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Dept. of Labor Claim Procedure Rules
by Sue Thomas, RHU, GBA
BSG Director, Contracts & Compliance
EXCERPT: "Also known as the patients’ rights claims procedure regulation, this set of rules creates new important patient protections that will ensure that group health plan participants in today’s managed care environment have access to a faster, fairer, fuller process for benefit determinations."
Full Article
1/1/03—The Benefit Services Group, Inc.
Message from Aurora Health Care
Ed Howe, President of Aurora Health Care writes: "In my conversations with employers in recent months, I've heard two clear messages. First is that the current levels of health care cost inflation are unsustainable. Second is that employers are eager to work in partnership with providers, insurers and brokers to find solutions. We at Aurora Health Care are committed to supporting these efforts. I'd like to share with you some of the things we're doing to reduce spending on health care as we improve the health of the patients and communities we serve."
Full Article
12/30/02—Aurora Health Care
IRS Revised Ruling 2002-88: Duration of COBRA Continuation Coverage and Divorce
EXCERPT: "If an employee eliminates the coverage of the employee's spouse under a group health plan in
anticipation of their divorce, when must a plan that is required to make COBRA continuation coverage available to the spouse begin to make that coverage available?"
Full
Article (See pages 15 and 16)
12/30/02—Internal Revenue Service
Employers Concerned About the Impact of Rising Health Care Costs and Are Evaluating Alternatives
EXCERPT: "Employers are concerned about the potential business impact of rising health care costs, are interested in offering new consumer-driven health plans, and would like the federal government to take helpful steps to ease double-digit cost increases, according to a new survey by global HR outsourcing and consulting firm Hewitt Associates."
Full
Article
1/14/03—Hewitt Associates
Privacy Again - Only This Time It's For Medical Records and Most Employers Have to Comply ...And Soon
EXCERPT: "In fact, by April 14, 2003, thousands of employers not in healthcare but representing virtually every other segment of our economy and work force will have to comply with at least some portion of HIPAA. The spectrum of compliance is wide-ranging, covering companies that have self-insured group plans —these are directly covered under HIPAA, and even employers that simply sponsor a health plan for employees."
Full
Article
October 2002—Nixon Peabody LLP
HIPAA Resource Web Site
The WEDI HIPAA SNIP Task Group has been established to meet the immediate need to assess industry-wide HIPAA Administrative Simplification implementation readiness and to bring about the national coordination necessary for successful compliance. Find a calendar of upcoming conferences, lists of resources, workgroups and listservs at the
WEDI SNIP web site.
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Compliance Tips for the DOL Claim Procedure Rules
Some TPAs have revised their procedures to fulfill the new requirements, but keep in mind that it is the ERISA plan sponsor and not the TPA which has the compliance obligation. Therefore, without pressure from plan sponsors, the TPAs have little incentive to redesign their procedures to comply with the regulations.
Consider asking your TPA for an amendment to the administrative services agreement. The amendment would state that the TPA agrees to process claims in accordance with the regulations and supply the necessary amendment and employee notice.
The plan sponsor is responsible for amending the plan document. Some plans have been amended, but it's worth a look to see if yours has. Check the claims section and see if there are references to urgent care, pre-service and post-service claims. If the wording is missing, call your
TPA. It is important that the amendment originate with your TPA, since procedures will vary slightly. Guidance issued by the Employee Benefits Institute of America states that, "Self-insured plan sponsors may be caught between a rock and a hard place: unable to directly dictate the details of the claim procedures used but subject to the legal compliance obligation and the adverse consequences of faulty procedures. It remains to be seen whether the courts will enforce the claim procedure requirements as strictly as the DOL currently expects, or if they will allow some room for error by plans that otherwise appear to be making a good faith effort to comply with the regulations".
The notice does not need to be in the form of an amendment to the
SPD, and the SPD does not need to include the wording. However, if you choose this method, your SPD must state that the description of the claim procedures is available as a separate document at no cost to the participant.
Find more compliance tips in this
issue's article on claim procedure rules.
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By providing links to other
sites, The Benefit Services Group, Inc. does not guarantee, approve or
endorse the information or products available at these sites, nor does a
link indicate any association with or endorsement by the linked site to
The Benefit Services Group, Inc.
The preceding is not
intended to be and is not offered as legal advice. We are prohibited
from the practice of law. Compliance is the responsibility of the
employer or Plan sponsor and affected employees, who should seek their
own legal counsel regarding questions about information presented in
this newsletter.
PlanAhead Direct is a
monthly newsletter provided free of charge to select BSG® client
representatives and associates. View and search back issues at www.bsg.com/news/index.htm.
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Copyright 2003 The Benefit Services
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Group, Inc.
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