Posted By bhoffman on July 20, 2010
HCAA, www.hcaa.org
Long-awaited regulations under the grandfather provisions of Section 1251 of the Patient Protection and Affordable Care Act (PPACA) were formally issued by the Departments of Health and Human Services, Treasury and Labor (the “agencies”) on June 14, 2010. The regulations are in the form of an interim final rule, and are effective immediately. They were published in the Federal Register on June 17, 2010. Comments on the regulations are due 60 days after publication in the Federal Register. (more…)
Category: Health Care Legislation |
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Posted By bhoffman on July 20, 2010
By Daran P. Keifer, Kreiner & Peters Co.
2009 was a rough year for subrogation rights in the United States, as we saw many more bills across the various states and even in Congress, which sought to undermine or eliminate subrogation rights. NASP continues to expand its influence as the premier resource for education about “subrogation” and its importance to society. Your Amicus Committee’s efforts in various states prompted other organizations to consult and rely on NASP for education about the vital role subrogation plays. The first quarter of 2010 continued the frenetic pace at which states sought to restrict subrogation rights while strengthening NASP position within the insurance community. (more…)
Category: Subrogation |
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Posted By bhoffman on July 19, 2010
www.seethebenefits.com
There is a well-known saying among baseball fans that the “tie goes to the runner.” This is true under one baseball rule that provides that a batter is out if he or the base is tagged before he reaches first. It is not true, however, under another rule that provides that a runner is out when he fails to reach the next base before a fielder tags him or the base. So, the answer depends on the situation, which rule the umpire applies, and who the umpire is. (more…)
Category: ERISA, Fiduciary Liability, Plan Language, Summary Plan Description |
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Posted By bhoffman on July 19, 2010
More and more small and midsize companies are looking to get off the insurance grid and cover their own employee health-care claims.
By Alix Stuart, www.CFO.com
Want to save money on health-care insurance? Try this strategy: stop buying it.
While self-insurance is nothing new to large companies — some 90% of those with more than 5,000 employees have been doing it for years — a growing number of smaller companies are self-insuring to cut co sts. According to data collected by PricewaterhouseCoopers, the percentage of employers with fewer than 1,000 people in their health-care programs that self-insure has almost doubled, from 29% in 2008 to 48% in 2010. (more…)
Category: Stop Loss, Welfare Benefit Plans |
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Posted By bhoffman on July 19, 2010
CCH® BENEFITS, www.hr.cch.com
On July 1, the Employee Benefit Security Administration provided a temporary safe harbor for outpatient mental health benefit provisions that commonly require a copayment for office visits (for example, physician or psychologist visits) but coinsurance for other outpatient services (for example, outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items). (more…)
Category: ERISA, Mental Health Parity |
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Posted By bhoffman on July 19, 2010
www.thompson.com
Health Net of Connecticut, Inc. agreed to pay $250,000 to resolve a HIPAA privacy lawsuit by the state of Connecticut that was the first to be filed under HIPAA’s recently added state enforcement powers. Connecticut Attorney General Richard Blumenthal had sued Health Net in January over a major data breach that the insurer suffered in May 2009. (more…)
Category: Connecticut, HIPAA |
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Posted By bhoffman on July 15, 2010
HCAA, www.hcaa.org
Fact Sheet: Keeping the Health Plan You Have: The Affordable Care Act and “Grandfathered” Health Plans
The Affordable Care Act gives American families and businesses more control over their health care by providing greater benefits and protections for family members and employees. It also provides the stability, and also the flexibility, that families and businesses need to make the choices that work best for them. (more…)
Category: Health Care Legislation |
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Posted By bhoffman on July 15, 2010
SIIA, www.siia.org
Departments of Labor, Treasury and Health and Human Services Jointly Release Interim Final Rule on Coverage of Preventative Services
The Departments of Labor, Treasury and Health and Human Services this afternoon jointly released an interim final rule on requirements to cover preventative services. (more…)
Category: Health Care Legislation |
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Posted By bhoffman on July 14, 2010
R. E. Moulton, Inc. is pleased to announce the availability of an unlimited specific coverage reimbursement option for American United Life Insurance Company® (AUL) stop loss insurance policyholders, effective immediately. Additionally, for AUL policyholders requiring a maximum specific benefit, R.E Moulton will continue providing annual maximums with options of up to $10 million in coverage. (more…)
Category: Stop Loss |
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Posted By Adam V. Russo on July 9, 2010
Business Insurance, www.businessinsurance.com
We’re disappointed that the Supreme Court ducked the opportunity to resolve the legality of “play-or-pay” laws once and for all.
As we report on page 4, the court last week declined to review a lower court decision upholding San Francisco’s health care spending law. (more…)
Category: California, Health Care Legislation |
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Posted By Adam V. Russo on July 9, 2010
By Julie Appleby, Kaiser Health News
When John McNally needed a knee-replacement operation, his employer, Alpha Coal West, offered to pay his travel expenses if he would have the surgery in Fort Collins, Colo., a five-hour drive from his home near Gillette, Wyo.
