jeanine

It is possible to store (cybergenically, I think) umbilical blood following the birth of a child. The cord blood contains stem cells which could be used to treat a variety of medical problems that manifest at a later time of the child's life. Is this the type of storage that you are referring to? Any other autologous donation of blood lasts a much shorter time. Some people have blood withdrawn and stored in anticipation of a pending surgical procedure so that they can receive a transfusion of their own blood rather than a transfusion from an anonymous source.

With the call-up of the reserves, we have a lot of companies asking questions of continuation coverage. I know it has to be provided under USERRA and that it is very similar to COBRA. Couple of questions: Is it OK to use a modified COBRA notice to provide notice? If the employer voluntarily contributes partial or total cost of coverage, are there any discrimination issues I should be aware of?

I'm looking for information on church plans--health and welfare benefits only. I know they are exempt from ERISA, COBRA, HIPAA. What then regulates them? Anything special the TPA should require in terms of the ASO agreement? I would appreciate cites to books, etc. if you know of good sources.

prucker, you need to add some more details. I know you posted previously about a self-funded company declaring bankruptcy. Just because the company continued to deduct contributions from employee checks (is this what you are referring to as premiums?) does not mean that the company forwarded them to the TPA. A self-funded company pays a TPA administrative fees, plus sends enough money to cover the claims submitted for a particular time frame. The TPA is probably still owed its administrative fees, along with the fact that there is no money in the company's account to fund claims.

You have 2 issues here. First, you say the providers verified coverage--they probably verified eligibility for coverage. This is a crucial distinction. In a self-funded plan there is no way to verify with finality whether something will be paid. When the patient goes to the provider they sign a form acknowledging financial responsibility if the insurance doesn't pay. The best thing you can do quickly is to try to negotiate a discount with the provider. Second is the issue of what happens to the benefits (including the withheld employee contribution). If the employer utilized a trust, the trust will be protected from the creditors, however if the employer underfunded the trust, there is no money to pay claims. You and the other employees can file a motion with the bankruptcy court to gain a more favorable creditor status. What type of creditor status will probably depend on the particular facts. Either way, you face a difficult challenge of receiving all of your contributions. Also, depending on whether it is Chapter 11 or Chapter 7 could have an effect on whether any claims are paid. In 11, the court could authorize the continued payment of claims as part of a reorganization. You might want to consider obtaining legal advice on this.

It's true you don't have to follow state law and offer any state mandated benefits. There are some federal laws though that affect the administration of your plan. For starters, read up on the Womens Health and Cancer Rights Act, the Newborns and Mothers Health Act, COBRA, Mental Health Parity Act, and the Health Insurance Portability and Accountability Act (at least for the pre-ex restriction requirements).

This doesn't sound good to me. First of all, make sure that you can prove that your enrollee was sent a COBRA notification form at the beginning of employment. You don't have to prove they received it, just that you sent it. If they claim they were never given an initial COBRA notification form and you can't prove otherwise through systematic record-keeping, keeping them off COBRA may not be a possibility. How is an enrollee supposed to know their rights if they are never given notice of them? As for the employer taking the child off and not notifying the TPA, the TPA may not be liable, but I think the employer still owes the child a COBRA notice. You can't disenroll someone without notice. The TPA may or may not be liable, depending on whether the TPA contracts to do COBRA administration for the plan.

COBRA is continuation coverage. If the company closed and there is no longer any plan of coverage, there is nothing to continue. If she would have terminated employment and the company kept operating and offering an employee health plan, she would have been continuing coverage under a group health plan and paying the entire premium herself. Yes, it most likely would have been cheaper than any individual policy she is being offered. Unfortunately, her options seem to be extremely limited. You may want to call or access your state insurance department to see if there other options available to her.

