jeanine

First check Texas law (excuse me for not knowing what to refer to--in Ohio it is the Revised Code). Anyway, there should be a general statement that states to whom/what the Texas law applies. For example, policies issued under section *** of your revised code. It may even state that it does not apply to self-funded plans.

Thanks, that was my feeling as well. I know I've read about this but just couldn't find the verification when I needed it.

Retiree has coverage under HMO. The company offers several plans in addition to the HMO. If the retiree moves out of the HMO area, does the retiree have special enrollment rights or must he wait until the open enrollment period?

The only "penalty" I understood was that the failure to have an appeals process that followed ERISA requirements would result in the determination that the enrollee had exhausted the appeals process and could move on to federal court where the judge could apply a de novo standard of review. I had some questions on this as well--mostly what to do when your state insurance law required a different appeals procedure. We were told (informally) that as far as the insurance department was concerned, an insured enrollee was entitled to both appeals processes. The DOL regulations really don't apply to the insurance company. They apply to the Group Health Plan regardless of whether the Plan provides benefits through the purchase of an insurance policy or self-funds the benefits. It is conceivable that the responsibilities of the group health plan will not be met by the insurance company.

We did it in less than 4 pages. We were able to avoid repeating ourselves for each type of claim by using a chart for the time frames by type of claim then using the same verbiage to describe the process.

I think I would argue that this is not well baby coverage and cover it as a dependent expense. The baby is receiving care while in the hospital, including observation care. Observation care may be medically indicated and if so should be covered by the plan. I guess I'm struggling to understand just what the plan is trying to save here ($$wise). The bulk of the expense is going to be in the labor & delivery charges and postpartum for mom. If the child does actually rack up some charges, such as NICU, then it isn't well baby care either. I think this is a horrible public relations issue to put in front of your employees.

PHI may be used and disclosed for payment, treatment, and health care operations. We need to be able to identify individuals in order to pay or process claims for them. The only option is to assign them another number. We do not currently support the use of alternate enrollee ID numbers. HIPAA originally called for 10 standards including an individual identifier. That idea was scrapped because of opposition. Your SS# is your default national identifier. If he really doesn't want anyone using his SS#, he can pay for his claims and not use his coverage. I can understand that he might not want it printed on his pharmacy card, just like you can request that your SS# not be printed on your drivers license. The fact that it is not on your license does not mean that you are not registered with your state's DMV under that number. Same issue with the health plan.

Whoever pays his claims has access to his social security number. We occasionally have requests like this. Our system is set up so that there is no real alternative. If we gave someone a new number it would affect their entire claim paying history. Unless you are in a state that requires you to use an alternate ID number, I would just deny the request. The only alternative we are currently exploring is whether we can just use the last 4 digits on any printed materials--of course the entire number would still be in the system.

I'm considering weighing in on this again, but need answers from kova7 first. What is your exact relationship with this client? Who is your client the employer or the plan? Is this even health care coverage? Is this a self-funded plan or insured? If insured, what state are you, plan, and insurance company located in?

If you had a contract with them, what does it say about this type of request? What is the nature of the agent/client relationship? Even if the information belongs to the client, you should make a copy and retain for your protection. If the information belongs to you, make the client a copy and charge a fee based on your state law for copying fees.

Amend your plan language so that working spouses are required to be covered first under their own employer sponsored health plan. We have seen this happen quite often the past year. (we're a TPA). We refer to this as a "mandatory working spouse" provision. Of course, this will add a little bit of work for you since you'll have to send coordination of benefit inquiries, etc. but you'll save more in the long run. We haven't seen any real backlash from this change.