The Colorado surgery center had data showing good results with such operations, and it charged far less than the hospital in Gillette. Despite feeling “every bump on the way back,” McNally was so pleased with the outcome of the operation that he returned to Colorado a few months later to have his other knee done. (more…)
Category: Medical Tourism |
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Posted By Adam V. Russo on July 9, 2010
By Matt McClellan, Smart Business Detroit
There are two predominant options for health plan funding in the marketplace: the traditional, fully funded option, and the self-funded model.
While most people think of the fully funded option when they think of insurance, Don Whitford, vice president of sales at Priority Health, says self-funding may be a better option for some employers. (more…)
Category: Welfare Benefit Plans |
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Posted By Adam V. Russo on July 9, 2010
In Kehoe v. 1st Source Bank Healthcare Benefits Plan,190 the court affirmed an ERISA plan administrator’s denial of health coverage where claimant had a blood alcohol level of 0.128, as tested at the treating hospital, and the plan excluded “[c]harges resulting from an illness or injury incurred while under the influence of alcohol or illegal drugs as evidenced by a blood alcohol level equal to or in excess of the legal amount allowed in the state where injury occurs or any other drug or alcohol screening test.”191 The court rejected claimant’s contention that de novo review applied because the administrator’s decision “was so unusual that [it] went beyond simply interpreting the Plan and, instead, modified the Plan’s terms and conditions.”192 The court held that the administrator’s interpretation of the exclusion did not modify the plan’s language, which did not require illegal consumption of alcohol to trigger the exclusion but rather than an injury incurred while “under the influence,” an objective standard based on state law.193 The court further held that the administrator’s claim decision was not arbitrary and capricious because it was not unreasonable to incorporate the Indiana motor vehicle intoxication statue, defining 0.08 as the minimum BAC for legal intoxication.
Category: Claims Review, Exclusion, Indiana |
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Posted By Adam V. Russo on July 9, 2010
This year, while the Sixth Circuit held that an illegal act exclusion could not be applied because of a lack of causation between the illegal act and the injuries for which benefits were sought, an Indiana district court found that an administrator’s decision to deny health benefits based on a plan exclusion was “not reasonable” even though it did not require the injury for which benefits are sought to be caused by the insured’s intoxicated state. In Shelby County Health Care Corp. v. Majestic Star Casino, LLC,184 plaintiff, acting pursuant to an assignment from its patient, challenged the ERISA plan administrator’s decision to deny the patient health insurance benefits. Plaintiff claimed that defendant improperly denied benefits for medical charges incurred by this patient, a plan insured, after he sustained injuries in a single-car accident while driving without a driver’s license or proof of insurance.185 Defendant denied benefits under the plan’s “illegal-act provision,” which excluded benefits for “any loss caused by, incurred for, or resulting from…[c]harges for or in connection with any injury or illness arising out of…the commission or attempted commission of an illegal or criminal act.”186 After rejecting the defendant’s attempt to assert a different basis for denial of benefits than that asserted by the claims administrator, the Sixth Circuit agreed with the district court that the term “illegal act” was ambiguous since it was undefined in the policy.187 It then found that a reasonable interpretation of “illegal act” might not include driving without insurance or driving without a license.188 Ultimately, since the record provided “no support for the assertion that driving without a license or driving without insurance ‘caused’ [the] accident and resulting injuries,” the Sixth Circuit upheld the finding that plaintiff erred in denying the claim for benefits.
Category: 6th, Exclusion, Summary Plan Description |
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Posted By Adam V. Russo on July 9, 2010
In addressing the contents of the administrative record that must be disclosed to a claimant, the court in Mondry v. American Family Mutual Insurance Co. concluded that a claim administrator’s internal documents and guidelines could be subject to mandatory production in ERISA cases if the claims administrator expressly cites to such documents and equates them to plan language when ruling on a claim for benefits. The letters denying plaintiff’s claim for benefits cited documents other than the SPD as the basis for the plan’s denial of her claim, and the reasoning behind the denials turned on language that did not appear in the SPD. The claims administrator initially refused to produce the documents requested by plaintiff, even when the plan administrator intervened on her behalf, but eventually relented. The documents showed that denial of plaintiff’s claim was improper and the claims administrator reversed it. The court further found that the plan administrator, even though it did not have direct control over the documents, could be liable for failing to produce them because it could have included in its contract with the claims administrator the right to obtain copies of any documents that it might be required to produce under ERISA. The Seventh Circuit also confirmed the documents at issue fell within scope of 29 U.S.C. § 1024(b)(4) and held that a plan fiduciary that fails to make the disclosures required by ERISA breaches its fiduciary duties to a participant like plaintiff.
Category: 7th, ERISA |
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