cmonfils | January 20, 2012
Excela Health entered the Great Recession as the largest mental health provider for the Pennsylvania county that’s home to its three hospitals.
A year and a half later, as the recession drew to a close, Excela began to refer and transfer outpatient mental health patients to primary-care doctors and community clinics to stem losses.
cmonfils | January 5, 2012
CHIP –AL, AK, CA, ID, IL, OA, KS, LA, MI, NJ, NM, OH, OR, WA, WI
Dec. 28 (Bloomberg) — Twenty-three states will share $296.5 million in U.S. payments for encouraging low-income families to enroll their children in public health programs.
Bonuses announced today reward states that streamline eligibility for Medicaid, the federal-state health program for the poor, or the Children’s Health Insurance Program. The effort is aimed at children younger than 19 from households with annual incomes of as much as $45,000 for a family of four, though some states have more generous criteria.
cmonfils | November 8, 2011
TRENTON, N.J.—Advocates of self-funding health benefits are fighting an attempt by New Jersey regulators to crack down on the practice among small businesses, saying it is part of a broader attack on self-insurance at the state and national levels.
cmonfils | October 27, 2011
In a strongly-worded letter addressed today to New Jersey Insurance Commissioner Thomas Considine, the Self-Insurance Institute of America, Inc. (SIIA) requested that Insurance Department Bulletin No. 11-20 (Selected Marketing of Stop-Loss Insurance) be rescinded immediately.
cmonfils | September 19, 2011
CCH® BENEFITS — 09/01/11
from Spencer’s Benefits Reports: According to the Kaiser Family Foundation’s State Health Facts, 23 states have established American Health Benefit Exchanges under the Patient Protection and Affordable Care Act (ACA), have enacted legislation with the intent to establish an Exchange, or have Exchange legislation pending.
Massachusetts and Vermont have established Exchanges, while California, Colorado, Connecticut, Hawaii, Maryland, Nevada, Oregon, Vermont, Washington, and West Virginia have enacted legislation to establish an Exchange. Hawaii’s Exchange will be a nonprofit, Vermont Exchange will be operated by the state. The rest of the Exchanges will be quasi-governmental.
The Exchange will be a clearinghouse and contract with all qualified health plans in Colorado and Hawaii. In California, Connecticut, Oregon, and Vermont, the Exchange will be an active purchaser contracting with selected health plans and/or negotiating premium prices with health plans. The other states have not yet decided the type of Exchange they will operate.
In Illinois, Indiana (by executive order of the governor), North Dakota, and Virginia, legislation has established the intent to set up an Exchange, while Alabama (by executive order of the governor), Georgia (by executive order of the governor), Mississippi, and Wyoming will study the feasilibility of an Exchange.
The District of Columbia, New Jersey, North Carolina, and Pennsylvania have Exchange legislation pending.
For more information, visit http://statehealthfacts.kff.org/comparemaptable.jsp?ind=962&cat=17.
Rate Review Programs
The federal government will either conduct or assist health insurance rate reviews in nine states, according to the most recent fact sheet from the Center for Consumer Information and Insurance Oversight (CCIIO), which discusses the rate review requirements included in the ACA.
According to the CCIIO, as of Aug. 15, 2011, state rate review procedures were as follows:
43 states, the District of Columbia, and one U.S. territory have effective rate review in at least one insurance market;
41 states, the District of Columbia, and the U.S. Virgin Islands have effective review for all insurance markets and issuers.
In two states (Virginia, Pennsylvania), the federal government will partner with the state to conduct reviews; and
The federal government will conduct reviews in seven states (Wyoming, Montana, Missouri, Louisiana, Idaho, Arizona, and Alabama) and four U.S. territories (American Samoa, Guam, Northern Marianas Islands, and Puerto Rico) until those areas are able to strengthen their review processes and authorities.
Starting Sept. 1, 2011, insurers seeking rate increases of 10% or more for non-grandfathered plans in the individual and small group markets are required to publicly disclose the proposed increases and the justification for them.
For more information, visit http://cciio.cms.gov/resources/factsheets/rate_review_fact_sheet.html.
cmonfils | July 11, 2011
Stark & Stark, attorneys for appellant (Kevin M. Bradway, on the brief).
Paula T. Dow, Attorney General, attorney for respondent (Lewis A. Scheindlin, Assistant Attorney General, of counsel; Stephanie L. Meredith, Deputy Attorney General, on the brief).
