ER chooses to pay for non-covered service outside of health plan

[Guest kchristy]

The biggest risk they run is one of discrimination. However, these day limits are not always written in stone, even in fully insured plans. I have seen carriers extend coverage beyond the maximum day limits for such things as physical therapy and skilled nursing care, but it was based upon the medical merits of doing so, not out of preferential treatment of a certain employee. This is more, I think, a matter of Utilization Review guidelines, which may, if you check into it, allow for the bending of these rules if it makes medical sense.

If it is a matter of completely overriding the rules of the plan, you better make sure that it's done for everyone across the board, and keep in mind that if you pay for benefits outside the guidelines of the plan, it may not be counted by the reinsurer in calculating "stop loss" limits.

[Guest YBrunson]

Does anyone have any guidelines if an employer chooses to make an exception and pay for a service beyond the limits that are covered under its health plan. The plan is funded minimum premium and has a 60 day limit for various therapy coverages. The company is considering paying for addtional days. I think I may know the dangers of this, but can it be done while minimizing exposure to future law suits?

[KIP KRAUS]

I agree with kchristy. In addition, you may want to check any tax consequences to the employee of the payments outside a qualified plan. Thaey may be taxable income, I'm not sure.

[Guest jamesfdavis]

For a discussion of a similar subject, please look at the Cafeteria Plans board under a thread called "Misc. Employee Benefits" on 12/23/98.

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Jim Davis