jeanine

Bankruptcy laws protect the secured creditors of the bankrupt company. Unsecured creditors and employees (even wages and vacations) come next in line. As unfair as this sounds, this is the way it is. You may want to speak to an employee benefits attorney to see if you have any recourse.

I can't imagine that the amount collected from participant premiums would ever cover the amount of claims paid. Typically, a plan collects 0-30% of the premium charged on an insured plan. The employer kicks in the rest of the premium. Self-funded uses a similar calculation. Most employees have no idea of the value of the benefit they receive through employer contribution to the premium or the total cost of providing benefits through self-funding.

The TPA can still limit the extent of its duties to be considered a fiduciary only for the purpose of claims determination. If all the TPA is responsible for is the first level of appeal, I don't see what the problem is. There is still one more level of appeal for a final determination by the Plan Administrator. The issue's going to be those circumstances that require a final review within 72 hours (urgent pre-service claims). You need to act to set up an arrangement where you are compensated by the Plan Administrator so that you can offset any additional liability.

Depends on the facts. Chapter 11 or Chapter 7? If Chapter 11 and their is debtor in possession financing and the court OK's payment for health benefits, and severance payments are also approved, then coverage should continue under COBRA. Even if your severance arrangement is not payable you can still continue COBRA by paying the premiums. However, especially if this is a Chapter 7 filing, chances are the plan will cease to exist. If the plan ceases to exist there is no COBRA. COBRA is continuation coverage, there has to be something left to continue.

Under the new claims and appeals regs that apply to all ERISA plans, any denial of a claim for benefits must include: -specific reason for denial of adverse benefit -reference to specific plan provision upon which denial is based -description of additional information needed to perfect claim -if relied upon, reference to internal rule or guideline used and how to request a copy of such -if medical necessity/experimental treatment, must explan scientific or clinical judgment and apply it to the claimant's condition -notice of right to request review and explanation of review process Is this what you are asking about? These regs are effective for claims for plans renewing on or after July 1, 2002 but no later than January 1, 2003. If you use the EOB as a notice of adverse benefit determination (as we do) you must find a way to get all of this on to the EOB, or use a different mechanism to advise claimants of your decision

FMLA also allows a person to take leave for their own illnesses, continuing care, etc. Certainly a stillborn birth involves the same recovery as a live birth to the mother. You would have to allow at least the minimum post-partum recovery time.

December 27, 2000 Federal Register. (access through benefitslink main page). If no coverage available for dependent child only, you may force the employee to enroll and withhold premiums. There's more to the analysis however, so read the National Medical Support Notice that is also in the Fed Reg

If the coverages are offered separately, they have the right to elect all or none of the coverages at the time they are electing COBRA.

If any of you subscribe to Thompson Publishing Group's COBRA guides, the May 2002 Update addresses this exact same situation. They state "although it is not clear from the statute, the legislative history and IRS final regulations clearly indicate that qualified individuals have the same rights to change their coverage during open enrollment periods as active employees." If an active employee can add a coverage, such as dental, then the QB must be able to do the same.

Just be careful that you can demonstrate that he was indeed terminated because of reduction in staff.

I stand corrected and should actually know better. It's just that I hear the word "HIPAA" and go into overdrive. We had an interesting time convincing some of our self-funded health plans that it was indeed true that self-inflicted injuries can't be excluded across the board any more.

We use a statement to the effect that self-inflicted injuries are excluded, except to the extent they are the direct cause of a mental or physical illness. "Sane" would be a bad standard indeed. As the Yates trial showed, severe mental illness is not necessarily insanity. I realize that a criminal definition of sanity might be different than a medical definition of sanity....I would just hate to be the one determining this.

As I read these posts I am certain this varies from geographic region, and probably due to state law. Most of our insured groups have a 90 day waiting period for coverage. Rare is the group in this area that has coverage beginning on the first day at work. The only exception to the waiting period is when a new group comes on from another insurance carrier, in which case, according to state law, we can't impose any waiting period.

