French

We are reviewing and trying to streamline our FMLA process. There are some disagreements amongst the team regarding some of the info contained within the regs and what level of flexibility the employer has. We currently offer the pay-as-you-go and catch-up payment options. Can we offer just one? We currently allow the employee to decide which of our benefit they want to continue. Can we eliminate this as a choice and state that they all must continue?

Are long term care insurance premiums reimbursable from a health FSA?

Everyone's input has been very valuable. To answer the question, our employee is not currently covered under his spouse's plan. We've been told that her coverage is employee +1 and yes she is currently covering herself and their first child. I have been looking at the regs and it does seem that we should allow him to drop coverage. Any further comments are welcome.

Our employee has single coverage in one of our health plans and contributes on a pre-tax basis. His spouse has employee +1 coverage with her employer. She recently had a baby and will change to family coverage at her employer. Our employee wants to drop his coverage and be covered under his spouse's plan. We have said that dropping his coverage is not consistent with the event - birth of a child. Are we wrong in saying that he cannot drop coverage. I've looked through some of the regs and cannot find anything that specifically agrees or disagrees with our statement. Can someone help.

No I mean specifically elective cosmetic surgery - facelifts, etc.

Does anyone have a Short Term Disability program which excludes coverage if a request for a medical leave is due to cosmetic surgery? It is my understanding that SDI programs cover elective surgery so I am assuming this would include cosmetic surgery. Thanks.

First of all thanks for the comments. As GBurns has stated, there are a few employees concerned with increases in their out-of-pocket expenses due to out-of-network services. Though I may not agree with their concerns since I believe we still have reasonable out-of-pocket maximums ($1500/ $3000 out-of-network), we agreed to at least look into this matter. Due to the type of work performed by our employees for specific clients, we work hard to keep our employees happy. We recently heard about a program through CIGNA and I will also check into GBurns' suggestion about a MERP, though I could certainly use more guidance in this area. Other suggestions/thoughts remain welcome.

Is it possible to purchase some type of plan/policy which provides just additional medical coverage for employees who are traveling in the US on company business. We recently reduced our coinsurance percentage and increased the deductible and out-of-pocket maximums in our self-insured medical plan. As a result, concerns have been raised by some employees of the increased financial liability when traveling. Comments/thoughts/suggestions?

Is anyone aware of health carriers providing different levels of reimbursement for office visits depending upon who provides the service (MD, NP or PA)? An employee addressed this question to us which in turn we relayed to our HMO carrier. Their response was that it was an industry wide practice to compensate at the same rate irrespective of who provided the service and that the CPT code does not differentiate between an MD, NP or PA for office visits. Any comments?

Thanks for all the comments concerning this topic. I've learned a little bit more and hopefully some of the other users have too.

Let me try and answer the questions so that it makes more sense. 1. The EE received the notice because it was sent to all "benefits eligible" employees, specifically to cover ourselves due to our EAP. From what I can tell from his records, he is not and has not been a participant in our self-insured medical plan or FSA but was a participant in our self-insured dental plan until 2000. With the exception of the enrollment/disenrollment paperwork in his benefit file, all other PHI for the dental plan would be with our ASO provider. If he is or has been a participant in our EAP, PHI would be with our vendor. 2. According to our legal dept., the privacy notice was intended to cover all of our self-insured plans (the one subject to the 4/14/03 date and those subject to the 4/14/04 date). It did not specify each individual plan and realistically only one plan - medical - is valid. When I asked our legal dept. what to do if an EE requested access to PHI for any of the other plans (even though not subject until 4/14/04), the answer was to comply with the request. I hope that the above information clarifies the situation a little bit more. These answers lead me back to my questions: 1. Since the EE is not and has not been a participant in our self-insured medical plan which is the only one of our plans subject to the 4/14/03 date, that plan has no PHI for him. However since the notice does not specify the plan, are our other plans required to provide access now? We do not have BAAs in place with our other ASO providers yet. 2. Should I ask the legal dept. to update the notice so that it is specific to the one plan required to comply with the 4/14/093 date? I'm thinking that their decision to simplify the communication has actually made it more complicated. Thanks.

Kowen, based on your comments, I think we are okay. We do have business associate agreements in place with our ASO provider and another vendor for our self-insured medical plan and are working on completing agreements for those self-insured plans which become effective on 4/14/04. Additionally, we have a designated workforce (our customer service reps and benefits staff) which has been trained with regards to the HIPAA regs. Again, to go back to my initial post, my concern with the employee's request was whether or not any information (no matter who supplied it) needed to be provided since he is not a member of any of our plans currently subject to the HIPAA regs. If the employee had been a current member of our self-insured medical plan, the answer would have been simple. On behalf of the plan, the information would have been requested of the ASO provider. Again, with respect to my initial post, should we amend the notice so that it references our self-insured medical plan and not all plans? The specific language in the notice says "We are issuing this privacy notice to all those who are or are eligible to become members in any of XXXXX self-insured health plans." My understanding is that we were not planning on issuing another notice next year for those plans complying as of 4/14/04.

