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|
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The White House News: New ERISA Chief for USA:
"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor
for Employee Benefits Security, Department of Labor"
Excerpt: "Until January 1995, [Phyllis] Borzi served as pension and employee
benefit counsel for the U.S. House of Representatives, Subcommittee on
Labor-Management Relations of the Committee on Education and Labor. She was
on the Committee staff for 16 years. . . . . Borzi has published numerous
articles on ERISA, health care law and policy and retirement security issues
and is a frequent speaker on programs sponsored by legal, professional,
business, consumer and state and local governmental organizations. An active
member of the American Bar Association, Borzi is the current chair of the
ABA's Joint Committee on Employee Benefits . . . ."
Excerpt: "President Obama on Tuesday during a
prime-time news conference linked issues within the U.S. budget in part
to high health care costs, stating that 'almost every single person' who
has examined the nation's budget has concluded that the government must
find a way to reduce health care costs, the Washington Post reports
(Shear/Wilson, Washington Post, 3/25)."
Comments from Jin Zhou:
Fixing healthcare without addressing ERISA,
the law 100% governing more than 90% of non-Medicare claims in USA, is
Impossible - Jin Zhou
ERISA laws will be definitely enforced by this new ERISA Chief.....
ERISA appeals and practice will mean more than ever before....
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Enforcement News from DOL |
 |
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Fact Sheet - EBSA Achieves Total Monetary Results
Exceeding $1.7 Billion
(DOL, January 2006)
"Through its enforcement of the Employee Retirement
Income Security Act (ERISA), the Employee Benefits
Security Administration (EBSA) is responsible for
ensuring the integrity of the private employee benefit
plan system in the United States. EBSA’s oversight
authority extends to approximately 730,000 pension plans
and another 6 million health and welfare plans. These
plans cover approximately 150 million workers and their
dependents and include assets of more than $4
trillion.......
Record $88.4
Million Restored to Workers through Informal Complaint
Resolution
When workers
experience a problem with an employee benefit plan,
EBSA has proven effective
in resolving their requests for assistance. In FY 2005,
EBSA’s Benefits Advisors
handled nearly 160,000 inquiries and recovered $88.4
million in benefits on behalf of workers and their
families through informal resolution of individual
complaints. Many of these inquiries were received via
EBSA’s toll-free number:
1.866.444.EBSA (3272) and Web site:
www.askebsa.dol.gov.
These inquiries
are also a major source of enforcement leads. When
EBSA becomes aware of
repeated complaints with respect to a particular plan,
employer, or service provider, or when there is
information indicating a suspected fiduciary breach, the
matter is referred for investigation. In FY 2005, 1,067
new investigations were opened as a result of referrals
from Benefits Advisors."
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|
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FAQs
about the UnumProvident Settlement
"What is the UnumProvident Settlement about?
The insurance regulators of all fifty states, the District of
Columbia, and American Samoa participated in an examination of the
claims handling practices of Unum Life Insurance Company of America,
The Paul Revere Life Insurance Company, and Provident Life and
Accident Insurance Company, the three disability insurers owned by
UnumProvident Corp. The U.S. Department of Labor conducted a related
investigation of UnumProvident’s practices involving employee benefit
plans covered by the Employee Retirement Income Security Act. As a
result of the examination and the DOL investigation, the three
UnumProvident companies mentioned above plus First Unum Life Insurance
Company, their New York affiliate, entered into a Settlement Agreement
requiring the companies to change their claims practices and to
reassess certain long term disability claims going back as far as
1997."
Advisory Opinions:
2005-02A,
ERISA Sec. 103, 02/24/2005
"Regarding the Schedule
A (Form 5500) requirements for reporting fees and commissions
paid to brokers, agents and other persons directly or
indirectly attributable to policies or contracts placed or
retained with or by an ERISA-covered employee benefit plan."
Final Regulations for HIPAA Health Coverage Portability
•
Model
Certificate •
Press Release
Health Care Continuation Coverage; Final Rule [Rules and Regulations]
[05/26/2004] |
[PDF Version]| [Notices]
| [Press
Release]
Release Date: 10/21/2004
"EBSA closed 4,399 civil
investigations in FY 2004. Nearly 70% of those investigations
resulted in correction of violations under the Employee
Retirement Income Security Act (ERISA).
