jeanine

We have many self-funded plans do this. If it is an insured plan, you may want to check with your state department of insurance.

Isn't there an annual Rx max or lifetime max on this plan? That's the first change I would make to rein in costs. If the cost of this medication is truly 400k a year or 400k and counting, there has to be an alternative available to this family. Either the drug is experimental or its an orphan drug in which case the family should petition the drug company. Also, certain states have programs to fund these types of costs for children even if the child has insurance coverage.

State law requires extension of eligibility for a disabled dependent reaching the attaining age of the plan as long as the dependent was confirmed as disabled before reaching the age. Self-funded plan has same provision. We are redrafting our disability extension application. We cite state law as requiring the extension. Question: Does federal law also require this? We are not suggesting any SF plan drop this extension of benefit, I'm just looking to cite a specific law.

As someone who works for a TPA that provides self-funded administration services and insurance products through an insurance company, I can tell you that we can not sell any insurance product that has not been filed with and approved by our state department of insurance. Therefore, any insurance policy sold to a Plan Administrator must contain all state-mandated benefits or it will not be approved for use in this state. To enter into the arrangement you are suggesting as a "test" would mean that we are engaging in unauthorized practices as an insurance company.

A quick look through Westlaw or Lexis will only give you examples of claims being denied. A better way to look at this is to find out how many claims WEREN'T denied. For every claim that is denied there are thousands of claims that are paid. Medical necessity, plan language, eligibility, standard vs experimental treatment--the plan usually has a different interpretation of what this means versus the enrollee. That's what these lawsuits boil down to and the plan is not necessarily arbitrary in its decision-making process. Check out the history of the Nadine Fox suit in California. Her attorney suceeded in the estate's claim for treatment the plan dubbed experimental. Several years after the fact, the only supporting study of the treatment's efficacy was completed debunked. As for Kerry's plan not being a big government take-over, if any claim over $50,000 is re-insured by the federal govt, and the fed govt requires case management of this types of claims, how has the govt not taken over? The fact is, certain illnesses will always exceed $50,000. By default, the fed will control the delivery & payment system for them.

We only return something to the sender or offer to forward to the appropriate party once we have contacted that party in person by phone. I can't erase what is in someone's mind, but if something is sent to us in error it means that the responsible Covered Entity disclosed something inappropriately. I stand by my statement that we do not keep copies or assume any responsibilities other than destroying or forwarding/returning. If they are not our enrollee or our patient, how do we have an obligation towards them?

Perhaps I'm wrong but I thought the poster was asking about information received in error, either by fax or mail. We get accidental information fairly infrequently but when we do we contact the sender. We give them the option of us sending it back to them or we shred it. If we return or shred I don't think we have any further responsibility for it.

c) health-insurers- to provide a service but also to make a profit. i stop short of labeling such organizations "bad" when they deny claims; i prefer to see them as capitalists who have no incentive to do anything different. There are plenty of non-profit health plans who don't have a capitalist interest in denying claims. To state that health plans deny coverage solely to make a profit indicates that you don't understand how one part of the equation works and that is how individuals use their health coverage. First, not everything is covered by every plan, nor should it be. Many employers choose to provide less rich coverage to their employees in order to be able to afford to provide them anything at all. Second, some people expect any medical service to be covered regardless of whether it is truly medically necessary or even effective. The biggest flaw of Kerry's plan (from my perspective) is that he proposes that the federal govt will re-insure all claims over $50,000. Do you know what that means? That means the federal govt will in effect control all transplants, most cardiac surgeries, most cancer treatments, and many chronic diseases. Couple that with Kerry's proposal for mandatory case management and you have almost a complete picture of govt-sponsored, govt-controlled health care.

Well, if you do it the way you did it, the TPA wouldn't make any extra money off of HIPAA. Your plan did exactly what we counseled our plans to do--sign the amendments. We didn't even ask for a copy and we certainly did not reissue plans or require them to be re-executed. In lieu of the signed certification, we have been relying on an attachment we added to our ASO agreements several years ago. In the attachment we have the plan state who represents the plan and is allowed access to PHI. I'm curious as to who your TPA is.

I don't disagree with your statement. I just meant that I don't think it's too difficult to prove you are an ERISA plan. Either you meet the definition (which is pretty broad) or you don't. You don't need a certification that you are. It's true that if you don't have the proper documents in place you are going to have a more difficult time on some issues and defenses but you're still an ERISA plan.

