jeanine

It might be helpful if you could tell us what type of business this is. Our last need for an increase was explained very well by showing how much money the institution spent on healthcare (we're self-funded), how much it spent in past years, and what it expected to spend in the future. We're all pretty intelligent people--we could see that the company spent much, much more than our current premiums or even the increased premium. It also wouldn't hurt to show how reasonable your plan is compared to other groups. One thing we did years ago, was switch from a flat rate Rx to a %charge. This meant the pharmacy had to show the retail charge. Most enrollees had no idea how expensive a benefit this was until then as they only ever paid $3.00 no matter what the drug. Tell them the truth. It might work.

Even a collective bargaining agreement doesn't last forever and ever! As long as you give adequate notice and implement the changes at the beginning of the plan year, or according to a new collective bargaining agreement, there's not much the employees can do. Why don't you start with a modest contribution? We went from $0 to $10 per month, then increased throughout the next few years. Or, you could increase the co-pays if that goes over any better.

If the common law spouse doesn't have to get a legal divorce or legal separation/dissolution, then the two are not married no matter that the state recognizes common law marriages of other states. Be careful here--Ohio does not recognize common law marriages that did not exist before 1991 (I think that is the correct year), no new common law marriages can come into effect, but previous ones are still valid. If the couple came from a state that recognized common law and in fact held them selves out as common law married in that state, then by the full force and credit clause the new state would recognize them as legally married. Then they would have to get a real divorce. My understanding is that COBRA only covers legal spouses, however if they can prove they were legally married (under common law in a common law state) then you would offer COBRA. How did the common law spouse get benefits in the first place?

I seem to remember that a public employer (state or local govt) can opt out of HIPAA on a yearly basis. Could someone provide me with a cite or analysis of this provision? Any experience dealing with a group that has opted out? I've got a group that wants to opt out but has no idea how to procede. Thanks

I see you are registered in Ohio. If this was truly an insured product plan, (and not self-funded by the employer), the Ohio Department of Insurance consumer services can help you. Talk to them first, you may want to consider seeing an attorney. If what you say is true and there are no other circumstances we should be aware of, it sounds like the employer may have violated several laws or the terms of the insurance policy. You need legal advice to determine this though.

Contact an atty in Illinois since that is where the harm occurred. In addition to contacting an atty right away, try contacting both states' dept. of insurance for any free help they might offer.(check states' govt website) Some states have guarantee issue policy laws (check insure.com website), other states have statutory open enrollment for HMO's which may be one way of getting you insured. Good luck, you are in for a difficult fight.

Just in case you are unfamilar with the lingo of this site, SPD means a Summary Plan Description. You also want your Benefits Book, all of the COBRA info you were given, etc. Do you know if your coverage was an actual insurance policy or did your employer self-fund? This can be a crucial distinction as to your remedies. If insurance, what state was the policy issued in?

My concern, as always, is that the employer will do something under the radar. This person is costing a lot of money. Certainly it would be to the company's advantage if this person was no longer on the plan.

May a reinsurance company quote specifics for different individuals based on medical statements? By this I mean a reinsurance company looks at the medical statements of all enrollees and offers an aggregate total which is quite high. Then the reinsurer breaks it down so that every one in the plan has a specific (say $50,000) except for one individual who has a specific much higher. This is more affordable to the company than the aggregate that was quoted. There is something about this that makes me uncomfortable. I would appreciate any thoughts or sites on this. Does it matter that the plan is self-funded and the reinsurer is issuing a policy in Ohio? Is it state law that regulates the reinsurer? What about HIPAA and non-discrimination?

I have in the back of my mind a court case I read somewhere, I think on CNN.com about a probate battle involving the son of the deceased and the deceased's new wife who used to be a man. The issue is whether they could have legally been wed in the state where the estate is situated since that state does not reissue birth licenses to sex-change individuals. Hence, there could be no legal marriage. If she is still legally considered a man, their marriage should still be legal. If they divorced, and there is no same-sex benefit, then there is no coverage. I'm afraid you're not going to find a definitive answer anytime soon. Let us know what state this involves. Perhaps you can get a friendly law professor from a school in your state to comment on the legal status of the individuals involved.

How does your state treat the legal status of someone who has had a sex-change operation? Is there a new birth certificate issued listing the person as a legal female? Are they still legally married? I sort of see your point that some health care gender distinctions apply given the surgery, however genetically she is still a male. Wouldn't male gender mortality, disease rates, etc. still apply?

It is a full-time job. In fact, that's exactly what I do for a living. We also have a full-time person who handles Medicare only. It helps to have a background in law. EBIA is a good source, so are Thompson publications. The best source by far is Benefitslink. My access was inadvertently cut off by my company for about 6 weeks so I spent time at home accessing this fine site. I was able to convince them this wasn't a "chat room".

What type of plans are you the TPA for, and who is the "ghost" you plan to subcontract out to?

We have considered getting signed consent every time someone is dropped even during open enrollment. We always question when they are dropped outside of open enrollment, plus we have a few companies with known "rogue employees" who attempt to do this. While the reason for dropping a spouse before a divorce is final is often to punish or stick it to the spouse one last time, this is really a foolish thing to do. At least in Ohio, any debts the uncovered spouse incurs before the divorce are the debts of both spouses. I also believe an attorney could get a court order to stop the spouse from dropping, much the same way attorneys obtain orders prohibiting transfer of assests or beneficiary designations on life insurance before a final divorce decree.