Criminal investigations led to the indictment of 121
individuals. In addition, EBSA received a record 474
applications to participate in its compliance assistance program
to help employers and plan officials to voluntarily correct
specific violations of the law."
"This legislation is especially necessary for
the nation's millions of small businesses, creating a level
playing field and giving them the same benefits of administrative
savings, negotiating clout, and uniform regulation enjoyed by
large businesses and labor unions."
EBSA Achieves Record $3.1 Billion in Fiscal Year
2004 Results
•
Press Release
"Atlanta, Georgia - The U.S. Department
of Labor has obtained a preliminary injunction removing the
trustees of the Paramount, California-based International Union of
Industrial and Independent Workers Benefit Fund (IUIIW) and
permanently barring them from service to the fund."
DOL Health Benefits Education Campaign
[New
Seminars:
IL,
NY,
KY]
DOL
Launches National Education Campaign "Getting It Right-Know Your
Fiduciary Responsibilities" •
Labor Department
Releases Form 5500 Annual Report and Filing Requirements for
2004
Press Release EBSA News Release: [05/18/2004]
DOL
Advisory Opinion on Certain Contributions to Health Savings
Accounts (HSAs) (U.S. Employee Benefits Security
Administration)
Employee Benefits Security Administration Issues Field
Assistance Bulletin on Health Savings
Field
Assistance Bulletin 2004-1 "Whether
Health Savings Accounts established in connection with
employment-based group health plans constitute "employee
welfare benefit plans" for purposes of Title I of ERISA?"
Text of Final
HIPAA Portability Regulations (PDF) (Internal
Revenue Service, Employee Benefits Security Administration,
Centers for Medicare & Medicaid Services)
Final Regulations for HIPAA Health Coverage
Portability •
Model
Certificate •
Press
Release
|
|
Seminars are scheduled for Florida, Ohio,
Massachusetts and Arizona, beginning in June 2004. The program
will emphasize the obligation of plan sponsors and other
fiduciaries to: |
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Understand the terms of
their plans; |
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Select and monitor service
providers carefully; |
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Make timely contributions
to fund benefits; |
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Avoid prohibited
transactions; and |
|
Make
timely disclosures to workers and their beneficiaries and
reports to the government. |
|
Meeting Your Fiduciary Responsibilities
Understanding Retirement Plan Fees And Expenses
Selecting An Auditor For Your Employee Benefit Plan
Reporting and Disclosure Guide for Employee
Benefit Plans |
|
Who Can Be a Medical Reviewer under ERISA?
(Copyright
© 2004
by
Jin Zhou, ERISAclaim.com)
U.S. SUPREME COURT
Docket for 03-83
ORAL ARGUMENT TRANSCRIPTS (page
46 0f 49)
| 02-1845.
Aetna Health Inc. v. Davila |
03/23/04 |
"QUESTION: Mr.
Estrada, you can address what you would like but there are three
points that have come up during the Respondent's presentation
that I'd be interested with a response to.
Number one, is it true
that the people who make the decisions for your client must be
medical doctors in Texas?
MR. ESTRADA:
Well it is true by virtue of DOL regulations which provide that
no claim may be turned down without input from a medical
professional in the relevant area"
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New Federal Claim Regulation
(Final Rule)
-
"Plans must
consult with
appropriate health care
professionals in
deciding appealed claims
involving medical judgment."
[70268-70269,
CFR § 2560.503-1(h)(3)(iii)]
-
"The term `health care professional' means a
physician or other health care professional
licensed, accredited,
or certified to perform specified health
services
consistent with State law." [page
70271
CFR § 2560.503-1(m)(7)]
|
"medical doctors in Texas"
=
MD licensed to practice medicine in Texas
for a Texas ERISA case;
|
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"a medical professional in the
relevant area" = relevant area of state laws in license
jurisdiction, scope of practice and relevant local standard of care;
|
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"licensed"
= licensed by the State Government/licensing board;
|
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"to
perform" = to practice
medicine or health care services in the
State;
|
|
"specified
health services"
= medical procedures or services being reviewed or denied, instead of
file review or insurance coverage reviews
services;
|
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"consistent
with State law"
= consistent with State laws where the health care professional is
legally licensed to practice medicine or health care services with
respect to state jurisdictions, scope of license and state local
medical standard of care.
|
"The term `health care professional' means, in layman term, a
physician or other health care professional who is at least licensed in
your state (and more, board certified too) to practice the
specified/specific health services being reviewed or denied of your
claims, consistent with your state law jurisdiction, scope of practice
and local medical standard of care. Someone who is not licensed to
practice the same health care services specified/denied in your claims
is not qualified as an "appropriate health care professionals" as
defined under ERISA
§ 2560.503-1(m)(7).
