jeanine

Interesting subject--we get a request like this every once in a while. I believe there was a law introduced in Congress recently that has a lot of insurance companies lobbying for its failure. It would eliminate the use of SSN's by insurance companies. If you look at HIPAA, one of the original standards was an individual idenitifier that would stay with you all your life (but not an SSN). This is no longer a standard since you had all these people arguing that the govt would know everything about them based on this national identifier. The trouble is, you have certain people who are always going to have an issue no matter how you identify them. One of the concerns with allowing someone to pick their own identifier (or to have one generated by one company) is that people don't always have the same insurance coverage throughout their lives. How would you pre-ex someone when you can't verify any coverage they received or care they received? What about insurance fraud? I think it would be easier to perpetrate fraud if someone is not tied to a specific number no matter where they receive coverage.

I don't have one I can share, but I can recommend an excellent publication, EBIA's ERISA Compliance for Health and Welfare Plans. It is updated every 3 months and has model forms, including forms for disability and health claims. Plus it has just about any information you need. Best $208 of the company's money I spent.

I'm going to give this a stab, so be forewarned that my interpretation is not necessarily correct. First, let's lose the "partially self-funded" definition. The plan self-funds and buys stop-loss. The stop-loss is a way of protecting the employer's assets, it is not for a provision of benefits. Even though GW functions as both the TPA and the stop-loss carrier, it has two distinct relationships with the employer. Under HIPAA (when fully implemented) the TPA relationship is subject to different regulation than the stop-loss arrangement because the stop-loss is not a "health plan." All HIPAA says about stop-loss is that a plan may only provide aggregate or de-identified info to a stop-loss carrier during the bidding process (placing stop-loss with a carrier). Once a carrier has been awarded the bid, you can provide detailed info such as that which is being provided. Also under HIPAA (when implemented), the "plan" must amend its documents and establish a process where it can relay protected health info to the "plan sponsor" (the employer), a part of this process being a firewall between the plan and the plan sponsor. I know this is very confusing. You may want to look to GW to see if they are providing any guidance to their clients.

Read the new HIPAA Privacy Regs. I think you are correct to be at least a little concerned about this. I'm not sure from your post--who does the actual claims administration?

Senator Kennedy's proposal goes beyond just mandating insurance for more employers by expanding FMLA, pension contributions, minimum paid sick time, limits on mandatory overtime, and an increased minimum wage. He also proposed postponing the reductions in the tax code that were part of the tax cut signed last year.

I love that Hank! Do you mind if I use your original verse?

Breach of contract is a state law claim. My argument is that regardless of your framing of this as a breach of contract, you will have to get over the challenge that this is not a breach of contract but a determination of benefits due under a health and welfare plan. I understand the point you are trying to make--I'm not sure I see it as a breach of contract. The contract in this case is between the plan sponsor (employer) and the insurance company.

Has anyone heard any good HIPAA stories or seen any good political HIPAA cartoons...especially Administration Simplification? I've been asked to dress up a HIPAA presentation with some humor. Frankly, I don't see anything humorous about this, but then again, maybe I'm just too cynical.

The trick here is whether this is an actual breach of contract. Breach of contract would be a state law issue, however, the insurer is going to argue that this is a provision of benefits issue.

Kip's right, he needs to exhaust all of his administrative remedies first. I would think he wants to avoid federal court. Of course, even if he does sue in state court, BC/BS will probably try to remove to federal court.

True enough, and my specific job classification is not listed either. I looked for professional degree, general area of employment, and found three job descriptions that most closely fit. I took the high and low to determine whether I was in the ballpark range. Also, if HR person is listed, or benefits position, if her (his?) job is more detailed, then it should pay more (as a starting point for an arguement for an increase). Again, it's free.

Have any of you tried salary.com? You can narrow your search geographically, level of position, etc. Plus, it's free.

Are you the employee or the employer trying to enforce this? Without knowing your level of COBRA knowledge its a little hard to point you in the right direction. From this site, if you go back to about Dec 1999 through early 2000, you will find all kinds of information on COBRA through COBRA 2000 clarifications issued by the IRS.