Before Judges Axelrad, R. B. Coleman, and Lihotz. (more…)
cmonfils | July 11, 2011
The Subrogator Spring/Summer 2011
By Kammy Poff, Allstate Insurance Company, Roanoake, VA and Daran Kiefer, Kreiner and Peters Co., LPA, Cleveland, OH
Bills/Legislation
In February of this year, the National Association of Subrogation Professionals (NASP) embarked on a trip to Pierre, South Dakota. House Bill 1184 had just passed in the South Dakota House of Representatives and was on its way to the Senate. NASP was slated to testify before the Senate Judiciary Committee. House Bill 1184 needed to be stopped in the Senate. (more…)
cmonfils | June 21, 2011
www.benefitspro.com By Angela Delli Santi, Beth DeFalco
TRENTON, N.J. (AP) — Bucking the state’s powerful public employee unions, the New Jersey Senate on Monday passed a bill requiring sharply higher contributions for health benefits and pensions from more than a half-million government workers, while suspending unions’ ability to bargain over health care. (more…)
Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
We are familiar with cases where ERISA and state laws conflict. As we know, self-insured health plans that are subject to ERISA may avoid the application of state laws because of ERISA preemption. As we have seen in our analysis of the case Bash v. State Farm Mutual Automobile Insurance Co. on page 11 of this Newsletter, the objectives of ERISA sometimes conflict with the objectives of state laws. (more…)
Adam V. Russo | August 25, 2010
Coordination of Benefits Handbook
Medicare clearly has a right of reimbursement of payments it made for medical services when a third party is determined to have responsibility for those expenses. 42 U.S.C. 1395y(b)(2). New Jersey’s collateral source rule provides that if a person receives benefits for injuries from any source other than a joint tortfeasor, those benefits shall be disclosed to the court and the amount that duplicates any benefit contained in the award shall be deducted from any award recovered by that person. (N.J.S.A. 2A:15-97). A recent decision of the Appellate Division of the Superior Court of New Jersey considered how those two statutes interact. The case is Jackson v. Hudson Court, LLC, 2010 WL 2090036 (N.J. Super, App. Div., May 24, 2010). (more…)
Adam V. Russo | January 29, 2010
January 22, 2010 (PLANSPONSOR.com) – A federal court has refused to dismiss a claim by a Jersey Construction employee that he was fired for pursuing health benefits for his wife’s chemotherapy.
The U.S. District Court for the District of New Jersey said it found that Christian Pailleret stated sufficient facts to support a prima facie case under § 510 of the Employee Retirement Income Security Act (ERISA). The court said Pailleret had no “smoking gun” evidence of intent, but the fact that almost immediately after he submitted medical claims of tens of thousands of dollars, he was assigned low-level and “degrading” tasks and shortly after that was terminated without notice or explanation was sufficient to show a plausible claim and “to thus unlock the doors of discovery.” (more…)
Adam V. Russo | February 4, 2009
Forty-seven states ban in-network providers from billing insured patients more than their required copayment or deductible and federal law prohibits providers from billing Medicare beneficiaries for unpaid balances. Some states also ban additional charges for insured patients who seek care from out-of-network providers and emergency departments. While national statistics on the practice are unavailable, economists and patient advocates estimate that consumers pay at least $1 billion annually for medical bills that they are not legally responsible to pay. (more…)
Adam V. Russo | June 11, 2008
Colorado:
June 5, 2008, Colorado Governor, Bill Ritter approved Senate Bill 11, abolishing subrogation for all medical payment coverage under auto insurance policies to be in effect of January 1, 2009. The new Colorado law will be in effect as of January 1, 2009. (more…)
Adam V. Russo | November 13, 2007
On September 25, 2007, a Federal District Court in New Jersey held in Mulholland v. UFCW Local 1776 Participating Employers Health and Welfare Fund, 2007 WL 2814648 (DNJ) that the purchase of stop loss insurance does not preclude self-funded ERISA status. The court went on to say that because self-funded plans can come close to becoming a fully insured plan, the question is not whether a self-funded plan has reinsurance, but rather, how high is their specific deductible. In other words, does the self-funded plan retain considerable risk of loss, or, does the Plan purchase an excessive amount of stop-loss insurance? (more…)