Someone who is not licensed in your state to
practice "specified health services" but who is merely registered under
state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization
Reviews (UR)
is not qualified as an "appropriate health care professionals" as
defined under ERISA
§ 2560.503-1(m)(7).
U.S.
Supreme Court visited ERISAclaim.com in regard to ERISA
§ 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this
No. one point.
Click here for more coverage of Supreme Court Visiting at
ERISAClaim.com.
|
DOL Home
>
Rulemaking > Federal Register Documents
(Selected Only, Click DOL Links for Updated Official Documents)
Legal Research Resources -Wirtz Law Labor Library
Interactive Tools
|
DOL Home
>
Rulemaking > Federal Register Documents
(Selected Only, Click DOL Links for Updated Official Documents) |
EBSA
Press Release:
LABOR DEPARTMENT
ISSUES FINAL RULES TO ASSIST PLAN PARTICIPANTS IN
OBTAINING SPDs AND OTHER PLAN DOCUMENTS [January 8, 2002]
Labor Department Rule Expands Electronic Disclosure Options For Employee
Benefit Plans [04/08/02]
DOL
Publishes Revised Guide: MEWAs Under ERISA-- a Guide to Federal and State
Regulation (PDF) (U.S. Department of Labor, Pension and Welfare
Benefits Administration)
79 pages; revised September, 2002. Excerpt: "The first
part of this booklet ... focuses on what constitutes an ERISA-covered plan
and the regulatory and enforcement authority of the Department of Labor over
such plans. The second part ... focuses on what is and what is not a MEWA
and the extent to which states are permitted to regulate MEWAs that are also
ERISA-covered welfare benefit plans."
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|
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Healthcare Providers:
In
a letter
from Republican Congressional leader, John Boehner,
to the
Secretary of Labor and
insurance/benefits industry,
he states that "specifically,
we are concerned about provisions in the final rule that go even further
than the patients' rights bills
passed by
the Congress",
and he urged DOL to revise and delay the entire claims regulation.
New rules for
80%
of
health-care claims
of your business bottom-line,
90 percent of the new regulation protecting health-care providers,
have arrived without welcome from our community after we have been
struggling desperately and fighting with political contributions for new
protections for decades. Whenever our claims were denied by an
insurance company/ERISA plan, we complained that insurance companies or
ERISA plans do not play by rules and spent millions to lobby for new
rules and new protections. Now that the new rules are here, we do
not care about them at all. We do not know the name of the game,
we do not know the rule of the game at all.
About
90 percent of the new regulation is protecting/favoring health-care
providers,
but health-care providers nationwide failed
or refused to learn about this protection they have been fighting for
many years in federal and state courts through association lawsuits. The
most state and national medical associations are focused or gambling in
state and federal courts for the results/protections already provided by
this new federal regulation but showed no interest or failed to realize
this "oxygen for managed care critical conditions!"
Listen to
what experts in the industry or battlefields have to say, most of them
are legal experts advising insurance companies and ERISA plans, in
compliance with federal rules in making claim denials. Or
they study the rules and use the rules to their advantages in their
compliance practice.
How many
medical/health-care provider associations, hospital associations,
academic or advocate groups studied, educated you and complied with
these new rules? We need to
wake up,
know the rules and play by rules to
our advantages in our compliance for our
daily business bottom-line and survivals.
Detailed and specific discussion of this new regulation
emphasizing protections for health care providers are available through
Seminars,
ERISA for Physician (CD Book & System) and
In-house Consulting as well as
Executive Brainstorming from
ERISAclaim.com
Without
sufficient understanding of ERISA,
health-care providers may never understand
this new
Federal Claim Regulation
and
Guidance.
Aetna
(DOL/ERISA),
First
Health,
Blue Cross Blue
Shield are ready to comply with new federal regulation (BCBSIL)
(BCBSMI)
(BCBSCNY)
(BCBSNE)
(CareFirstBCBS)
&
(BCBSAL), are
you ready to get paid
faster and fairer?
