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Showing results for tags 'health plans'.
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I am at a loss on this, in-network provider successfully sued patient for balance bill in state court despite denial of benifits with non-liabilty and both appeals being adminstratively denied for improper billing with non-liabilty of enrolle. Lawsuit was for breach of oral contract but the written ERISA contract had a hold harmless, and included language to prevent any form of out of network contract unless the provider informed the patient in writing services would not be covered under the plan (they did not). The judge ruled as if patient had insurance and would not correct to state it was Self-Funded ERISA, would this be a cause? -
Several of our clients have been approached by vendors to offer telemedicine products outside of their group health plans (e.g., to part-time employee groups who are not eligible for medical coverage). It has always been my understanding that telemedicine benefits would constitute a group health plan and be subject to Affordable Care Act requirements (preventive services, etc.) that would be functionally impossible for a telemedicine benefit to meet (e.g., the requirement to offer immunizations). I have seen some vendors make the argument that the telemedicine benefits could fall under the excepted benefits rules, as EAPs. However, in order for an EAP to be an excepted benefit, it cannot offer significant benefits in the nature of medical care. I find it hard to believe a telemedicine benefit could meet that requirement. Are you guys also seeing these products becoming very common? Is there some rule I am missing that is allowing employers to offer standalone telemedicine benefits to their employees? TIA for any thoughts!
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Background: Client is in the middle of selling a division and will be keeping those employees in it's medical plan for the rest of the year to avoid disruption, thus creating a self-insured MEWA with two employers for this short period. I'm trying to determine the potential risks and requirements of keeping these employees in the plan for the rest of the year under Tennessee law. So far I've found the applicable rules and regulations (Tenn. Comp. R. & Regs. 0780-01-76), but I'm a little confused as to if these regs apply to a two employer MEWA because 1) the regs say they apply to "self-insured qualified" MEWAs and 2) then go on to define a qualified MEWA as consisting of ten employers. Anyone have any insight here? Would really appreciate it - feel like I'm just spinning my wheels at this point. -
Here is an odd situation. I tried to find a similar situation on the boards, but no luck. Our company with 51 employees sponsors a conventional group health insurance plan through a major carrier, for which we pay 85% of the premium. We have one employee who lives in Dallas, Texas (we are in Kansas). Our carrier has no group business in Texas except an HMO in the San Antonio area. Coverage through the carrier's national network is only available for employees who are traveling in Texas, not those who are Texas residents. Consequently, he is not eligible for coverage under our group plan, so he was forced to go to the exchange to purchase individual coverage that is roughly equivalent to that of our group plan. We would like put him in the same position as if he worked at headquarters. My question is whether we can set up an HRA for just him so the employer portion of the premiums can be reimbursed on a tax-free basis, or will we have to report the premiums paid as taxable income and gross up his wages? We have a number of other employees who are out of state, but they are covered under our plan, and he would be too if he didn't live in Texas. Thanks!