Appreciate all the comments. Re: the question about PHI, as an employer with several self-insured plans, several ASO providers, and an internal Benefits Service Center, we have been the recipient of occasional PHI due to claims issues. In addition, if I understand the PHI definition, it would also include enrollment/disenrollment information which we maintain in a separate benefits file. Re: this person's request, I would agree with mroberts and GBurns in that it was prompted by the HIPAA notice and that he probably only wants to see if there is any info about him anywhere in a file. In the end, we are of the belief that with the exception of the enrollment/disenrollment paperwork on file, there is no PHI being maintained since he is not a current member of any one of our self-insured plans. We intend to direct him to his current provider(s) and his prior fully insured health plan carrier. My one concern was our EAP, but in that case we determined that we should send him to that vendor also. Any other comments?

We maintain several self-insured health plans (medical, dental, FSA and EAP) but only one plan met the $5m threshold - our medical plan. We sent the privacy notice to all active employees eligible to particpate or participating in the health plans and to former employees participating in the health plans. The notice was not specific to the medical plan. Question: An employee who waived medical coverage (in a fully insured plan) and dental coverage (in our self-insured plan) in 2000 has requested access to his PHI. What are our obligations? Question: Should we change our privacy notice to be specific to the medical plan? Thanks.

We received a request from an employee who wants to inspect and copy the health information contained in his designated record set. Does anyone have a definition of the term designated record set? Is this information we have collected prior to or after April 14th? At this point in time, he is only a participant in our self-insured EAP but was previously a participant in the other "health" plans 2 years ago. Thanks.

As we prepare for Monday, I have a HIPAA question for which I have received conflicting information. Do I need to update my SPD with the entire Privacy Notice or can I use just a summary? We are doing it on line and will be finishing it today. My plan was to use a summary piece but I have heard otherwise from other employers at a recent benefits gathering. Thanks.

I have a follow up question. A little background first. We have self-insured medical, dental, FSA and EAP plans. Our initial plan was to send a privacy notice to the participants of each of these plans. When we realized however that the EAP would result in all benefits eligible employees receiving one, our legal department decided that only one notice was necessary. It's not that I am questioning my legal department but I wondered if others in a similar situation were doing the same thing. Thanks.

Thanks for the confirmation.

We have a self-insured EAP. It is my understanding that the EAP provider requires a Business Associate Agreement. It is also my understanding that the HIPAA Privacy Notice should be mailed by us (the employer) since it is a self-insured plan. We are planning to mail it to all eligible employees. Is this what other employers are doing who have self-insured plans?

Thanks to both of you and I especially appreciate the specific section of the regs for proof of my understanding. Apparently our employee not only wanted to drop vision but also dental and medical. The only plan with any significant change in cost is medical.

We offer our benefit plans to full and part-time employees who work 20+ hours/week. (Note that the premiums are slightly higher for a part-time employee). A current employee enrolled in our pre-tax vision plan wants to drop it due to her choosing to reduce her hours from 40 to 29. I believe that is not a qualifying event (FT to PT) since she is still benefits eligible. Am I wrong in my interpretation of the Section 125 rules? Can someone direct me to a the specific reg which may address this issue? Thanks.

Dopinante, I would very much be interested in any data that you could provide. I have just sent out the RFP as part of the TPA rebid and expect to send out the Rx RFP by the end of July. Thanks.

I appreciate all the comments. This same question was asked of a local and a national consulting firm that we have worked with during the past few years and we received 2 distinctly different responses. One firm said that the PBM vendor market is extremely competitive today and that employers can reap the benefits by negotiating deep discounts, steep rebates and low admn costs. The other firm made many of the same comments as Mary Anna and mroberts did. So we have decided to do 2 RFPs for prescription drugs - on a standalone basis and as part of rebid for TPA administration. Due to the anticipated increase in prescriptions, we plan on some major tweaking of our 3 tier copayment structure on the mail order program. And we have begun discussions on the design of a healthcare education program for our employees in an effort to address some of Kip's comments. Though we are too conservative a company at present to promote the defined contribution/consumer drive design, we do recognize the need to create awareness for our employees.

My company (approximately 4,000 ees nationwide) is finally thinking about creating a healthcare strategy for the future. One possibility we are exploring is a standalone prescription plan. At present, our mail order program (for participants in our self-insured POS) is with one vendor and our retail program is with a different PBM through our TPA (an insurance carrier). We are also considering carving the prescriptions out of our 15+ HMO plans (about 50% of our employees are enrolled in HMOs) so it seemed natural to create a standalone plan. By having one vendor we would finally gain some control over the formularies, dispensing fees, co-payments (and/or co-insurance if we make that move), etc. However we are having second thoughts now simply due to economics. If both the mail order and retail programs were serviced by the PBM of the TPA as part of our POS, would it make more sense than creating a standalone since the TPA undoubtedly has greater price leveraging power than us alone? I am just wondering if anyone else has experienced this issue and what the results were. Thanks.

There is no question that these particular employees would have been eligible for a match during the year. Thanks for confirming what I understood versus what is being done.