From
Aetna's ERISA yesterday (Aetna Video Shows ERISA
Patients Mistreated) to
Aetna's ERISA today
(DOL/ERISA) =
Aetna ERISA
Actions or intention in compliance and in
control.
From
AMA's ERISA
yesterday (The
latest Harvard & RAND study) to
AMA's ERISA today (JAMA
Editorial) =ERISA Actions or Not?
That's why physicians, healthcare
providers and hospitals must
wake up on ERISA
now!
AMA
has finally noticed the existence and effective date of this new
federal claim regulation, as described in its
January 20, 2003 online edition of American Medical News: "Federal
regulations that dictate rapid turnaround times for health plan claims
and appeals quietly went into effect this month, with little noise from
the managed care industry."
However AMA has failed, as it did in past 28 years,
to practically and meaningfully understand
the
ERISA
and its
significance as protections for
health-care providers, entire industry has failed to offer any
educational programs and
occupational trainings to health-care
providers in this most important
federal law and regulation that governs and regulates up to
80% of
health-care claims and
60% of
U.S. healthcare expenditures.
As reported by AMA as to the time it may take for
this
new federal claim regulation to take effect in marketplace,
Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho,
states "it often takes years, even decades, for the marketplace to fully
adopt new regulations".
Life is too short, our nation's health-care system is going through
the
worst crisis since World War II and can't afford another 28 years to
realize and implement the
ERISA
regulations. We, everyone including health-care providers,
legislators, regulators and
insurance companies, should take immediate
actions to educate everyone in the system and to implement this
new
federal claim regulation as we are fighting against terrorists to
save our nation's
health-care system from worse-than-terror-war crisis.
Our
seminars are
for everyone,
physicians, health-care providers, clinics, hospitals,
insurance companies,
ERISA plans, third party claim administrators and plan sponsors as
well as state insurance regulators.
Industry Resource
Aetna
(DOL/ERISA),
First Health,
Blue Cross Blue
Shield are ready to comply with new federal regulation (BCBSIL)
(BCBSMI)
(BCBSCNY)
(BCBSNE)
(CareFirstBCBS)
&
(BCBSAL), are
you ready to get paid
faster and fairer?
2004 Reporting and Disclosure Calendar for Multiemployer Plans Online
from the Segal Company (The Segal Company)
2004 Reporting and Disclosure Calendar for Single Employer Plans Online
from the Segal Company (The Segal Company)
What Sites Do You Visit To Keep Up with Employee Benefits Compliance and
Design Developments? (BenefitsLink Wiki)
ABA Joint Committee on Employee Benefits
Agency Q-As
ABA
Reports Various Employee Benefit Regulators' Views on Health Issues
(Deloitte's Washington Bulletin) |
|
The Segal Company's 2005 Reporting & Disclosure Compliance
Calendar for Multiemployer Plans (The Segal Company)
The Segal Company's 2005 Reporting & Disclosure Calendar for
Multiemployer Plans in Printable Form (PDF) (The Segal
Company)
Nixon Peabody's August 2004 Benefits Briefs: Legal Developments for
Employee Benefits (PDF) (Nixon Peabody LLP)
6 pages. Articles include: Getting burned by
ignoring people with 'colorable' claims to plan participation; Court
holds that ERISA forbids a plan from recouping excess benefit payments
in court; Anti-cutback rule KOs suspension of benefits amendment.
Nixon Peabody's September 2004 Benefits Briefs: Legal Developments for
Employee Benefits (PDF) (Nixon Peabody LLP)
7 pages. Articles include: What's discrimination in
the design of ERISA plans?; Elect-it-yourself tax treatment for
disability benefits; Insurance companies as plan fiduciaries; Retiree
health benefits--Vested or not?
COBRA's Bite (Forbes.com)
Excerpt: "[T]he consequences for a company that
makes a mistake in following the new [notice] rules can be
significant. In May, for example, a Nebraska federal judge fined a
human resources company $307,000 for failing to provide an ex-employee
with the proper COBRA notice. The court assessed the maximum statutory
penalty of $110 per day for each beneficiary ... as well as their
actual medical expenses. Attorneys' fees and costs may be awarded
later."
