Identical Health Care Options by Different Providers - Ability to Freely Change Providers

[rocknrolls2]

Company maintains Cafeteria Plan Y, which among other options provides employees with the right to elect a preferred provider organization offered by Provider M, a point of service arrangement also offered by Provider M, a preferred provider organization offered by Provider N and a point of service arrangement also offered by Provider N. The PPOs offered by Providers M and N have the same deductibles, copays, coinsurance amounts and out-of-pocket limits and have the same net employee cost. The POS options offered by Providers M and N have the same deductibles, copays, coinsurance amounts and out-of-pocket limits and have the same net employee cost. There may be some geographic areas where physicians on the network of one provider are not participating in the network of the other provider. The plan document for Plan Y has a definition of change of status does not specifically permit an employee in Provider M's PPO to elect Provider N'a PPO unless there is some other change in status event. Operationally, if, say an employee elected the POS by Provider M and learned that her/his favorite physicians no longer participate in its network, the employee may contact HR and would be permitted to switch to Provider Y. Although there is no change in the employee's net cost on a "pre-tax basis," does anyone have concerns about this not following the plan document and not being made as a result of a change in status as well as not being communicated to participants?

[leevena]

I suggest you go to the health plan contract and read it's provision. Usually they will not allow a change in enrollment because a physician left a network.