If this is an insurance plan, the next thing you should do is contact the insurance issuer. It's the responsibility of the insurer to file any amendments with the department of insurance, and they probably have the expertise to help you accomplish this.

Ohio defines "full-time" for purposes of insurance coverage under a small employer policy as 25 hours a week or more. Just a comment--I think its really helpful to know what state someone is from. It would be a good idea to list it in your profile.

Not so much fun as it was a sanity saver. It's hard to imagine the mind-numbing horror of beating a simple concept to death day after day, class after class....with the added bonus that out of the blue you would be called upon to expound even further. Plus, every law class always had some moron who could not resist hearing the sound of their own voice. Its people like them who made these games possible.

I have seen someone reach the lifetime maximum. Actually, more than one. If the question was meant to ask if this counts against them only to the extent they are insurable (the portability aspect of HIPAA) how about this line of reasoning: Even though they have no benefit left, they are still covered under the plan, i.e., there is no break in coverage. Person still enrolled under the plan, just when benefit is computed, nothing is paid because the maximum has been met...sort of like a reverse deductible.

Either on this site (Benefitslink) or some other, I saw an article just a few weeks back on OutBack Steakhouse Restaurants who do exactly what you are stating. Very interesting, but we haven't seen anyone locally willing to do the same thing.

If he's providing insurance under a group health insurance policy you may want to check your state's insurance laws. Start with your state Department of Insurance. In Ohio, a small employer must offer coverage to all its employees who work full-time (defined as 25 hours for a small employer). It's important to realize that insurance law differs from state to state.

For a biological or adopted child, you can't condition enrollment on whether or not the child is claimed as a dependent on the federal income tax form, whether the child resides with the parent, or whether the child was born out of wedlock. Step-children are another matter. We see plans do different things. Our more generous plans will enroll step-children living in the home if the custodial parent (new spouse of the employee) has a QMCSO that requires the custodial parent to maintain coverage.

I believe the regs say you must provide an initial notice. When the IRS issued multiple changes in 2000 we updated our COBRA notices and sent them out to everyone for whom we administer COBRA. (we're a TPA). I hesitated to do this because I didn't want people to think their jobs were in jeopardy....we drafted an explanatory cover letter to explain the reason they were receiving a new notice. If you want to send another, go ahead. As long as it is distinct from the WHCRA notice, I don't see why they can't be mailed together.

I think you need to get a copy of whatever law was passed in that city. Generally, I think it is correct that if you are a self-funded plan, you do not have to go along with that local law. My guess is that the city law applies to the city as employer and any other company wishing to do business with the city as a contractor.

I am basing this on IRS definition as "dependent" for basis for declaring as a dependent on Federal income tax filing. Can't really tell you why our employers choose to follow this particular way of determining eligibility, but I got this from IRS publication 504 (for use in preparing 2000 returns, maybe it's changed a little since), page 7. I know this publication is titled "Divorced or Separated Individuals" but I believe the definition of "dependent" and "student" is the same. However, I am open to the argument that perhaps we are not following the right guidelines. All I know is that we are told by our Self-funded plans to follow IRS definitions for determing dependent student status.

We use IRS support guidelines as a guide. According to the IRS, to qualify as a student, your child must be, during some part of each of 5 calendar months during the year (not necessarily consecutive): 1) a full-time student at a school that has a regular teaching staff and course of study, and a regularly enrolled body of students in attendence],....... The term "school" includes elementary schools, junior and senior high schools, colleges, universities, and technical, trade, and mechanical schools. It does not include on-the-job training courses, correspondence schools, or night schools. Since this is the criteria we use, I would vote "no"

No comment on other states, but don't overlook the Federal Employee Health Benefit Plan law which allows (I'm not sure if its mandatory) grandparents to cover dependents of dependents, among others. Eligibility is determined by the employee's hiring office.