Employer Health Plan Nightmares ... and Other Things That Go
Bump in the Night (Chang Ruthenberg & Long PC)
Excerpt: "[I]f you can identify the intended
benefits, the intended beneficiaries (e.g., employees and their
families), and a procedure to apply for and receive benefits, then you
probably have one or more ERISA welfare plans. Your company's welfare
plans may be 'wrapped' together as one plan, or the company may have
multiple welfare plans. Even if the benefits are provided solely by
insurance contracts, there is a good chance that the company is the
sponsor of an ERISA welfare plan."
Taking Advantage of DOL Guidance to Identify and Correct Gaps in Health
Plan Compliance (PDF) (The Segal Company)
4 pages. Excerpt: "All of the laws discussed in
this Executive Letter apply to group health plans and health insurers.
In general, there are no distinctions in compliance obligations [under
the federal laws discussed in this Executive Letter] for a
self-insured plan versus a fully insured plan."
Preventive ERISA Compliance Medicine for Health and Welfare Plans (PDF)
(Milliman USA) At pp. 1-3 of 12-page document.
Overview: Proper Handling of ERISA Benefit Claims (ERISA
Controversy Report, by Reish Luftman Reicher & Cohen)
Excerpt: "Claims by individual participants for
plan benefits have long been the 'bread and butter' of ERISA
litigation, and continue to represent the vast majority of cases
filed. This article outlines some common-sense tips for employers,
administrative committees and the members of those committees whose
job it is to respond to benefit claims."
Summary
Plan Description Deadline Is Here (PDF) (Trucker Huss)
Excerpt: "[T]he final SPD regulations are now fully
effective. Plans were required to comply with the new SPD content
requirements no later than the first day of the second plan year
beginning after January 20, 2001: January 1, 2003 for calendar year
plans. If you have not already done so, it is imperative that you review
your SPDs to ensure that they contain all of the information now
required under DOL Regulation § 2520.102-3."
Clinton Administration Pushes for Revolutionary Benefit Claims Final
Rule for Erisa-Regulated Plans, Daly Temchine, October 27, 2000
(ebglaw.com)
Excerpt: "Given
the revolutionary nature of this proposed claims regulation, welfare and
pension plan sponsors and administrators need to be on the lookout for the
final adoption of this regulation and of its consequences to their plans."
Regulating ERISA Claims Procedures: New Rules for Handling Benefit
Claims (Paul, Hastings, Janofsky & Walker LLP)
Excerpt: "The chances of
defeating most ERISA lawsuits can be greatly enhanced by effective use of
the plan’s ERISA-required claims procedures. Effective utilization means..."
Analysis: DOL Guidance on Complying with the ERISA Claims
and Appeals Regulation (PDF) (The Segal
Company)
11 pages. Excerpt: "Starting this year, all employee
benefit plans governed by the Employee Retirement Income Security Act
(ERISA) must comply with the claims and appeals regulation issued by the
Department of Labor (DOL) in November 2000. Plans affected include most
retirement, health and welfare plans sponsored by an employer, union or
joint board of trustees."
DOL Finalizes Major Changes to ERISA Regulations (PDF)
(SEYFARTH SHAW)
8 pages. Excerpt:
"Late last month, the United
States Department of Labor ("DOL") issued final regulations in response
both to President Clinton’s health care reform directives and more than
700 letters of comment that addressed the DOL’s previous proposal. The
final regulations:
• completely overhaul ERISA’s claims procedures for
group health plans and disability plans and, to a lesser extent, for
pension and other welfare benefit plans, and
• extensively amend the disclosure requirements for
summary plan descriptions ("SPDs") for all plans."
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Ringing in the New Rules (PDF)
(Gardner Carton & Douglas)
A Service to Our Clients and Our Friends
DOL guidance could help plan sponsors confronting
the new ERISA claims procedure regulations
Excerpt: "It
will not rank up there with bad fruitcake or silly hats and
noisemakers, but the Department of Labor ("DOL") may be starting a
holiday tradition of its own – weighing in
with new ERISA claims
procedure guidance. Just
weeks before the
claims procedure rules it finalized before the holidays last year
take effect for disability and other non-health plans, the DOL has
issued informal question-and-answer guidance that should prove
very useful to plan sponsors."
|
2002: the Claims Odyssey Continues (PDF)
(Gardner Carton & Douglas)
Excerpt: "All ERISA disability plans, even
those with non-calendar year plan years, [are] required to comply
with the new rules for claims submitted on or after January 1,
2002.... The new claims procedure rules take effect for claims
filed under an employer's health plan for plan years beginning on
or after July 1, 2002, but not later than January 1, 2003 (for
calendar year plans, the rules will be effective for claims filed
on or after January 1, 2003)."
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DOL Issues Final Rule on SPD Content Requirements
(Groom Law Group)
Excerpt: "There are no big surprises in the
final rule, as it largely adopts the changes set forth in the
DOL's proposed rule issued on September 8, 1998. The final rule's
primary focus is on SPD requirements pertaining to group health
plans, although the rule also identifies and clarifies SPD
requirements for pension and other welfare benefit plans."
|
Department of Labor Issues Final Claims Regulations
(7/1/2001)
(Groom Law Group)
Excerpt: "The final rule does contain some
significant improvements compared with the proposed rule. For
example, it distinguishes between prior authorization claims and
retrospective review claims and has different time frames for
both. (The proposed rules treated all non-urgent claims the same.)
......The final rule also has a more reasonable effective date
than the proposed rule, allowing plans more time to prepare for
compliance.
Even so, the final regulation is a major departure from the
current rule. In addition, DOL included several new requirements
that were not found in the proposed regulation. We discuss below a
summary of the final regulation, focusing on group health plans,
and highlight areas that are likely to cause significant
compliance burdens."
|
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Administering Health and Disability Plans Under DOL's
Final Regs on Claims Procedures and SPDs (PDF)
(Pillsbury Winthrop LLP)
Excerpt: "The claims and appeals procedures
will apply with respect to claims for benefits filed on or after
January 1, 2002.... The claims procedures set forth in the final
regulation must be followed closely. If a plan fails to establish
or follow claims procedures consistent with the regulations, the
claimant is deemed to have exhausted the plan's administrative
remedies and is entitled to pursue any available remedies under
Section 502(a) of ERISA."
|
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DOL
Makeover for Health Benefit Plans' Claims Procedures and Summary
Plan Descriptions (McDermott, Will
& Emery)
Excerpt: "Compared to the current rules, the
new rules require (a) greater disclosure to participants of plan
claims procedures and provision to claimants of the complete and
specific reasons for any claim denials and all information
relevant to such denials; (b) more procedures intended to assure
fair treatment of claimants and (c) faster decisions on both
initial claims and appeals of denied claims."
Benefits Claims Defenses (pdf) (McCalla
Thompson)
Excerpt: "This paper is a survey of virtually the entire
body of federal case law on benefit claims under ERISA Topics covered
include the new claims regulations, exhaustion of plan administrative
remedies including the adequacy of the process and exceptions to the
exhaustion requirement, standards of review of fiduciaries' benefit claim
decisions."
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|
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ebsa Delays Applicability Date of Claims Procedures
Rules For Group Health Plans Only (Spencernet)
The Department of Labor's Pension and Welfare
Benefits Administration (ebsa) has delayed 'for at least six
months and not more than one year' the applicability date for its
final regulations under ERISA Sec. 503 governing benefit claims
procedures of group health plans. Notice of the delay was
published in the July 9 Federal Register.
|
|
|
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Analysis: DOL Finalizes Regulations With Penalties
for Failure to Produce Documents on DOL's Request
(EBIA Weekly)
Excerpt: "The DOL's request for documents is
limited to documents that a participant or beneficiary could
examine and obtain ... 'Participant or beneficiary' is broadly
defined for this purpose, specifically including even prospective
alternate payees (under a qualified domestic relations order),
prospective COBRA qualified beneficiaries, and prospective
alternate recipients (under a qualified medical child support
order)."
|
Furnish Documents to DOL in 30 Days or . . .
(Kilpatrick Stockton LLP)
Excerpt: "TRA '97 also gave the Department
authority to assess penalties on a plan administrator that fails
to provide the Department with the requested documents within 30
days of the request .... [F]inal regulations were issued on
January 7, 2002, effective March 8, 2002."
|
|
Significant Delay in Application of New Claims Procedure
Regulations--But Only for Group Health Claims
(EBIA Weekly)
Excerpt: "The deadline to comply with the DOL
regulations on claim procedures has been extended, but only for
ERISA group health claims. There is no extension provided for
disability and other ERISA claims, including those under 401(k)
and other pension plans. These plans must comply with the new
rules by the original applicability date (i.e., for these plans,
the new rules apply to claims filed on or after January 1, 2002)."
|
| |
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What Information Must Go Into Group Health Plan's SPD?
(EBIA Weekly (Question of the
Week))
Excerpt: "[U]nder DOL Reg. Sec. 2520.102-3(j)(3),
the SPD for a group health plan is required to contain a description
of the following laundry list of specific items relating to benefits
... [S]ubject to one exception, the regulations specifically allow
detailed schedules of benefits to be described generally in the SPD,
if the SPD refers to the schedules of benefits and explains that they
are available without charge to any participant or beneficiary who
requests them."
New HIPAA Privacy
and ERISA Claims Review Rules: 10 Reasons To Comply (Brown
Rudnick Berlack Israels L.L.P.)
Group Health Plan Compliance with ERISA and HIPAA: Navigating the Legal
and Administrative Maze (PDF) (Brown Rudnick Berlack Israels
L.L.P.)
72 pages. A 'Question and Answer
Resource Guide."
Full Text: Group Health Plan Compliance with HIPAA and ERISA (PDF)
(Brown Rudnick Berlack Israels LLP)
73 pages include 'Questions and Answers Relating to
HIPAA,' 'Questions and Answers Relating to the New Claims Review
Regulations,' 'Questions and Answers Relating to Group Health Plan
Document, Summary Plan Description and Document Disclosure
Requirements."
DOL’ S
FINAL RULE ON CLAIMS AND APPEALS ESTABLISHES A COMPLICATED STRUCTURE FOR
HEALTH AND DISABILITY PLANS (THE
SEGAL
COMPANY,
www.segalco.com)
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TESTIMONY OF THE SPECIAL COMMITTEE ON HEALTH INSURANCE OF THE NATIONAL
ASSOCIATION OF INSURANCE COMMISSIONERS BEFORE THE UNITED STATES
DEPARTMENT OF LABOR ON THE PROPOSED ERISA
CLAIMS PROCEDURES REGULATION February 18, 1999
TESTIMONY OF THE SPECIAL COMMITTEE ON HEALTH INSURANCE OF THE NATIONAL
ASSOCIATION OF INSURANCE COMMISSIONERS BEFORE THE NATIONAL ASSOCIATION
OF ATTORNEYS GENERAL ON
MANAGED CARE-POLICY IMPLICATIONS George Reider, Jr.Commissioner of
Insurance State of Connecticut, April 21, 1999
|
|
A
New Diagnosis & Prescription
for
Our Nation's Health-care Crisis
(ERISAclaim.com)
Contrary to the popular belief, our nation's health-care
crisis has been truly and mainly caused by the
lack of understanding and
failing in compliance with
ERISA, the federal law regulating about
80% of
health-care claims or
60% of
health expenditures in the U. S. by both
insurance/benefits
industry and health-care providers for 28 years, through reckless
and
fraudulent as well as
revengeful, inflationary spiral
billings and
claim denials that
destroyed
or foreclosed the hope,
faith and
the Law
&
Order for our nation in health-care quality and
cost control, and the lack of meaningful and practical federal
administrative
enforcement of ERISA claim regulations, because this
inflationary spiral skyrocketing increases in
managed
care claim and denial war behind
ERISA shield between
health
insurers/ERISA plans and healthcare providers
have
overwhelmingly outnumbered increases in cost of living and national
gross domestic products, causing
annual
double-digit increases in
health
insurance premiums and
skyrocket health-care costs
($1.55
trillion
in 2002, 14.9% of the U.S GDP)
after
every managed care strategy and
model
failed to
contain or control health-care costs in long run
despite short-term savings, while entire country has devoted
more and more money in
litigation,
legislation
and
noncompliant managed care campaign, which practically have
solved little or no problem.
In order to
resuscitate U.S. Healthcare/managed care from such a
critical
condition, the strategy and solution must to be a
common ground acceptable to all parties involved, instead of hostile
and contradictory debate of
punitive damage therapy vs.
the uninsured coverage in
Congress. This
common ground for our national health-care crisis is the
ERISA
Claim Regulations, applicable and existing laws and regulations on
the book, originally designed by Congress in 1974 to
regulate
health-care claim dispute and to avoid fiduciary breach and
failures we are facing today.
A new practical and effective solution to
saving our nation's health-care system is to implement
ERISA as
Congress intended by creating a new
occupation or profession, ERISA claim specialists and departments,
t0 bridge the gap FROM
medical billers and coders &
insurance claim processors TO lawyers for both health-care providers and
insurance companies/ERISA plans, and to
educate everyone in health-care and employee benefits system,
health-care providers and their associations and leaders,
IPA's, MCO's,
health insurance, employee benefits TPA's and
legislators as well as
regulators to
truly understand ERISA, and comply with existing
ERISA's claim procedures and benefits
administration rules, to make practical sense for
health insurance delivered as
employee
welfare benefits under ERISA,
protecting participants and beneficiaries and safeguarding plan assets
through compliance of
ERISA laws and regulations by everyone.
How do
we know this is the right diagnosis and prescription?
Plain and simple, imagine what would happen if the U.S. healthcare
superhighway transported
$1.55 trillion for 283 million Americans each year without an
understanding, without compliance by any
one and
without
the enforcement of any existing
laws and
regulations governing those
80% of
the
healthcare claims,
60% of the
healthcare expenditures and
163
million Americans under
ERISA?
The latest Harvard & RAND study for Congress and state legislative
debate on Patients' Bills of Rights, conducted by David Studdert and
Carole Roan Gresenz, study authors from the Harvard School of Public
Health and RAND, funded by federal government, Department Of Labor, and
Agency for Health Care Research and Quality, revealed that
"little is publicly known about such appeals system", and concluded
that "A
majority of preservice appeals disputed choice of
provider or contractual coverage issues, rather than medical necessity.
Medical necessity disputes proliferate not around life-saving treatments
but in areas of societal uncertainty about the legitimate boundaries of
insurance coverage. Greater transparency about the coverage status of
specific services, through more precise
contractual language and consumer education about benefits limitations,
may help to avoid a large proportion of disputes in managed care."
A JAMA
Editorial commenting this study further supported the conclusion of
this study and advanced the
right solutions
more precisely at
New
ERISA Claim Regulations: "Regulations
issued by the Clinton administration in 2000
were designed to infuse rigor into the appeals process maintained by
employer-sponsored health plans covered by the Employee Retirement
Income
Security Act (ERISA),10 which governs insurance arrangements
for more than 150 million workers and their family members. Whether
these rules will be vigorously enforced remains to be seen."
This valuable study has pointed out the direction but failed to provide
a turnkey practical solution.
ERISAclaim.com has provided this nation with
a turnkey operational solution with ERISA compliance,
to educate
everyone on ERISA, coverage and
claim procedures, to ensure
"Bill Of Rights" for Patients, Providers, Plan Sponsors and Insurers.
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Advisory Opinion
95-10A
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Your correspondence concerns applicability of Title I of the
Employee Retirement Income Security Act of 1974 (ERISA) to
certain benefit plans for the University's employees.
Specifically, you request an advisory opinion concerning whether
those benefit plans are church plans within the meaning of
section 3(33) of Title I of ERISA.
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Advisory Opinion 96-14A
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"Thus, it appears that the schedule of "usual and
customary" fees described in your letter would be required
to be disclosed to participants and beneficiaries in accordance
with section 104(b)(2) and 104(b)(4) of ERISA."
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Advisory Opinion 97-11A
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"......as amended (ERISA), to furnish a participant with a
copy of the contract between an employee benefit plan and a
third party administrator (TPA)."
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Advisory Opinion 97-21A
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ERISA SEC. 4(b)(3)
"You ask whether ERISA § 4(b)(3), which excludes from ERISA
plans that are maintained solely to comply with state-mandated
disability benefits, would apply to a disability benefits
program (hereinafter, the Program) offered by the Association of
Independent Colleges and Universities in New Jersey
(hereinafter, AICUNJ) to its members for their employees."
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Advisory Opinions
for 2002
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Information Letter [08/23/02] "Section 514(a) of
Title I of ERISA generally preempts state law purporting to
regulate an employee benefit plan covered under that title.
There are, however, exceptions to this general preemption
provision....
Accordingly, in the Department’s view, Title I of ERISA does
not preclude Georgia from applying its insurance law to the
IUIIW Fund as a MEWA in accordance with section 514(b)(6)(A) of
ERISA, as described above.(1)" |
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GAO
Report: Improvements to Retirement Income Data Needed
(U.S. General Accounting Office)
"What GAO Recommends:
The Congress should consider
directing Labor to obtain from plan administrators electronic
filings of SPDs and summaries of material
modifications and make them
publicly available." |
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