Sandra Pearce

No, we would not reimburse that expense for exactly the reason you stated. There is no service performed.

I agree with the previous post. You must first check eligibility in your plan. A dependent child, in our plan, must reside with the employee. Any court order issued would obligate the spouse, not the employee or the employee's employer sponsored health plan, to provide coverage.

The monthly fee the TPA charges for each FSA participant is usually paid by the company; however, some companies do have the employee's pay the fee. The TPA handling the admistration should be able to answer the question about whether the fee is pre tax eligible.

A claim for a medical spending account must have been INCURRED by the person during the applicable period, and must not be reimbursable through another means (another plan such as a health or dental plan). The participant does not need to prove the expenses were paid for, only that the expenses were incurred.

QDROphile, Do you mean that you would not take the back premiums owed?

If you mean that the employer needs to back-charge the employee for the benefit that the employee was in fact enrolled for, there is nothing that would prevent that. I am sure the employee knew that the benefit had a cost and should have called the oversight to the attention of the employer as soon as the first deduction was skipped.

Pregnancy cannot be subject to a pre-existing limitation in a group health plan; however, this does not hold true for a short term or long term disability policy. The summary plan description for your short term disability policy should spell out the pre-existing condition limitations. In most policies there is a period of time prior to the effective date of the coverage which will be reviewed to determine if the person was given medical care (consulted a physician or was treated for a specific condition)during that period.

If the surgery is medically necessary it would probably be reimbursable by the person's health plan. Then the 125 plan would be paying from an EOB which would show charge, payment, deductible, out of pocket, etc. like any other medically necessary surgery.

I would start with your employer contact; i.e., the person you mailed your payment to. Have the employer verify the receipt, or prove receipt to the employer by copy of your cancelled check, then request the employer contact the insurance carrier or plan to correct any oversight.

The 63 day period allowable begins when your coverage is lost and ends when the waiting period for new group coverage begins. Uusually a 30, 60 or 90 day waiting period for group coverage is imposed on new hires. The date of hire in these cases would be the date that the 63 day clock stops ticking. In the case cited no matter when the waiting period began, the period from November 1 - January 1 would be less than 63 days and would not cause your previous creditable coverage to be excluded. There would be no exclusion of pre-existing conditions in the new group coverage. Be sure to get the certificate of creditable coverage from your prior carrier or carriers and present that to your new carrier.

If the employee is paying for coverage under a Section 125 plan that plan governs when the elections for payments may be changed. Many 125 plans require that notice be given within 30 days of a qualifying event. The underlying health plan has its own rules regarding changes and definitions regarding eligibility. The health plan rules would govern when the dependent loses coverage, the 125 plan rules would govern when the premium payment for coverag could be changed (reduced).

Your plan's definition of eligibility probably does not include former employees, with the exception of employees continuing under COBRA.

This is the employer's side of the risk. The annual election is available in a medical flexible spending account while the employee is active or participating through COBRA.

The employee makes an election for the calendar year and then at the time of termination (retirement) either elects to continue under COBRA or contributions and participation ends.

Questions and answers regarding Mergers and Aquisitions were published in the Federal Register 7/31/2001. 26 CFR - CHAPTER I - PART 54, § 54.4980B-9 Business reorganizations and employer withdrawals from multiemployer plans.

We have all employee's sign a document (provided additional to the SPD although included in the SPD) defining an eligible dependent in our plan. We do allow domestic partners and the document states that Domestic Partners will be regarded as eligible dependents under the Plan, with the same rights as legal spouses, with the exception that they will not be extended COBRA continuation privileges upon termination of coverage. Also stes that children of a Domestic Partner may be considered eligible on the same basis as children of a legal spouse, with the same rights as children of a legal spouse, with the exception that they will not be extended COBRA continuation privileges upon termination of coverage. DP's are not sent the initial COBRA notice since they would not be eligible for COBRA continuation in our plan. By having them read and sign the definition document they are put on notice that there will be no COBRA coverage offered.

Health FSA coverage can never be changed on account of cost or coverage changes.

The original post is headed "Military Leave." Is the employee out on a military leave and not working? If so the provisions of USERRA would apply.

Do the regulations say "reaches the maximum age allowable under the plan?" Everything I have (not the regs themselves) says "A dependent child's ceasing to be a dependent child of a covered employee under the generally applicable requirements of the plan."

COBRA coverage is continuation of existing coverage offered when someone loses that coverage due to a COBRA-qualifying event. If the child did not have coverage in your plan and has not lost coverage in your plan, the child has not experienced a COBRA-qualifying event in your plan. However, if your employee has gained legal custody of the child this may be an eligible reason to add the child to your plan. You will have to look at the dependent eligibility provisions of the plan and documentation regarding the custody.

This would not be considered in our health plan. We have a basic benefit % that is paid for eligible medical services. We increase that benefit, pay a larger %, for a provider in our preferred provider network. We are able to pay the larger amount on those claims because of the discount arrangements which reduce our cost. That discount is shared with the employee in the form of a larger % reimbursement. We never pay the larger in-network % for providers that are not in the network. Many anesthesiologists, pathologists and radiologists refuse to participate in networks simply because they have, for the most part, a captive audience.

Since this was an administrative error why can't the correct payment and interest be brought current - no harm, no foul?

We considered adding to our health plan a year or so ago; however, with costs skyrocketing the Administrative Committee of the plan didn't by adding it. This what we intended to provide: Coverage for Alternative Therapy ProvidersMassage Therapists, Naturopaths and Acupuncturists. The Plan will pay 80% of medically necessary reasonable and customary Alternative Therapy expenses, subject to the Maximum Benefits and Limitations and Exclusions of the Plan. The maximum Alternative Therapy benefit payable for any one covered individual during any one calendar year is $1,000.A doctor of medicine must make referral or recommendation for alternative therapy. It is suggested that all claims for Alternative Therapy providers be submitted with a copy of the referring MD’s prescription or recommendation. The Alternative Therapy Provider must be licensed by the state in which they practice. Treatment must meet the requirements of the Plan regarding medical necessity, must be in accordance with good medical practice, and not to improve the patient’s appearance, general health of sense of well-being.

The portability rules apply to individual and group health coverage, exlcuding accident only, disability, liability, WC, credit insurance, on-site medical clinics, limited scope dental and vision benefits provided under separate policies, long term care benefits, medicare supplemental plans and specific disease or illness policies. If you're dental and vision are provided in separate policies then I think they would not be subject to the special enrollment provisions. Voluntary life is definitely not included or subject to special enrollment. Your FSA, if your document allows, could have provisions for special enrollment circumstances - birth, marriage, adoption.

Most of the plans I have seen have a 90 day period after the end of the plan year. The plan document and SPD should have the claim filing deadline spelled out.