What happens to the spouse in the interim? If the spouse is dropped in anticipation, then incurs major medical expenses (such as open-heart surgery as in one instance I remember) these aren't covered retroactively once COBRA is elected. For this reason, even though the regs allow the spouse to elect upon divorce, we strongly discourage enrollees from doing this. Thanks all, for the heads-up on cites that address this issue as I was unaware of this provision.

As far as I know, anticipation of divorce is not a qualifying event. If the employee does what you are stating, then the soon to be ex-spouse is without coverage for a length of time. At the time of divorce, there is no group coverage so even though there is a qualifying event, there's no COBRA because the QB is not covered under an employer group plan. As the soon to be ex-spouse, I would vigorously oppose being dropped from coverage. As the TPA, we wouldn't do it without the soon to be ex's consent. What does the STBES (soon to be)'s attorney say? We would point out that if the STBES has no coverage, until the divorce is final her medical expenses are marital debt. If she waits too long, she loses HIPAA eligibility status. We won't drop anyone without consent or a final divorce decree. So, to answer the rest of your question, if the STBES stays on coverage, after January 1, the STBES would have COBRA coverage that mirrors the new group coverage.

My understanding of the regs is that the turn around time has more to do with the provision of services to the enrollee, rather than the provision of payment to the physician. If the service is already rendered, there's no urgency. Maybe I'm misunderstanding your question. Our concern about these regs is, as a TPA, what happens if the Plan is not funding timeley to meet the payment turnaround times. I'm guessing that not even a Bush administration will prevent or change the claims regs. I suppose there still is hope that the Privacy regs just issued will be reevaluated by a Bush administration.

Unfortunately, when a company is not funding the plan to pay claims, this usually signals severe financial problems with the company. I'm not saying this is what is happening in this particular situation. However, if the company files bankruptcy, there is very little relief for the plan participants. If the plan is set up to pay claims through a trust, the trust is usually more secure than a company funding from its assets from month to month. Yes, there are fiduciary duties involved in funding, and the new claims procedures (effective 2002) attempt to address the issue. But if there is no money, there's no money.

In your initial notice of COBRA rights (which I know you provided to your enrollee upon enrollment) you should have a clear statement requiring the enrollee to notify the employer upon divorce so that COBRA continuation is triggered. If you have provided the proper documents and can verify that the enrollee and spouse received notification, you should have a pretty good case to deny COBRA based on untimely notification. As far as the other ramifications, you might have a strong case to deny benefits during this period based on common law fraud. I don't think that state insurance fraud law applies since this is technically not insurance. I can tell you that we successfully defended a case where we went back several months for refunds paid to providers, who then billed the patient, based on the fact that no one provided us notice that the parties divorce was finalized.

The first thing you must do is get a copy of all relevant documents for your plan. At the absolute minimum you should have a benefits booklet. That booklet must contain language pertaining to HIPAA, a federal law that sets limits on pre-existing conditions. Ask your insurance company for a HIPAA notice if you can't find any information about it in your plan booklet. As far as your claims not being paid timely there could be other explanations. The insurance company you describe is likely the third-party administrator of your company's plan. If the company does not fund the plan, i.e. forward the proper amount of money to cover the claims, the TPA won't pay the claims.

Probably the best thing to do is log on to the benefitslink homepage then go to benefits buzz. Scroll to the bottom of the page and click on older benefits buzz. It will take you back a week at a time. You will probably have to go back to at least March. There are some very good articles that explain the rules. Otherwise, this was (I think) IRS regulations that took effect Jan. 1, 2000 so they might have the complete rules on their website. Check benefitslink first though. This is where I got most of my information.

I beleive that notice via the SPD is insufficient for precisely the reason you give, the spouse may or may not receive notice. However, all is not lost even though you did not send initial notices. If your company agrees, send a new notice to home addresses now. We did this for all our clients for whom we administer COBRA when we were trying to put together a COBRA manual and realized we could not prove we sent initial notices in all cases. What made this easier for us to produce and send (without scaring the enrollees into thinking they were in danger of termination) was the new COBRA 2000 rules. We used this opportunity to update the COBRA notice and clarify the changes. Took a little time and money but now we can verify we are compliant.

I think the argument that more federal mandates makes self-funding less attractive is this: In a state such as Ohio, there are relatively few requirements for health insurance, an exception being HMO's which are more heavily regulated. If the federal govt starts requiring benefits such as maternity stays, mastectomy reconstruction, etc. that bring the mandates up to par with state mandates, why not insure and let the insurance company bear the risk. I don't think we have quite gotten to the point where federal mandates are as burdensome as state mandates. But every time the feds do mandate something it causes some of our groups (especially smaller ones) to rethink the self-fund vs. insure situation.

Probably because our insured product guy tells them it is. I guess its more a mental thing. We do have some self-funded plans that don't offfer benefits that they would be required to offer under Ohio insurance law. I guess they figure this saves them money. So whenever they are required to offer something under ERISA it appears they are losing some advantage. I still stick to the proposition that self-funding is more advantageous. I'm not sure if this is because you can control the plan/benefit design, there is some better tax consequence, or just the preemption issue and removal to federal court. I'm trying to prove a point here at work but I don't have any idea whether the tax advantage is substantial.

I'm not so sure it makes insured more attractive but rather makes self-funding less attractive. I don't agree with this but some in our organization do.