Try the Federal Register, December 27, 2000, At pages 82128-82153. I believe you can access the Federal Register from the Benefitslink home page.

we have several employers with a self-funded plan who wish to do the same thing. I see a distinction between paying premiums or paying USERRA contributions for reservists and paying COBRA premiums for terminated employees. USERRA also requires that the employer maintain retirement contributions, allow the reservists to return to work, etc. COBRA does none of these. My argument is that Congress meant for this to allow employers to be more generous if they wanted and any difference in paying USERRA vs. COBRA is not going to amount to discrimination. There are many reasons someone may want to maintain their employer coverage for their families. We are not a military town but we have plenty of reservists called up. Their families are not going with them. There is no armed services hospital, etc. anywhere near here and obtaining health care services through private providers using TriCare (or whatever it is called) is more of a hassle than using your own employer funded coverage. Additionally, our state law requires that employers provide USERRA coverage through health insurance plans.

Kimberly, are you asking about paying down assets before medicaid kicks in?

COBRA is continuation coverage. You are continuing whatever coverage you had as a member of a group health plan, therefore the provisions of coverage of that plan apply. Typically, the only "extension" you might have would be coverage until the end of the month for which the last premium was paid, or depending on state law if it is truly insurance, extension coverage for hospital confinement. You aren't going to get much of anything from a plan once you stop paying the premiums.

Your health plan is a Covered Entity under HIPAA. All health plans are Covered Entities except self-funded health plans with less than 50 enrollees where the plan is self-administered. By virtue of the fact that a TPA processes your claims (I'm assuming this from your post), you are a Covered Entity.

Have been dealing with an awful lot of COBRA questions lately.... I need some help recalling what I think is correct in this situation. An employer provides benefits to its employees through the purchase of several group health insurance policies. Due to layoffs, there are no longer any current employees covered under one of the policies, just terminated employees who want coverage. Employer wants them to continue COBRA through this policy. Insurance company says "no" because minimum participation by active employees is not met, therefore the policy is cancelled. Shouldn't the terminated employees be receiving COBRA through any of the policies that are still in effect?

This is too tough of an issue to address in this forum. We've had similar companies with the same issue and had them get a legal opinion from an atty with COBRA experience. All I can tell you is that based on their corporate set-up, they had to offer COBRA. You need a detailed analysis as to the legal implications of your corporate design and COBRA responsibilities.

You don't need consent (under HIPAA) for payment, treatment, or healthcare operations. I believe HHS addressed disease management in a FAQ or some other material. Anyway, our analysis of their opinion was that disease management was allowable as treatment. You can still do many things under HIPAA besides underwriting and payment. Quality Assurance programs are still allowable as long as you have a direct relationship with the patient's whose data you are using. As a health plan, you would satisfy that relationship with your enrollees.

Were you offered COBRA?

I think we still need to know what the procedure is that can only be done in France, and why? Not approved by FDA in USA? Wouldn't that be experimental?

Your rights are going to depend on how you receive your coverage--group health plan insured, group self-funded, individual policy. Check your policy to see what type of appeals process the plan allows then follow it. You have a fairly reasonable argument that this should be paid for a couple of reasons. First, you state that there is no in network anesthesiologist. Second, even if there were, this type of service is not one you can control by choice. Your anesthesiologist is whoever the hospital assigns to you.

An employer offers a group health plan that is non-contributory. Is it necessary that all otherwise eligible employees be covered or may they waive coverage? Is there a difference if it is an insured plan and the employer is paying the total costs of the premiums for those employees who want coverage?

Even if the selling company is no longer maintaining a benefit plan, the purchasing company will have possible COBRA obligations at the sale. Check the IRS 2000 COBRA rules. I believe Kirk is right about the bankruptcy rules giving certain protections to retirees, but in this case I think the merger and acquisitions rule under COBRA would apply since this is Chapter 11 and not Chapter 7.

I'll admit that this is pretty out there--but you did say you could not see ANY reason they would need to see the birth certificate--some states have laws that say that your gender cannot be changed on your birth certificate. So if you had a sex-change operation, in Ohio and some other states, you are still a man or woman according to what your b.c. says. The issue becomes whether you can legally marry in that state. There was a newspaper story locally a few months back where the procecutor was considering fraud charges against someone in this particular situation, relative to a marriage license application but not sure what became of it.