cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
By Adam V. Russo & Ron Peck
As avid readers of this article are aware, every month we write from the perspective of a self-funded plan, address how the health insurance industry should work, and what needs to be done to lower the cost of health care. Generally, we represent self-funded benefit plans and their third party claims administrators (“TPAs”). You may also know, specifically, that we have been spending a lot of our time dealing with conflicts that arise between these benefit plans and the health care service providers (“Providers”) that treat the plan participants. In this article, we want to look at these issues from the Providers’ perspective. You may be surprised by the differences in opinion regarding the value of preferred provider organizations (“PPOs”), and more shockingly, our common ground. (more…)
Category: Balance Billing, PPOs, Usual and Customary |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
A federal district court upheld a claim administrator’s denial of payment for stays at a hospital and a skilled nursing facility (SNF) for a plan participant on life support deemed not medically necessary under plan terms because his condition was past the point of improving. Most of the care he got at the facilities could have been provided in a less intensive setting. (more…)
Category: ERISA |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
In a lawsuit involving denied gastric repair services, a third-party administrator (TPA) argued its way out of an ERISA claim for denied benefits and alleging fiduciary abuse, after the court agreed it only did what the plan sponsor told it in documents, e-mails and conversations.
The plaintiff accused the TPA of being a de facto plan administrator, in spite of the fact the plan document expressly disavowed any fiduciary role for the TPA. (more…)
Category: 10th, ERISA, Fiduciary, Third Party Administrators |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The attempted treatment of stop-loss coverage as “health insurance” subject to state insurance law has been a thorn in the sides of self-funded plans seeking to maintain ERISA preemption of state insurance laws.
In Goyen v. Vail Corp., 2011 WL 4479091 (D. Colo., Sept. 26, 2011), a federal district court rejected a plaintiff’s argument that a plan stopped being self-funded and lost ERISA preemption, all because it had taken out a stop-loss policy. (more…)
Category: 3rd, 6th, ERISA, Preemption, Self-Funding, Stop Loss |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The recently proposed summary of benefits and coverage (SBC), while still a work in progress, will fill a currently unmet need for a tool enabling plan participants to comparison-shop for coverage, federal regulators told a recent conference. They sought to allay plan sponsors’ concerns that the SBC is redundant, confusing or even regressive. (more…)
Category: DOL, ERISA, Health Care Legislation, HHS, HIPAA |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The lack of cost transparency stands in the way of health cost control because it makes plan members unable to see prices before services are actually rendered, and harms their ability to budget health spending. Problems include: (1) multiple providers; (2) multiple network-provider contracts; (3) providers that often don’t know how extensive a patient’s treatment needs are until they start treatment; (4) insurers say contractual obligations with providers prohibit the sharing of negotiated rates; and (5) providers afraid of sharing negotiated rates due to their proprietary nature. Leah Binder, CEO of the Leapfrog Group, suggested that most employers can bring more efficient purchasing to their health plan in two ways: (1) change plan documents to reward members for using high-performance providers (for example, by waiving deductibles); and (2) computerize drug ordering and management systems, which would have quality as well as cost and efficiency advantages. (more…)
Category: California, CMS, Florida, Massachusetts, Medicaid, Medicare, New Hampshire, Transparency, Wisconsin |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The U.S. Supreme Court definitively announced on Nov. 14 it will decide the question of whether Congress exceeded its powers to regulate commerce when it decided to require people to buy health insurance (that is, whether the individual mandate is allowed under the U.S. Constitution). The court will hear National Federation of Independent Business v. Sebelius; and Florida v. HHS. The High Court will hear oral arguments in February and March 2012; it said it will issue a ruling in June 2012. It will also cover the question of “severability;” that is, the issue of whether the entire law must fall in the event that the individual mandate is stricken. The National Federation of Independent Business expressed hope that the Court would overturn the law, saying that it was putting a damper on business growth and job creation. (more…)
Category: 11th, 4th, Health Care Legislation, HHS, PPACA, Supreme Court, Washington D.C. |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
Health plans outside of health reform’s system of state-run insurance exchanges are not required to observe the health reform law’s essential benefits package (EBP), so self-insured plans will have an option of carving out benefits in the interest of affordability. Individual and small-group policies offered through exchanges must cover the package, which includes outpatient services, emergency services, hospitalization, maternity/newborn care, mental health/substance abuse services, prescription drugs and four other categories. The EBP takes effect in March 2014. (more…)
Category: Health Care Legislation, HHS, Self-Funding |
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cmonfils | January 3, 2012
A report on Pender County’s wellness program reveals cost savings for the county in employee health care as employee health improved over three years.
County Human Resource Director Amber Parker said EbenConcepts, the county’s benefits broker, conducted a return-on-investment analysis of actual claims data of 83 county employees who participated in the county’s voluntary health screening all three years and determined that the net savings for the county, minus the cost of the screenings, is $74,576.
Category: North Carolina, Wellness |
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cmonfils | January 3, 2012
Employers are moving beyond small rewards and dangling large health insurance discounts or penalties in front of employees who must prove they can lose weight or reach other wellness measures.
Even Medicare is getting into the incentives game, now offering elderly who are obese free initial counseling and a six-month extension if they lose 6.6 pounds.
Category: Wellness |
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cmonfils | January 3, 2012
There is broad acceptance and understanding among employers that the health of their workforce can have an impact on the productivity and performance of the organization. That’s why allowing higher financial incentives to promote employee health earned a prime spot in the landmark Patient Protection and Affordable Care Act (PPACA). While this visibility is good for efforts to improve the health of employees, the specifics of what practices are allowable and the types of incentives that work best merit further discussion.
Category: PPACA |
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cmonfils | January 3, 2012
WEST BRANCH — Ogemaw County Commissioners have opted out of a new state public health insurance plan that aims to limit the amount employers contribute to employee health care.
Beverly Scott, chairman of the county’s budget and finance committee, said commissioners voted unanimously to opt out of the plan during the board’s Dec. 22 meeting. She said county employees will continue to contribute 10 percent of their health insurance costs next year.
Category: Health Insurance, Michigan |
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