Sandra Pearce

If you notified the employee of the obligation to pay the employee portion for the health coverage while on the unpaid FMLA leave, and if you give the employee 15 days notice of cancellation of coverage you may cancel the coverage. You may not cancel it retroactively. This is not a COBRA qualifying event. The employee must be reinstated (not retroactively) to the health plan upon return to employment (during the FMLA leave period). If the employee does not return to employment at the end of the FMLA leave period that would be a qualifying event (not retroactively to the date of loss of coverage for non-payment).

I believe a viatical settlement or purchase from an ouside company would also require that the covered person be terminally ill.

I believe from an employer's standpoint the same information, such as a group billing with employee name, effective date, type coverage, monthly premium, is not considered Protected Health Information.

I used the word "might" for exactly that reason. I would not consider the information they are receiving to be PHI; however, it appears that everyone is erring on the side of caution at this point in time.

The health plan itself would be the Covered Entity effective either 4/14/2003 (large plan) or 4/14/2004 (small plan). ADP might be considered a Business Associate of the health plan when the regulations effect the specific health plan.

I agree with Steve72. No SPD requirement.

An additional thought might be that when budgeting for a future year you really should be using one figure for the benefits of each potential employee. Employees are terminated and hired and they change their benefit elections. Our company has the department heads use a figure for the cost of health benefits which is pre-determined using data (not PHI data) from the health plan. The dollar figure is used for all employees.

In an asset sale (which I realize this is not) the employees of Company A that were terminated prior to or in connection with an asset sale to Company B would be COBRA qualified beneficiaries to Company B. Logic would make me believe that since Company A was a part of the controlled group and obligated to offer COBRA coverage to the employees and did not, the obligation would then fall to the remaining company, Company B. However, before I actually did that I would do my research, put my thoughts in writing and present it to a Benefits Consultant or Attorney.

The original post said that the employee was applying for the hardship on the basis that the hardship was to purchase a primary residence that the employee would live in but not be named as buyer. The last post suggests that perhaps this should be considered as a hardship to prevent eviction from a primary residence. If so I believe most administrator's would require an eviction notice. If there is one and the employee applied without giving all of the necessary information then this could be reconsidered. Otherwise, I don't think you can assume the eviction.

Our health plan has denied experimental treatment whether or not the treatment was stated to be medically necessary by the treating physician. In our Exclusions - Charges for care, services, supplies, treatments, procedures, devices, drugs or medicines which are determined to be experimental or investigational. This means that one or more of the following is true: 1. the device, drug or medicine cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the device, drug or medicine is furnished. 2. reliable evidence shows that treatment, procedure, device, drug or medicine is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. 3. reliable evidence shows that the consensus of opinion among experts regarding the treatment, procedure, device, drug or medicine is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

I started to comment on the unborn child issue but dropped it. I agree the child has to be born to have coverage.

Most health plans are subject to the special enrollment provisions of HIPAA. Birth of a child is a HIPAA special enrollment reason which would allow your employee to add coverage for the new dependent and that coverage is effective the date of the birth. Also this child would have to meet the plan's definition of an eligible dependent. In most plans the natural child of the employee is an eligible dependent. Proof might be required in the form of a copy of the birth certificate which would show the employee to be the father of the child. I do not agree that the only way for a child to have coverage is for the mother to have coverage. In our health plan the common law wife of the employee would not be an eligible dependent but the natural child born to the common law wife and our employee would be an eligible dependent. Read your plan document and/or SPD for the definition of an eligible dependent and for the provisions for enrollment.

As an employer I would be very upset if our 401(k) administrator thought this qualified.

Procedures that are strictly cosmetic are not reimburseable.

These notices are sent out by Medicare to employers. In the ten years our health plan has been in existence the plan itself or the TPA has never received a notice, only the employer companies participating in the plan. If you look further you will probably find that the original questionnaire was sent to the employer and the employer probably forwarded to the TPA.

If the client is fully insured then the insurance policy should be provided to the client to support the client's inability to keep this person on the plan, other than as a COBRA participant. If the client is self-insured then the reinsurer might have some words of wisdom for you. The client will likely be paying a premium for a benefit that does not exist.

Perhaps you can convince the client to follow the rules of USERRA and offer the employee (who is no longer an active employee by any plan definition) continuation of coverage under COBRA with the employer picking up the cost of the COBRA coverage. The employee called up to military duty will probably not complete the COBRA paperwork as he or she will probably understand the benefits provided through the military. Worst case if the employee completes the COBRA enrollment form then the employer pays for a benefit with no real value. USERRA does require an employer to offer COBRA continuation.

What does your plan document or policy say regarding dependent eligibility? Legal separation or divorce is a COBRA qualifying event. A court can order the employee to continue coverage for the spouse but cannot order the plan to provide coverage it would not otherwise. The spouse may be eligible for COBRA-continuation and the employee may have to pay for (provide) that coverage.

I believe when the employer allowed the agent in to offer a product to be paid through the employer's payroll, the employer has sponsored that plan. Any life insurance of over 50,000 provided would be taxable to the employee if it were paid for a a part of a 125 plan with pre-tax dollars.

As an employer, I would look at the materials given to the employee when the election was made. If the materials stated clearly that the dependent care account was for "day care" expenses and the form stated "day care" expenses I wouldn't be able to reimburse the funds because the employee didn't understand that medical expenses would not be eligible.

An unpaid leave of absense is a qualifying reason.

There is no federal requirement regarding notice of pending termination of COBRA coverage. There may be a California state law requiring such a notice.

Eligibility for coverage is determined based on the definition which can be found in the Plan Document and the Summary Plan Description. Part time employees may be excluded and the definition of a covered employee and eligibility will address the number of hours of work per week required.

As MattJ says you first look at the definition of an eligible dependent in the plan document. In our health plan a 21 year old "dependent" child not in school full time would not be an eligible dependent for any purpose. If your plan is subject to COBRA and is notified timely that a previously eligible dependent has lost eligibility as a dependent (such as age 19 but not a full-time student) the plan should offer COBRA continuation to the previously eligible dependent. COBRA does not have to be offered when the notice to the plan of loss of eligibility is not provided within 60 days of the loss of eligibility.

If this would be like an insurance premium then it would not be reimburseable under an FSA.