COBRA coverage may be terminated by an employer: 1. if the employer no longer offers any group coverage to any of its employees; 2. if the premium is not paid on time; 3. if the covered person becomes covered under another group plan after they elect coverage and their is no pre-existing exclusion relevant to the covered person in the new plan; 4. person becomes eligible to medicare after the date cobra coverage was elected; 5. person has 29 month extension due to disability and person is no longer disabled. Based on the limited information provided, it may not be allowable to terminate. What exactly does the release say? Does it specifically mention COBRA? COBRA is an independent right. Any waiver would have to be specific.

May a self-funded health plan impose different waiting periods for eligibility between salary and hourly employees? I would appreciate a cite to back up any opinions. I thought that as long as you treated similarly situated individuals the same it was OK. However, an earlier post to this board (2or 3 years back) indicated that the IRS had issued a determination letter saying this was discriminatory in a self-funded plan.

Has she filed a workers compensation claim yet? She would need to check to see if this is covered under her state's WC definition of disability. Also note, some states limit your right to sue your employer for a work-related condition--that's what WC is for.

Yes, and as a matter of fact they apply earlier to disability than to health benefits. They were supposed to apply to denials after 1/02 for all types of plans, but the health plan denials were delayed (I think up to one full year) because of the concern that a Patients Bill of Rights law would create 2 different claims and appeals timelines. Now, with no Pt Bill of Rights this is not an issue.

Off the top of my head I can think of two times when they can do this. If you have open enrollment season COBRA participants can change carriers in the same manner as active employees. Also, if the COBRA beneficiary moves out of the service area, and there is another carrier that services that area I believe you have to let them switch.

Sorry, I was referencing a provision of state law that requires group health insurance to follow the 18 months extension. Might want to check your state law if these are not self-funded clients.

Read the userra regs again. I believe they have the same requirements for additional coverage beyond the first 18 months. Yes, they run concurrently. As far as offering both options to the reservist, there probably are a few good reasons why you just want to offer userra not COBRA. First, userra must be offered even if the employer is not required to offer COBRA. Also, the law allows the employer more discretion (I feel) to underwrite the entire cost of the premium. I would guess the employer could pay all of the userra premium for its reservists, while still requiring former employees on COBRA to contribute the entire premium cost of their coverage.

I agree with Kip. There was supposed to be a Uniform Child Medical Support Order in effect this October, although I'm thinking they might have delayed it. Search the Federal Register from about Dec. 2000-Feb 2001. It gives some very good guidance. In this instance, if you had one of the new orders, you would be required to fill out the response section. That section has an option just like you are describing--employee not yet eligible for coverage. Once employee is eligible for coverage you must bring the child on as a dependent (if all the rest of criteria is met). You may force the employee on to coverage to get coverage for the child if you don't offer dependent only coverage.

Sorry my first response was so brief--I was interrupted. I am basing this on the clarification of HIPAA nondiscrimination rules that was published earlier this year. The clarification says "participation" in a plan can not be denied because of pre-ex, risk-taking activity, etc. It does say you can pre-ex a limited time and exclude claims for injuries resulting from risk-taking activities, you just can't deny participation in the plan in the first place. I think the only way you can utilize the wellness program factor is in your ability to set premium differential based on participation in a wellness program. Having said that, if the person can demonstrate that they are unable to comply with the wellness program (smoking cessation for example) because of an underlying medical conditon (nicotine addiction--inability to quit) then you can't use the differential against them.

No.

My understanding is that you can only raise rates just prior to the 12 month period and that those rates are then good for 12 months. The only way I could see an incremental approach working would be to set the higher rate at the proper time (yearly renewal) and inform your enrollees that that is the new 12 month rate. You could subsidize the premium and gradually cut back the amount of the subsidy, but that probably isn't the result you want.

I wasn't agreeing that it was a reimbursable expense....I was just responding as to the medical reason/vanity reason that was questioned.