If your employer buys a more limited plan, then they are paying less in premiums. If you want to have the same benefits as your neighbor, then you have to pay higher premiums. No insurance company, or HMO, can continue to operate with losing margins. I am upset by the entitlement mentality that Congress seems to think all Americans share. I have very good coverage--I actually get coverage through my husband's employer. This was a deliberate choice. I could have gotten a less restricted PPO instead of an HMO but chose the lesser hassle of an HMO. (don't laugh, it has to do with COB'). The point is we receive the services we are entitled to because we (and his employer) pay higher premiums. He deserves these benefits because of the stress he puts up with at work and in partial lieu of better pay. If you look at some of the versions of the Patients Bill of Rights, there are some people who think you should have medical services that "should be covered" not just those that are actually covered. In effect, this negates the purcase contract between the plan and the employer. Don't like what your employer gives you?? Get another job or buy your own benefits. There's no law that requires employer sponsored health care. I'm afraid that this will just ruin it for a lot of people and there will be more uninsured than there are now.

If I'm not mistaken, a minor must get a court declaration of emancipation from their parents. Think of it like a divorce. You would ask for the divorce decree and support order. In this case, you should at least be able to get the decree of emancipation from the minor. At that point, I would run it by a family law attorney (you are in Louisiana?) and get their opinion on whether they should be offered COBRA.

I say yes. (unfortunately). Earlier versions of a patients' bill of rights didn't, but I believe the Senate version and House version include self-funded plans. I would guess that whatever is hammered out to reconcile the House with the Senate would apply to SF's also. The thing that really bothers me about the press coverage of this bill is that all anyone ever hears about is that we are going to hold HMO's responsible. First, not all HMO's are villians. We have a non-profit HMO...we are not monsters. Secondly, this applies to all health plans, not just HMO's and really attempts to gut the entire basis of managed care. Everything that an enrollee thinks they should have covered , should be covered, makes no economic sense. If I buy car insurance it only covers what I've bought, not what I think it should cover. I can't wait to see the fallout from this one.

Wish I could take credit for this one. This appeared in the May 16, 2001 Washington Times as unsourced. What rules the world in simple two cow terms. Socialism: you have two cows. You keep one and give one to your neighbor. Communism: you have two cows. The government takes them both and provides you with milk. Fascism: you have two cows. The government takes them and sells you the milk. Bureaucracy: you have two cows. The government takes them both, shoots one, milks the other, pays you for the milk, and then pours it down the drain. Capitalism: you have two cows. You sell one and buy a bull. Corporate: you have two cows. You sell one, force the other to produce the milk of four cows then act surprised when it drops dead. Democracy: you have two cows. The government taxes you to the point that you must sell them both in order to support a man in a foreign country who only has one cow which was a gift from your government.

At least once a month we receive notices of class-action settlements and an option-in form, or bankruptcy settlements for health care companies I have never even heard of. Does anyone out there respond to these? Does a TPA have the duty to pursue these settlement amounts on behalf of a client, notify the client that they exist, or what? The latest one would require that we search through hundreds of thousands of pharmacy records to see if we paid for certain drugs that are the subject of the settlement. No idea whether the settlement is pennies on the dollar. Help!

Some employers self-fund and self-administer. The plan is in fact a separate legal entity, distinct from the employer. The plan administrator (different from the third-party administrator) is often a key employee of the sponsoring employer. The TPA is only following the orders and guidelines of the plan adminstrator and hence the employer. We have sucessfully removed ourselves from subrogation litigation but have never had to argue this position in a benefits claim litigation (yet) as a TPA. Look at the new privacy rules under HIPAA. One of the things it explains really well is the separate but intertwined relationship of the employer and the plan.

Of course he can sue in state court--the question is, will he be able to keep his case in state court. Any defense attorney who is on the ball will remove it to federal court. A lot is going to depend on the circumstances and the district where the self-insured plan is located. Five-ten years ago I would have said "absolutely not" but given the political climate I'm not so sure. The Ninth Circuit has been pretty creative in this area lately.

If the plan provides coverage through an insurance contract, be sure to check your state law regarding this. In any case, check the plan language. Most, if not all, of our plans include an automatic coverage for the first 30 days. I think this is a very fair way to treat your enrollees. You would not believe the trouble we have getting people to enroll their dependents within the 30 days after birth--I can't imagine expecting them to enroll them beforehand.

