KIP KRAUS

I have never seen any ERISA or HIPAA regulations that address EOB content. The state insurance commissions may regulate this, but I have never come across any such regs. by a state. If the insurer has the option of what goes on EOBs then I would contact them for guidance. Most EOBs I’ve seen are lacking in detail as to the exact reasons for denials, but if the claim is paid then they usually give enough detail as to how it was paid. I'm not sure that ERISA or HIPAA addresses EOBs.

Why not just amend the plan to have $250/$750? What is the difference? The only advantage I can think of is that by doing this it is cheaper than the additional premium for the lower deductibles, but then if the plan is experience rated it shouldn’t make a difference. What is the rational behind this decision?

If your welfare plan document is a “Wrap” document that encompasses all of your welfare plans into one plan (including your self-insured medical plan) it’s my understanding that you can file one 5500.

It has always been my understanding that monies put into a FSA must be differed before earned, so I would say that a retroactive deferral would not be allowed.

Go to this web site and read section 1.125-4 for election changes. http://www.125plan.com/FlexLinks.htm

EMC: I’m curious. I haven’t seen this type of practice in the Rochester, NY and surrounding area whereby physicians are charging this monthly fee. Where are you located? Are these people in HMOs or PPOs?

Acquiring a new dependent is a qualifying event for adding that dependent to your existing medical plan it doesn't necesitate changing which medical plan you are enrolled in. I guess if the employer wanted to allow a change in plan they could, but if it results in a change in premiums and premiums are paid pre-tax I'd say it would violate Section 125. What reason other than higher dependent child coverage or lowere premiums would necesitate a change in plans because of child birth?

I would still argue that if these plans a clearly separate plans then open enrollment does not apply to any medical plan (what ever definition you want to give to a medical plan) that a QB was not enrolled in at termination of coverage. If the IRS intended to allow QBs to chose separate and distinct plans that they were not originally enrolled in I think they may be smart enough to clarify their position. Of course as I’ve said before, do any of the IRS employees really understand welfare benefits? I would not allow a QB to elect coverage that he/she had not been enrolled in. Changing between medical plans clearly is their option.

Because she wasn't enrolled in dental or vision I would'nt allow her to enroll in them at open enrollment.

Having a new baby does not qulify for a change in medical plans. Do it at open enrollment.

I believe that in the states that mandate STD benefits you would be required to continue to pay STD benefits. I know that in New York you would have to continue to pay. Typically in a fully insured STD product I have experienced that STD benefits would continue even if a person was terminated from employment while disabled. In a self-insured STD plan where benefits are not mandated by the state you should have this covered in a plan document. It makes no sense from an employee relations viewpoint to cut off STD benefits when you terminate an employee who is on STD. If you had an insured LTD plan and this person continued to be disabled through the benefit waiting period (say 6 months) he/she could typically be entitled to LTD benefits even though he/she was terminated from employment.

Just my opinion, but if we are to get prescription drug costs under control we are going to have to force consumers to make economic decisions about what drugs they are willing to pay for. Go back to the old 80/20 co-pay for all prescriptions and let the consumers decide if they want to buy the high price brands. To further their economic decision, only reimburse the cost of generics when generics are available and let the participants pay the difference if they decide to buy the brand names. If generics are not available of course you reimburse the cost of the brand name. This may force down the price of the brand names, but if it doesn’t it will surely reduce the employer’s costs.

Tcunagin The simple answer is that very few LTD and Group Life plans are experience rated unless there are typically over 1,000 participants. STD, on the other hand can be experienced rated on 100 or more lives. Experience rating on medical plans typically starts at around 200 lives, but insurers vary this based on their underwriting standards. The group insurers are required to provide the plans with Schedule A information and this information will tell you if the plans are experienced rated. Contact the insurers.

I never thought that HIPAA applied to any plans but medical plans. What about the pre-ex in LTD plans? I don't think they would meet HIPAA pre-ex requirements and I haven't seen LTD plans change these provisions.

What do you mean by selling the defaulted 401(k) loan to the profit sharing plan? What value you would you put on the defaulted loan? Seems to me that a qualified plan would have no interest in acquiring a worthless document of any kind. Could this be a breach of fiduciary responsibility under the profit sharing plan?

I agree with papogi.

mroberts: I believe that a major increase in premiums to the high option plan would be a qualifying event to switch to the low option plan if the increase came at mid-year. I believe the regs specifically allow for this type of change.

Why do you ask? Have you heard this term some place?

I agree with GBurns. I don’t see the applicability of HIPAA. However, assuming that you are running premiums through a 125 plan what qualifying event would justify changing from a high option plan to a low option plan? Did the premiums increase substantially in mid-year, if so a change may be in order?

I agree with mroberts and GBurns. In the past I have had the insurers print the additional ERISA information in their insurance certificates. Or, on the other hand, you can do as mroberts suggests and provide a summary and the certificate and in the summary refer the participant to the certificate for details not included in the summary.

My response is that if an insurance company writes a non-contributory group life policy they will require all employees to be enrolled. I also find it hard to believe that any insurer would write a fully contributory LTD policy and not require at least 50% to 60% participation. Why not just write the LTD policy and make it 50% employee paid and 50% employer paid? Of course the way you posted your question I’m not sure what benefit is going to paid at 50%.

I agree with mroberts. If you are a large enough group insurance case most insurers will allow you to include part-time employees with any where from 20 hours and up per week. In addition, some states may require some group plans to cover employees who work 30 or more hours per week. Check the group insurance contracts. Your other policies may be a matter of choice.

Ah Ha. Makes sense to me G.

CAROYLNN I guess I’m confused, but that’s not uncommon at times. My understanding of WC is that the employer pays the premiums in most if not all states. Do some states make employee’s pay the premiums? I know that in California and New York employees pay a portion of the short- term disability premiums mandated under the WC laws. I’m not sure about New Jersey, Rhode Island and Hawaii. I also was under the impression that WC benefits were not taxable, but short-term disability is only on the portion paid by the employer. What employee money is for WC is being funneled through a cafeteria plan?

If the employee’s medical plan changed so that he had higher deductibles and co-payments then the addition of a FSA, in my opinion would be consistent with the change in status.