Regulations regarding Health Insurance benefits

[Guest AJS]

What are the regulations with regards to providing health insurance benefits to employees. All of the employees of my wife's company receive healthcare benefits while holding similar positions, yet her employer has refused her request for coverage. The company has over 30 employees.

[KIP KRAUS]

There has to be more to the story. Why would her employer single her out as someone not eligible for health insurance? Does she meet the definition of an eligible employee,i.e full-time,or salaried.

By the way, with a plan that small, if your wife meets the eligibility requirements, the insurance company is obligated to insure her. If her employer will not offer her the coverage, have her call the insurer. If that doesn't work have her contact the state insurance commission.

[Guest chris7777]

I changed jobs in the middle of the year. I had less than a 63-day gap in my group health coverage between employers (the health plans are different; my employers are in different states). In my former employer's plan, I had satisifed my deductible (which was $500).

My question is, under my current employer's plan, is the insurer required to give me credit for the deductible paid to my former insurer this year? If so, would the same be true re: total coinsurance amounts paid?

Does HIPAA affect this at all (I know that HIPAA prevents my new insurer from imposing any pre-existing condition limitation on benefits).

[KIP KRAUS]

There is no obligation for your new employer to give you credit for any deductibles or co-insurance payments that you satisfied from your former employer. HIPAA has no bearing on this type of situation.

[Guest G Burns]

Credit for previous coverage and application of pre-existing conditions or clauses are never controlled by an employer. The Master Group Contract, the policy and State laws dictate what can occur.

[Greg Judd]

G Burns remarks are accurate for insured health benefits. Sponsors of self-insured plans can and sometimes do exert some control over the plan's pre-existing condition provisions, even in HIPAA's wake. State law provisions may not play any role in such circumstances.

[KIP KRAUS]

I have never in twenty years seen a group insurence contract give an employee credit for deductibles and co-pays from his/her former employer. By the way, if an employer group is large enough,and totally experience rated, the employer most certaintly has flexability to cover a lot of things that a normal group contract would not cover, including non-mandated state benefits. If a large enough employer on an experienced rated contract wanted to give credit for prior employer deductibles and co-pays they could. It wouldn't make since to do it because of claims exsperience.

[Guest Carmel]

To Kip Kraus: I have seen an employer give credit for deductibles but this was in a merger/acquistion situation. The considerable size and resources of the acquiring company allowed it to convince it's deductible medical provider to accept the explanation of benefits from the other deductible provider and to administer the claims. This was done in a obvious attempt to gain the good will of the newly acquired employees.

[KIP KRAUS]

Carmel:

I can understand a company doing something like that, but to give a new employee from a former employer credit is not wise.

[Guest G Burns]

To: Kip & Carmel. There has never been an employer who had any say in the granting of any condition of any policy. The terma and conditions of a policy are ALWAYS governed by State law, COBRA and HIPAA. HIPAA governs almost all of the conditions regarding pre-existing conditions. State law governs ALL elegibility and some of the pre-existings. There is nothing else. I had hoped that someone else would have answered you by now, but I guess I might as well.

[Larry M]

Gee, G. Burns, what a revelation.

All these years my employer clients, in their and my ignorance, have been choosing their benefits and designing their plans and they did not know they had no control over the benefits they are paying to their employees.

And my insurance company and hmo clients have been wandering in the wilderness, naively ignoring the world around them as they agree to provide benefits requested by those employers who are willing to pay for them.

Yes, some states and the federal government impose some restrictions and mandates, but, generally, an employer can choose the level of benefits and the ones who will be covered.

The extent to which states decree mandates varies from the extraordinary exception in Hawaii to the let them do whatever they want attitude which prevails in other states.

[This message has been edited by Larry M (edited 08-21-1999).]

[Guest G Burns]

The insurance co designs the plan the employer can only choose what is offered by the insurance co and the insurance co can only put in what is allowed by LAW.There has never been an employer who can issue an insurance policy, they can only CHOOSE.

[KIP KRAUS]

G. BURNS:

You are so wrong. Large employers have been designing their group insurance plans for years. If a large employer (1,000 empls. and above for example) has a group insurance finacial arrangement with an insurer which is covered by state insurance laws, once you get past the mandated coverages required by the states, the employer and insurer have the latitude to provide non-mandated levels of benefits, especially if claims liabiltiy is totaly the employer's responsibility. Take as an example invitro fertilization, which is mandated in only 6 states. If the large employer's contract is written in a state that does not mandate this coverage, that employer certaintly will have the authority to tell the insurer that they want this to be a qulified item of coverage. All group insurance contracts are not off-the-shelf contracts.

I'll give you another example. I don't know of any state that mandates coverage for some-sex partners, but a lot of companies provide this coverage. I can assure you that if Kodak, for instence wanted to cover same-sex partners their group insurer is not going to say no because it is not something in their standard contracts and underwriting procedures.

You might want to contact some large employers and find out from them how much power they weild with their insurers.

[Guest nac]

Me, too!

State law doesn't govern eligibility. An employer can theoretically choose to make only blue-eyed people an eligible group - unwise from an ER and EEOC perspective, but technically valid if it's adequately communicated and documented.

And while we're on the subject, self-funded plans (my particular area of expertise) are frequently NOT subject to state mandates. For example, in the great state of CT, they've recently mandated parity for bio-based mental health, and coverage for OC's. We still don't comply, and will not unless and until it comes from the feds.

[Guest ScottN]

In the state of Colorado some eligility requirements are regulated by the state for small groups (under 50 employees) that are covered under fully insured plans. In effect, the regulation tells the insurer they can impose no restrictions on employers outside of specific parameters.

Colorado has also passed a bioligically based mental illness parity law. The rules are much tighter than the federal mental health parity act.

Of course, state regulations rarely apply to any self funded plans. Let's hope the current attempts to change this do not materialize.