I think the simplest thing to do would be to change your plan language so that the "child in the same HMO area" provision does not apply to children who are covered under a QMCSO. If you have the option of enrolling them under dependent coverage only, fine. However, I believe the clarification issued earlier this year allowed you to enroll the employee (against their wishes) in a plan if that is what it took to get the child covered.

My problem with the "business venture" or "profit or gain" arguments is that I believe it is illegal to pay for surrogate services. I think you are allowed to pay for the mother's medical expenses, but you can't pay someone to profit by the service. So...you pay the cost to have the embryo inplanted, then only pay the delivery costs if the surrogate has no insurance. I looked through some of our language and saw this exclusion. How do you enforce it unless someone tells you its a surrogacy? We don't question anyone who gives up their baby for adoption.

There is a charge for services regardless of the presence of insurance, although this is at the county jail level, not the state or federal penitentiary. (those might be "free"). The inmate is responsible for payment and can even have a lien attached to personnal property. I'm pretty sure we continue to administer our insured product and our clients self-funded plans without this exclusion, we were just asked if we could withhold by a potential client.

I don't think I understand your question Larry. My thoughts are that they have to pay claims as long as there is no loss of coverage. I guess this really matters when they are in for more than just a "short term stay" .

Opinions please. I've seen many self-funded plans that exclude coverage for injuries incurred as a result of committing a felony. What about claims that are incurred while the enrollee is incarcerated? The inmate could still be covered as a dependent of the employee or continuing COBRA coverage. In Ohio, the facility is required to provide access to health services and also required to submit bills if there is any coverage. If there is no coverage, the inmate is ultimately liable for the care except the govt entity (state, county) usually ends up paying. Do we need to rethink plan language or is a plan obligated to pay if the enrollee is incarcerated. Or am I missing some sort of exception here?

Which language prevails is up to the court. Some courts take the view that what you have given to the enrollee is what matters, despite whatever your documents claim.

I'm not really sure about that "business venture" theory...however, let's start with what should be at least covered. Any complications resulting to mom would have to be covered because they're covered even if a plan doesn't offer maternity coverage. What does your state law say about the legal status of a child born to a surrogate mother? A few years ago there was a court decision in Ohio which (if I'm remembering correctly) overturned the requirement that the biological mother adopt the child born of the surrogate. Up until then the surrogate was considered the legal mother, I suppose with the same right to coverage as someone who bore a child and then gave it up for adoption. You would still cover delivery in that instance. How did the employer find out it was surrogate? I am unaware of this happening with any of our plans. However, nothing ever surprises me any more. It's situations like this that keep me employed.

Unfortunately, how this Act works can not be stated simply, however as a start you may want to look at the insure.com website that has a simple explanation of COBRA. COBRA provides that some individuals can continue coverage under their former group coverage. If the plant closed, and there is no group plan left, there is nothing to continue coverage under. But there still may be hope for you. The very first thing you need to do is find out whether the employer provided health benefits under an insurance plan or if they self-funded benefits. Many large employers self-fund--this means that they pay for benefits out of assets or a trust instead of buying an insurance policy from an insurance company. Even if you had an insurance card with an insurance company name on it, it may not be insurance but just administration of your company's self-funded plan. Look through all health plan materials you have from the company. Somewhere in there it must tell you if benefits are provided under an insurance policy or if the plan is self-funded. If benefits were provided under an insurance company, you may have some relief available to you under your state's insurance laws. Contact your state's Department of Insurance. If it was self-funded, unless there was a trust or if the closing was due to bankruptcy, you have very little recourse. Let us know more facts as you get them.

Smaller employer wants to offer some type of health care coverage to employees, not to exceed $10,000 per enrollee per year. Employer also wishes to self-fund because of low participation rate which is making it difficult to secure insurance. Any opinions as to what is best in this situation? I'm thinking that this may be a good defined contribution case--he can just give them the money to buy their own coverage. I'm not sure what the tax ramifications would be though. Also, can you offer a self-funded health plan with this low of a level of coverage? Opinions or references to sites discussing this would be appreciated.