel.com). Although the TPA I work for has not had any plans drawn up by them, I access the site frequently for information. Sorry I can't give a personal recommendation as all our plans are done in-house.

If you have a large enough company and expect a high enough demand, you may want to set it up and run it in-house. For example, I work at a place where the employees are about 80% female, and quite a few are childbearing age. We have a constant demand for child care because of the nature of our company and the characteristics of our employees. Our center is on-site and the child care employees are company employees. The center is limited to children of employees. Child care tuition is well below current market prices in this area. Tuition is payroll deducted and may come out of an employee's FSA if they have elected into this benefit. Check with your state and local officials for state mandated staffing levels and other health and safety requirements. It has been our experience that in-house care is terrific and can be cost controlled better by the company instead of outsourcing. As an added benefit, parents are nearby and can drop in whenever they want, although access to the building is controlled by key cards.

The US Supreme Court refused to hear an appeal on whether the ADA is violated by a lower lifetime cap for benefits for AIDS and AIDS related illnesses in Doe v. Mutual of Omaha Ins. Co. (U.S., No. 99-772). My question to you is: Is the plan refusing to cover all medications related to AIDS or coverage of medications that are only used to treat AIDS patients. For example, HIV patients often take an anti-viral medication, such as flagyl, that is not used exclusively for the treatment of AIDS. Most of the other drugs they take are marketed exclusively for AIDS/HIV. Are the excluded ones maintenance drugs or are they treating some manifestation of the HIV status, such as pneumonia? Does the plan cover some of the older, standard drugs (AZT) and not the newer, even more expensive drugs?

nac, you are absolutely right. We do 3rd party administration of COBRA and my 30 day resonse was a confusion of our time limit to send notices with the election time frame. My apologies to Heidi and ghoss, nac is correct as far as your election time frame.

Your company has 14 days from the day you terminate employment (cease working, not just give notice) to send you COBRA election forms. You then have 30 days to accept or waive, and additional time to pay the first payment. The election form will state the premiums that are due. Heidi--you can't receive COBRA for benefits you were not receiving before you terminated. You would have to add the dental before you quit, if that is possible. As far as COBRA eligibility, your company must employ at least 20 employees to even have to offer COBRA. Check the SPD or any other health plan information you received from your employer. There are also certain state rights to continuation policies you may have if the employer does not have to offer COBRA. You both may want to check the insure.com website. They have a good article written for the lay person that explains COBRA well.

We have six paid holidays--New Years Day, Christmas, Thanksgiving, July 4th, Memorial Day, and Labor Day. We also get 3 paid personal days which can be added on to vacation time or taken one day at a time. Since we are a health care facility, we staff 24/7/52. If it is your holiday to work (alternating years), you receive another paid day off within 30 days of the holiday.

Our on-site fitness center is my favorite benefits perk! We previously offered health club & fitness centers discounts only, but now we have the discounts and an on-site center. It's not a huge place, only about 40X20 but there are also male & female locker rooms/showers. The center includes complete nautilus equipment, free weights, 3 high performance treadmills, 4 airdyne bikes, 3 step machines, a rower, and some other equipment. Our first rule is that it is for employees, students, and physicians only. (part of entity is a teaching hospital & nursing school) Access is by key card only for safety and liability purposes. It probably is one of our most utilized perks, even more than on-site child care. I would caution on the liability issue but we require a viewing of an equipment use & safety video, signed consent, and strict limitation to staff use only. We have had no major problems with our center.

if a covered employee loses coverage due to entitlement to medicare, this is a second qualifying event for spouse or dependent. Spouse would get 36 months measured from the initial qualifying event.

I was reluctant to answer this, but at least you have both sides checking in with an opinion now. I work for a health care entity. Part of the entity is a TPA, part is a hospital. The hospital administers its own HIPAA and COBRA while the TPA does HIPAA and COBRA for self-fundeds as well as an insured product line. I think the best answer I can give you is that there should be no problem as long as you have the capability to do it. By this I mean the time and resources available to you. If you are looking to do this on top of many other obligations or work requirements, it will be a disaster. Both the hospital and the TPA have one full-time employee who does nothing but administer HIPAA and COBRA, in addition to getting clerical support.

It's not clear to me whose medical records you want and why. From your message it appears you want to look at someone's medical records to make a decision for treatment of another individual, who I think is your employee. Is this correct? If this is the case I don't see how you will ever get those records, even with a subpoena.

Kip is right in most respects. The only coverage a self-funded plan has to offer is that coverage mandated by federal law which amends ERISA and certain other federal nondiscrimination laws. There are very few mandates (HIPAA, WHCRA, NMHCA, COBRA to name a few) and this benefit, to my knowledge at least, has not been litigated under any of the nondiscrimation statutes. Not too long ago, one of the large insurers had a high profile case in which they refused to cover a breast reduction in a 17 year old male and relented only after extreme public pressure and media coverage. The place to look for this exclusion is in the explanation of benefits. If the SPD states that benefits are provided pursuant to a schedule of benefits and the schedule is provided to the enrollee, then the exclusion will stand even if the procedure is medically necessary. Perhaps the physician can exert some pressure on the plan reviewer if the matter is one of extreme medical necessity that would take it out of the realm of automatic exclusion.

We have this question come up at least once a week as we are a third-party administrator of about 150 self-funded plans and over 1000 insured product plans. Although we are not administering FSA's, we are administering ERISA health plans and perhaps I can point you in the direction you are looking for. Regardless of plan language, federal law requires ERISA plans to honor any QMCSO (Qualified Medical Child Support Order) issued by a state court or state child support agency regardless of whether the child lives with the enrollee, is born out of wedlock, or can be claimed as a dependent on the employee's federal income tax. Any exclusionary language to the contrary is void if a valid QMCSO exists. I have greatly simplified this explanation and an unsure if it even applies to FSA's since I am not sure if ERISA applies to them.

We have about 3800 employees and a self-funded plan. Coverage starts the first day of the next month following hire and enrollment. Probationary employees (less than 6 months) pay a slightly higher premium for the first 6 months of coverage. Family coverage is less than $100 per month for full-time employees. We also offer full coverage for part-time with as little as 16 hours a week, again with a slightly higher premium than full-time.

Several thoughts spring to mind. ERISA does not apply to government plans--federal, state, political subdivisions or agencies thereof. Who is this employee? Is it the plan's admininstrator? Plan administrators make decisions like this all the time. What kind of discretion does the employee have in denying or approving prescriptions? If the employee is just checking off a list of approved medications, i.e. a formulary, I don't think you have a problem especially if 1) this is a term or condition of the plan, and 2) the employer can demonstrate there is a system in place which assures confidentiality.

I can understand your confusion in this situation as I have also seen both of these dates used in differing publications. Another thought that registered with me was your referring to a COBRA continuant and not a COBRA qualified beneficiary. Only children born to or adopted by the covered employee or spouse can become a qualified beneficiary, i.e. a child born to a dependent child who has COBRA coverage will not be a COBRA qualified beneficiary. I'm not sure if this helps at all.

Don't even think about distributing the money to A until you have consulted an attorney with experience in this area. I am unfamiliar with what is required to "complete" a transfer. If the deceased completed all the necessary acts before his demise, then you have more than just the mere intent of the IRA holder to consider.

Any suggestions for short payment checks? I know this topic was brought up at a June 8 IRS hearing regarding COBRA 2000 but my impression was there was no consensus about was short enough to trigger cancellation. I favor the 2% approach but management wants a dollar amount. Any upsides or downsides?

My personal favorite is our on-site fitness center which is open 24 hours a day. A lot of our employees rave about on-site childcare center; lukewarm response to dinners to go. Of course, cheap but extension health care coverage is also appreciated

Can a new enrollee in an insured health plan claim coverage at VA facilities as creditable coverage? Enrollee is not retired military and has used facilities because he had no other coverage. VA was absolutely no help in this matter.

If you're not planning this in conjunction with an open enrollment period and just conducting a true health fair for employees, I would suggest having your providers present the health fair. My employer, a health foundation, only offers one option for health benefits to its employees but holds an annual fair such as what you seem to be suggesting. We have offered cholesterol screenings to blood donors, mammography screening information, fire safety, bicycle safety, immunization information, blood pressure screening. Your local police, fire, and paramedics can be a good source also.

Any suggestions as to how a 3rd party administrator can protect it's interest in the event of client's bankruptcy? My thought is to secure administration fees and adequate funding in advance of 90 days. Not sure if we want to alienate client in this manner.