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 »
Tags:
cmonfils | November 16, 2011
Employer’s Guide to Self-Insuring Health Benefits October 2011 | Vol. 19, No. 1
The Four-Page Mini-SPD: Coming to a Plan Near You, By Adam V. Russo, Esq. & Ron E. Peck, Esq.
New proposed rules explaining the health reform law explain how employers and insurers must provide Summaries of Benefits and Coverage (SBCs), which every plan and insurer will have to give to plan members starting in March 2012. SBCs must disclose: definitions of insurance and medical terms; descriptions of coverage provisions, benefits and limitations; cost-sharing provisions; and more. On one hand, they may be useful because the four-page summary will be very easy for members to read and for sponsors to distribute, Contributing Editor Adam Russo and Attorney Ron Peck say. On the other, they swim against the stream of the history of ERISA litigation, which has pushed sponsors into ever more detailed plan documents and summary plan descriptions. (more…)
Category: Summary Plan Description |
No Comments »
Tags:
cmonfils | November 16, 2011
In our prior blog, we explained that under principles of triage, employers may need to focus on the current annual enrollment and wait to take care of the Summary of Benefits and Coverage (“SBC”). Although the SBC does not need immediate attention, we caution employers not to wait too long or take the SBC responsibilities too lightly. The penalties for failing to satisfy the SBC requirements are severe. This blog will explain what those penalties are and the steps to take to avoid them. In a subsequent blog, we will provide more details regarding specific content requirements and the different groups of people who must be given the SBC.
Category: ERISA, Health Care Legislation, Plan Language, PPACA, Self-Funding, Summary Plan Description |
No Comments »
Tags:
cmonfils | September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
By Jack B. Helitzer, Esq.
This issue of the Newsletter features a unique legal strategy used by a participant’s attorney who claimed that the auto liability insurer and the plan abused a plan member’s protected health information (PHI), when pursuing a subrogation claim. That approach raises the question of how plans can prevent subrogation situations from violating privacy laws. Well-drafted summary plan descriptions (SPDs) should include the plan’s privacy policies, including when PHI may be disclosed. One feasible approach may be for the plan’s subrogation and reimbursement provisions to cross-reference to the plan’s privacy provisions, and to have those provisions state that PHI can be shared with other insurers for benefits coordination. In addition, the plan’s privacy provisions should state that PHI may be disclosed to support a reimbursement claim. (more…)
Category: PHI, Subrogation, Summary Plan Description |
No Comments »
Tags:
cmonfils | September 16, 2011
The Self-Insurer August 2011
From the Bench Michael Friedman and John Eggertsen
The U.S. Supreme Court, in GIGNA Corp v. Amara, et al., 563 U.S., 2011 WL 1936077 (May 16, 2011), revisited, and likely expanded, the scope of equitable remedies available under ERISA § 502 (a)(3). The Court also rejected Plaintiff’s effort to sue under the terms of the SPD as opposed to the terms of the actual ERISA plan document. (more…)
Category: 2nd, 9th, ERISA, Summary Plan Description, Supreme Court |
No Comments »
Tags:
cmonfils | September 16, 2011
www.smarthr.blogs.thompson.com
September 14, 2011 – 12:42 pm | By Todd Leeuwenburgh | No comments yet
Health care reform is still alive and kicking. Employer-sponsored health plans have implemented many of its thorny provisions, but one provision now looks like the biggest thorn of all.
We are talking about Section 2715 of the Patient Protection and Affordable Care Act (PPACA). You must, of course, know all about this section … no? Well, Section 2715 explains how employers and insurers are supposed to provide “Uniform Explanation of Coverage Documents.” (more…)
Category: ERISA, Health Care Legislation, PPACA, Summary Plan Description |
No Comments »
Tags:
cmonfils | August 31, 2011
www.mckennalong.com
August 22, 2011
Proposed health care reform regulations issued on August 17, 2011, by the Departments of Labor, Health and Human Services, and Treasury (the “Departments”) impose new rules on group health plans and individual and group health insurers that are intended to enable consumers to more easily understand the health coverage they have, and make apples-to-apples comparisons of available options. These rules are intended to carry out certain provisions of last year’s health care reform that required the Departments to develop standards for plans and insurers to compile and provide an accurate summary of benefits and coverage. These rules apply to both grandfathered and non-grandfathered health plans. Failure to comply may result in significant monetary penalties. (more…)
Category: DOL, HHS, Summary Plan Description |
No Comments »
Tags:
cmonfils | August 31, 2011
www.lrlaw.com
August 19, 2011 Peter Wand, David Manch
The Department of Labor recently announced plans to substantially increase the number of ERISA compliance audits it conducts each year. This is the first in a series of Client Alerts that Lewis and Roca LLP will publish over the coming months to help our clients evaluate their compliance with ERISA and related federal mandates, including COBRA, HIPAA and the Patient Protection and Affordable Care Act of 2010. (more…)
Category: DOL, ERISA, Plan Documents, Summary Plan Description |
No Comments »
Tags:
cmonfils | August 22, 2011
Coordination of Benefits Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
By Jack B. Helitzer, Esq.