I'm not sure why you would need help determining whether a plan is ERISA or not. It seems pretty simple to me. We have had certain providers asking us for "ERISA information" that they think they are entitled to. They don't know what it is they are requesting, but they went to a seminar and the seminar provider told them to ask for it. We respond by giving them the plan documents and letting them look for it themselves. Other than the MEWA certification that was mentioned, I don't know of any other certification. If you have provided them with the plan document (which they have a right to request), that should be sufficient.

This sounds like something from back when plans were required to file plan documents with DOL. Ask the requestor for the authority for the request. We deal with a lot of plaintiff attorneys. They are not always correct in what they ask for. By the way, what type of authorization did they provide you with on behalf of their client?

Are you being asked informally, or through a set of Interrogatories?

My man came through last night again! Unfortunately, I watched mostly the highlights because the game was on so late. Here's the greatest example of network bias--the Yankees always get the prime time starts in the playoffs.

I think the Sox have got an awful lot of talent (left) but personally, I think their most under-rated and unappreciated player has got to be Jason Varitek. I love that man. Sure, he's not the best at throwing out base-stealers but he performs consistently, under pressure, when you need him. I really can't see Pedro being part of this team in 2005.

We purchased Extra Innings from our cable supplier this year. Living in Ohio, we only got to see the Sox if they were playing the Indians or were on ESPN (or if we managed a trip to Boston.) I'm not sure if it's a blessing or a curse to be able to watch almost every Sox game.

I seem to recall a case (I have no citation) where the QB was incapacitated due to being in a coma. The court held she did not receive notice. I believe the issue was, and might be in this case, whether sufficient notice is given due to the fact the QB was incapacitated. I'd ask the son to produce some proof of incapacity then allow her to enroll.

Who's doing the screening? The employer or the health plan? As far as the incentives, I believe that you are clear under HIPAA non-discrimination requirements to offer incentives for bona fide wellness participation as long as there is a mechanism to allow those not able to make the modification able to benefit from the incentive. For example, if you offer an incentive (or waiver of a negative incentive) to stop smoking, and someone tries but can't overcome his/her addiction can demonstrate this, you have to treat them the same as a smoker who does overcome his/her addiction in terms of incentives.

You would have to amend your plan language in order to do this, but we've seen many plans do this recently. We don't advise a complete lack of coverage. Our suggestion is usually to require the spouse to cover themselves as primary on their own employer's plan before they can be covered as secondary on their spouse's.

We allow spouses to access information that would appear on an Explanation of Benefits sent to the enrollee's address. According to either a FAQ or commentary from HHS (don't recall which), you do not have to send separate EOB's to subscribers and dependents. All that is on the EOB is limited information such as date of service, amount paid, etc. Anything requested beyond that--diagnosis, treatment plan, etc--would require either a signed authorization or proof of ability to act as personal representative. If a dependent requested alternate communications, then the EOB information would not be available to the subscriber.

I seem to recall a previous thread that discussed this but I need someone to point me in the right direction. When a company that offers health insurance to its employees changes insurance companies, are there any certificate of creditable coverage obligations by any party? I say no cert of creditable coverage, because coverage is not lost. The new insurance company is requesting for pre-ex purposes. Can't they get this information from the employer without a cert?

As a TPA, we are finding that the opposite is occurring, at least in our market. Our employer plan sponsors are increasingly exploring "mandatory working spouse" coverage provisions and covering spouses as secondary only if they have the exercised the option to pick up coverage with their employer.

i'm looking for recommendations for a good seminar on HRA's. I need to attend one quickly. I will consider any geographical location.

Any thoughts on whether Amish Aid would count as creditable coverage for purposes of reducing a pre-ex period? We've counted Mennonite Mutual as creditable coverage. I don't know enough about Amish Aid to know if it would fit the definition of previous coverage. I'd appreciate any thoughts.

Two grand may or may not be too much to pay for HIPAA assistance. There is more to HIPAA than just amending the Plan language. If this is an employer who sponsors a self-funded plan, then the plan itself is a covered entity whose HIPAA compliance efforts will likely come from the employer. The SF plan will need to draft and distribute a Notice of Privacy Practices to its enrollees. It must also create firewalls between the employees who work for the plan and everyone else. In addition, it must understand that even with the plan amendment, it is limited to what information it may give to the employer and for what purpose. Any good program is also going to come with training and educational materials. I've seen plans pay a lot more for this. What about the TPA, is it offering any assistance? If benefits are provided through insurance, what is the insurer telling you?