cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits    January 2012 | Vol. 19, No. 4

Expenses incurred for gender reassignment surgery and hormone therapy are now deductible medical expenses under Code Section 213.

 The IRS announced in Action on Decision (AOD) 2011-03 that it has acquiesced to a 2010 Tax Court ruling that these expenses are deductible. The AOD appeared in the Nov. 21 Internal Revenue Bulletin. See: http://www.irs.gov/pub/irs-aod/aod201103.pdf.  (more…)

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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits      January 2012 | Vol. 19, No. 4 

As illustrated here, ERISA did not preempt the Washington Mental Health Parity Act. 

Even though it correctly applied an insured ERISA plan’s coverage restrictions on neurodevelopmental therapy for children over six years old, the administrator’s refusal to pay a 10-year-old dependent’s mental health treatment violated a state law that bound insurers and HMOs. (more…)

Category: ERISA, Health Care Legislation, Mental Health Parity, PPACA, Preemption, Supreme Court, Washington | No Comments »
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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits       January 2012 | Vol. 19, No. 4

The effect of the Mental Health Parity and Addiction Equity Act (MHPAEA) on prior authorization practices and other “nonquantitative treatment limitations” was clarified Nov. 17 in guidance from the U.S. Department of Labor (DOL).  (more…)

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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits        January 2012 | Vol. 19, No. 4 

A claims administrator lost an attempt to dismiss negligence and breach of contract charges relating to its failure to process and pay a large claim before the final day of a stop-loss policy’s run-out period. 

The self-insured Hebrew Home health plan sued administrator CoreSource and stop-loss insurer Sun Life for negligence and breach of contract under state law, alleging that the administrator dragged its feet paying the claim and ended up missing a March 31 deadline that would have enabled the plan to collect $180,000 in stop-loss reimbursement. (more…)

Category: 4th, ERISA, Maryland, Preemption, Stop Loss | No Comments »
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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits         January 2012 | Vol. 19, No. 4 

Most self-insured governmental plans adopt ERISA principles in governing trusts, and use ERISA-style plan documents and summary plan descriptions (SPDs). However, just because they look to ERISA for guidance when crafting programs, they would be mistaken to assume they have ERISA-style rights. 

In Daugherty v. Wayne County Bd., 2011 WL 5028365 (Ohio App. 9 Dist., Oct. 24, 2011), a self-insured county health plan argued that because it reserved itself discretionary authority in the SPD, that its disputed denials should be entitled to a more favorable review in court.  (more…)

Category: ERISA, Ohio, Self-Funding, Summary Plan Description | No Comments »
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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits        January 2012 | Vol. 19, No. 4 

The U.S. Department of Labor (DOL) on Dec. 5 proposed new enforcement and oversight rules targeting Multiple Employer Welfare Arrangements (MEWAs). Officers who ran sham MEWAs were using plan funds improperly, absconding with funds and disappearing to set up fraudulent entities in other states, DOL Assistant Secretary Phyllis Borzi said. Under the proposed rules: (1) MEWAs would register with DOL before starting business in a state; (2) they would file the Form M-1 with DOL, regardless of their size; (3) DOL could issue cease-anddesist orders against MEWAs without prior notice or hearings, if they commit fraud and abuse; and (4) DOL would gain fast-track power to seize assets from a MEWA when there is probable cause that the plan is financially unstable. This would enable DOL to preserve plan assets before they’re totally dissipated, she said.  (more…)

Category: DOL, Health Care Legislation, PPACA | No Comments »
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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits     January 2012 | Vol. 19, No. 4 

In a surprising decision, the 3rd U.S. Circuit Court of Appeals used the concept of “appropriate equitable relief” to restrict an employer-sponsored health plan’s recovery from a third-party settlement. Full reimbursement of what the plan paid out would have been “inappropriate and inequitable,” even though the plan had asserted recovery rights over any monies collected from a third party. Full recovery would have been unfair because: (1) the plan participant’s recovery ended up being less than what the plan paid after attorney’s fees were deducted; and (2) the plan never intervened in the third-party recovery. The outcome diverges from many recent cases, which upheld plans’ claims on total proceeds, regardless of whether the plan participant was “made whole” or had money to pay attorney’s fees.  (more…)

Category: 3rd, Common Fund, ERISA, Pennsylvania, Reimbursement, Subrogation, Third Party Agreements | No Comments »
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cmonfils | January 18, 2012

Employer’s Guide to Self-Insuring Health Benefits        January 2012 | Vol. 19, No. 4 

Sponsors and administrators of employer-sponsored health plans will spend lots of 2012 in implementing the health reform law, because there’s still a lot of uncertainty that will decide the fate of self-funded health plans in particular. Plans will have to raise annual limits on essential benefits (as defined by reform rules) to $2 million starting next Sept. 23. Plans won’t have to pay new fees to fund comparative effectiveness research in 2012. But 2012 will be the year plans learn the payment frequency of and the method used to calculate the fees they will start paying in 2013. Similarly, plans won’t have to start issuing summaries of benefits and coverage (SBCs) to all participants, but they will be waiting and watching for rules about the SBC to develop, so they know how to satisfy that requirement.  (more…)

Category: Accountable Care Organizations, DOL, Health Care Legislation, HHS, Medicare, Plan Sponsor, PPACA, PPOs, Third Party Administrators | No Comments »
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