This issue of the Newsletter features a unique legal strategy used by a participant’s attorney who claimed that the auto liability insurer and the plan abused a plan member’s protected health information (PHI), when pursuing a subrogation claim. That approach raises the question of how plans can prevent subrogation situations from violating privacy laws. Well-drafted summary plan descriptions (SPDs) should include the plan’s privacy policies, including when PHI may be disclosed. One feasible approach may be for the plan’s subrogation and reimbursement provisions to cross-reference to the plan’s privacy provisions, and to have those provisions state that PHI can be shared with other insurers for benefits coordination. In addition, the plan’s privacy provisions should state that PHI may be disclosed to support a reimbursement claim. (more…)
Category: ERISA, PHI, Subrogation, Summary Plan Description |
No Comments »
Tags:
cmonfils | August 22, 2011
The Self-Insurer August 2011
From the Bench Michael Friedman and John Eggertsen
The U.S. Supreme Court, in GIGNA Corp v. Amara, et al., 563 U.S., 2011 WL 1936077 (May 16, 2011), revisited, and likely expanded, the scope of equitable remedies available under ERISA § 502 (a)(3). The Court also rejected Plaintiff’s effort to sue under the terms of the SPD as opposed to the terms of the actual ERISA plan document. (more…)
Category: 9th, ERISA, Summary Plan Description, Supreme Court |
No Comments »
Tags:
cmonfils | August 8, 2011
www.myhealthguide.com
Uniform Summary of Benefits and Coverage — Due March 23, 2012
MyHealthGuide Source: Gallagher Benefit Services, Inc., 7/ 2011, www.gallagherbenefits.com
A much-anticipated requirement under the Patient Protection and Affordable Care Act (PPACA) is the introduction of the “Uniform Summary of Benefits and Coverage Explanation” (Summary).
The primary purpose of the Summary is for use by health insurance Exchanges that will be available in 2014. However, because consumers will be comparing coverage available outside of the Exchanges, its use is required by all health insurers and group health plans. (more…)
Category: HHS, PPACA, Summary Plan Description |
No Comments »
Tags:
cmonfils | July 11, 2011
www.ebn.benefitsnews.com By Shana Sweeney July 1, 2011
How well do your employees really understand their health plan? Do you know the readability score of the materials you provide them? How much jargon is included in your summary plan descriptions? How do you educate new grads entering the workforce and individuals working in the U.S. for the first time on the intricacies of health insurance? Is it even an employer’s responsibility to improve health literacy? (more…)
Category: HHS, Summary Plan Description |
No Comments »
Tags:
cmonfils | July 4, 2011
www.cooley.com 6/22/11
The U.S. Supreme Court in CIGNA Corp. v. Amara1 has reshaped the remedies for an employer’s breach of its ERISA fiduciary obligations in a way that likely will prove to be a mixed blessing for plan sponsors. The Court unanimously held that the remedy under ERISA Section 502(a)(1)(B) to enforce “the terms of the plan” is not available for inaccurate or misleading statements in a summary plan description (“SPD”) or other communications about plan terms2. (more…)
Category: Summary Plan Description, Supreme Court |
No Comments »
Tags:
cmonfils | June 7, 2011
www.orrick.com
The Supreme Court’s recent decision in CIGNA Corp. v. Amara, No. 09-804, 563 U.S. ____ (2011) has important implications for plan sponsors and those involved in benefit plan administration. In Amara, the Supreme Court held that ERISA does not grant the ability to a court to “reform” a plan to change plan terms to match those in a summary plan description (SPD), and that claims for benefits by plan participants under ERISA cannot be based on incorrect information in SPDs. The Court clearly held that the formal plan document, not the SPD or other informal benefits communications, controls the provision of benefits under the plan. If the Court had ended its analysis there, the decision would be an outright victory for plan sponsors. (more…)
Category: Plan Language, Summary Plan Description, Supreme Court |
No Comments »
Tags:
cmonfils | May 26, 2011
www.healthplanlaw.com Roy Harmon III May 17, 2011 ·
Why the Court embarks on this peculiar path is beyond me. It cannot even be explained by an eagerness to demonstrate — by blatant dictum, if necessary — that, by George, plan members misled by an SPD will be compensated. (more…)
Category: ERISA, Plan Language, Summary Plan Description, Supreme Court |
No Comments »
Tags:
