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Health costs have been growing much faster than the rate of inflation, and most observers agree that while health reform addresses the issue of access to insurance, it inadequately addresses the underlying problem: the cost of care itself. Unanswered questions surround reversing the unsustainable cost of health services. For example, would replacing the fee-for-service system […]
Government audits, participant lawsuits and the dreaded play-or-pay rule could heap liability and risk on employer plans, all as a result of the reform law that was just affirmed by a majority of the U.S. Supreme Court. Employers must take into account new liabilities when they move workers to part-time status or divert retirees into […]
The U.S. Supreme Court’s landmark ruling on June 28 to uphold nearly all provisions of President Obama’s health-reform law removes any excuse for employers to drag their feet implementing reform-driven changes to their health plans. Uncertainty on whether the law still would be binding on plans was hindering implementation, many sources say, but with the […]
The U.S. Supreme Court agreed on June 25 to decide whether an employee health plan is subject to equitable limits when it demands reimbursement of benefits paid to care for a covered employee who also recovers money from third parties. A 2011 ruling on this issue by the 3rd U.S. Circuit Court of Appeals troubled […]
As you must know by now, regardless of how the U.S. Supreme Court rules on the federal health care reform, a couple of very large insurers announced they would continue several of health reform’s insurance mandates. The impact of this announcement directly applies to companies that buy full insurance. But self-insured plans and employers big enough […]
Regardless of how the U.S. Supreme Court rules on the federal health care reform, Humana and UnitedHealth Group on June 11 announced that they would continue several of health reform’s insurance mandates. The U.S. Supreme Court is considering whether the “individual mandate” (for everyone to get health insurance or pay a penalty) is unconstitutional, but […]
In a May 18 ruling, the Texas Supreme Court compelled a stop-loss insurer to pay a direct premium tax on stop-loss policies sold to self-funded health plans. Stop-loss insurance written in Texas for self-funded plans is not “reinsurance” and thus must pay state levies and follow state insurance rules, the court held. American National, a […]
While ERISA self-insured plans themselves are not subject to state regulation, states are clamping down on stop-loss coverage as a way to discourage self-funding, say attorney Ron Peck and legal administrator Chris Aguiar at the Phia Group, Braintree, Mass. The Texas Supreme Court ruling in TDI v American National Ins. Co. and the passage by […]
Because an employer health plan gave a full and fair review resulting in a reasonable benefits decision, a federal court upheld the plan’s lifetime limit on obesity services and its prohibition on payments to treat complications from earlier gastric bypass surgeries. The plan also weathered an allegation that it was not properly segregating plan funds. […]
ERISA can be the key to upholding benefit decisions based on plan language before money is paid, but it may be far less helpful once overpaid money goes out the door, particularly when the plan is indemnity-based with no provider contracts. This situation became evident in Int’l Longshore & Warehouse Union v. Sharp Surgery Center, […]