sharonfoster

The provision relates to the coverage effective date for a new hire. If I offer my employees group health plan coverage on the first day of the month following the date of hire, the health plan is permitted to require the employee be actively at work on the date coverage is effective. However, because of HIPAA's prohibition on the use of health status, if the employee is home sick or in the hospital (rather than taking the day off or not scheduled to work), the coverage must be effective on the stated effective date, the first of the month. The provision is not useful any longer since its purpose was to avoid making coverage effective if the person was sick on the effective date.

If the group health plan is not an 'excepted' benefit plan (the mini-medical plans our President allowed to be sold again), and is subject to the ACA, the plan cannot impose annual or lifetime limits on essential health benefits. There is no way this plan would meet the minimum value requirements with a $1,800/day hospital limit.

There is no specific guidance on this topic. As a plan sponsor, before I took any action I would first make sure that the required COBRA notices are being sent properly and you were 'auditing' your process periodically to ensure procedures are followed. Also, does your health plan summary plan description address COBRA coverage, when notice is required and to whom notice must be given. Also, did HR receive notice of the divorce in some other way (QDRO, QMCSO, employee coming in to remove spouse from life insurance, etc.)? If the plan sponsor/administrator has taken care to fulfill its responsibility, then if a late notice is received, the plan administrator should send a 'Notice of Unavailability of COBRA' explaining the basis for deny the spouse COBRA rights. If not, you may have to make an accommodation and make an offer of COBRA. If the error is on the part of the plan, to avoid penalties you need to restore the individual to a position at least as good had the error not occurred. That is a judgement call. Whatever you do, document the basis for the decision and keep it with your plan document.

The EEOC updated its pandemic guidance for COVID-19. Great employer resource, especially if there is a second wave (how to prepare). https://www.eeoc.gov/facts/pandemic_flu.html

Both Ohio and Maine are requiring insurers to allow employers to continue coverage for employees furloughed or reduced hours. Employer cannot select specific employees.

The HHS Secretary's declaration is in effect until the Secretary rescinds the declaration, to a maximum of 90 days (see below). If you check the HHS web page on these declarations you will see that it is common for them to be renewed as needed. I would think this one will be extended. https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx 42 U.S.C.United States Code, 2009 EditionTitle 42 - THE PUBLIC HEALTH AND WELFARECHAPTER 6A - PUBLIC HEALTH SERVICESUBCHAPTER II - GENERAL POWERS AND DUTIESFrom the U.S. Government Publishing Office, www.gpo.gov §247d. Public health emergencies (a) Emergencies If the Secretary determines, after consultation with such public health officials as may be necessary, that— (1) a disease or disorder presents a public health emergency; or (2) a public health emergency, including significant outbreaks of infectious diseases or bioterrorist attacks, otherwise exists, the Secretary may take such action as may be appropriate to respond to the public health emergency, including making grants, providing awards for expenses, and entering into contracts and conducting and supporting investigations into the cause, treatment, or prevention of a disease or disorder as described in paragraphs (1) and (2). Any such determination of a public health emergency terminates upon the Secretary declaring that the emergency no longer exists, or upon the expiration of the 90-day period beginning on the date on which the determination is made by the Secretary, whichever occurs first. Determinations that terminate under the preceding sentence may be renewed by the Secretary (on the basis of the same or additional facts), and the preceding sentence applies to each such renewal. Not later than 48 hours after making a determination under this subsection of a public health emergency (including a renewal), the Secretary shall submit to the Congress written notification of the determination.

IMHO, you are wise to question the rates you were given with your election notice. I have worked with employee benefits for decades, with special emphasis on 'compliance', and could count on one hand the number of self-insured group health plans that calculate COBRA rates properly. I am not saying that vast numbers of plan sponsors are cheating as most rely on advice from their broker or consultant. The lack of knowledge on the part of the employees whose position includes setting these rates for clients is alarming. It is not uncommon for self-insured COBRA rates using expenses that should not be included and using the plan's maximum claim exposure to set the rates. I am also suspicious when a concern involves a PEO. While there are many fine PEOs, the track record of several PEOs, both large and small is a concern. Comparing the cost of very similar coverage on your insurance Marketplace can help you get a rough idea of what the plan should cost. An individual policy that is very similar to your current coverage should cost more through the Marketplace. The older you are the greater the difference will be, with the cost of COBRA being less. I have attached the section of the Internal Revenue Code that addresses how COBRA premiums are set (it is several pages, but it is bookmarked and highlighted). I recommend pushing back on the PEO. If this is a private employer (not public sector e.g., city, school district, etc.) you can also call the Department of Labor. Your state insurance department may be able to help if your employer is in the public sector. Good luck. IRC_4980B_Failure_to_satisfy_cont_coverage_require_of_group_health_plans.pdf

His loss of coverage is a Special Enrollment event (under HIPAA Portability rules). As such, he is allowed to enroll for coverage for both himself and his spouse. There is an exception if your health plan (1) requires an employee declining coverage to state in writing the reason for declining coverage is the existence of other coverage and (2) at or before the time the employee declined coverage, the employee is provided with notice of the requirement to provide the statement (and the consequences of the employee's failure to provide the statement), and the employee does not provide the statement. In that case the employee's request to add the spouse could be refused.

Reed, The plan administrator is required to provide your wife a copy of the plan document, inclusive of any contract or other instruments under which the plan is established or operated), upon her written request. As part of the request, I recommend stating you want the established policies setting the objective criteria for the determination of Medically Necessity under the health plan. It is important to be as specific as possible in your request for all the materials that make up the plan document while at the same time making a broad request. I also recommend documenting in your request your need for the documents to prepare you appeal. The Plan Administrator should be named in the health plan’s Summary Plan Description, however, it is most likely the employer. As to the parties to name in litigation, the plan document should identify the plan named fiduciary (again, usually the employer) as well as any ‘person’ to whom claim fiduciary authority has been delegated. It is likely the claim fiduciary authority has been delegated to Anthem. If this is the case, both the health plan and Anthem would be the appropriate parties in litigation. The plan administrator must comply with a written request for copies of documents, within 30 days of receipt, by mailing the material requested to the last-known address of the requesting participant or beneficiary or to the address provided by the participant. Submitting a proper, thorough appeal identifying any information the plan failed to provide will be important in litigation. The outcome of litigation can (and frequently is) hampered by steps not taken during the appeals process. I have been in your shoes and it is incredibly frustrating, but employers/plan administrators and claim fiduciaries are frequently ineffectual and, assuming you have facts on your side you can obtain the benefits you believe are due. Sharon

Indirectly this topic was litigated by the EEOC against JC Penney. Head of Household rule. Case decided in favor of JC Penney http://law.justia.com/cases/federal/district-courts/FSupp/632/871/2260256/