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New Federal Health Claims & Appeals Laws
&
Regulations
for 193 Million Americans
Effective 09-23-2010
©2010, Jin
Zhou, ERISAclaim.com |
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President
Obama Signing Health Bill on
03/23/2010
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President
Gerald R. Ford Signing ERISA on 09/02/1974 |
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New Webinars,
Seminars & Certification Classes Announced for New Federal Health
Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS,
Effective On Sept. 23, 2010 for 193 Million Americans |
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UNITED STATES
DEPARTMENT OF LABOR
(Links to DOL)
©2010, Jin Zhou, ERISAclaim.com |
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Statutory Laws [PDF]
[PDF]
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Employee Retirement Income Security Act ERISA |
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Webinars,
Seminars & Certification Classes for New Federal Health Claim Appeals
Regulations
ERISAclaim.com
- Free Webinars - New Federal Claims & Appeals Regulations, Effective
Sept. 23, 2010, for 193 Million Americans
ERISAclaim.com: Seminars - 2010 Two-day
Basic ERISA Appeal Seminars - Denials and Overpayment Appeals
ERISAclaim.com - 2010
PPACA & ERISA Claim
Specialist Certification Programs in Chicago, Illinois
ERISAclaim.com: Create An Appeal
Department for Your Hospital or Practice
(In-house, onsite ERISA Claim Specialist Certification Programs)
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HSA &/OR ERISA
"95% of HSA Are Still ERISA's"
© 2004 - 2005 Jin Zhou, ERISAclaim.com
In order to make HSA's (Health
Savings Accounts) &/or ERISA understandable, as easy as 1-2-3, and a
no-brainer for dummies, we present the official guide from the IRS,
Treasury Department, DOL, Department Of Labor, Federal ERISA Enforcement
Agency, with some experts views and industry news, to show the basic
idea and a picture of the latest storm in healthcare market mixed with
the most complicated ERISA law for 80% of US health care claims.
HSA &/OR ERISA, What's
the Big Deal & Who Cares?
$5,000 to $10,000
deductibles for you and your family are and will be the way of your life
this year and next year for the most and as popular insurance plans
around the country.
If $10,000 or more
is not a big deal to you, then
HSA &/OR ERISA
won't matter.
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Plan 1 |
Plan 2 |
Plan 3 |
Plan 4 |
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In-network |
Out-of-network |
In-network |
Out-of-network |
In-network |
Out-of-network |
In-network |
Out-of-network |
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Individual Deductible |
$2,500 |
$5,000 |
$2,500 |
$5,000 |
$2,500 |
$5,000 |
$2,500 |
$5,000 |
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Family Deductible |
$5,000 |
$10,000 |
$5,000 |
$10,000 |
$5,000 |
$10,000 |
$5,000 |
$10,000 |
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Maximum Annual HSA
Contribution |
$2,500 ($5,000 for
families) |
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Do
you know 95% of HSA May Still Be ERISA's by HSA Set up and Fund
Distribution (Fund Used for)?
HSA can be set up with or
without ERISA exemption and HSA fund can be used with or without High
Deductible Health Plan (HDHP) ERISA jurisdiction for employer-sponsored
health plans in private sector.
Predicting the Future of Health Savings Accounts
(PDF) (International
Society of Certified Employee Benefit Specialists)
"The Department of Labor (DOL) has issued
guidance as to the circumstances under which HSAs
will or will not be subject to ERISA.
In order to avoid ERISA, employer involvement with HSAs must be
limited. While 58% of survey
participants indicated that it would be somewhat or very likely that
their organization would choose to avoid ERISA, a sizable minority
(35%) said it was not very likely they would structure an HSA so as
to avoid ERISA."
As HSA can only be set up on top of HDHP,
and is mainly designed to offset and supplement high deductibles of
ERISA plans, among other functions, the practical,
legal and financial significance of ERISA compliance and risks of HSA
have to be determined not only
by HSA's design and set up but also more importantly by HSA's fund
distribution, fund used to pay for ERISA health plan covered medical
expenses in satisfying high deductibles and co-payments, for more than
$2,500 to $10,000 deductibles, such as in
HSA
Blue Eligible Plans.
Blue Options - HSA Blue With HSA
Blue, you get... (www.bcbsnc.com)
"Control of your
health care budget
HSA Blue is an
innovative, tax-free way for your employees to pay for current and
future out-of-pocket health care expenses. HSA Blue pairs our most
popular plan, the Blue Options PPO, with a health savings account
(HSA). HSAs work like IRAs for qualified medical expenses.
Funds can be used to pay
for deductibles, over-the-counter medications, medical supplies
and more. Get details about
using HSA funds
or review our
list of FAQs."
Although HSA can be set up by anyone in
addition to or other than employer, an individual covered under HSA must
be covered by a HDHP and can not be covered by any other health plan
that is not HDHP. Subject to certain requirements under ERISA
regulation as explained in
DOL Bulletin 2004-1, a HSA can
be set up by design subject to ERISA regulation and jurisdiction.
Even if a HSA is set up with exemption of ERISA jurisdiction under HDHP of
an ERISA plan, when such HSA fund distribution, money spent and used to pay
for covered medical expenses in satisfying high deductibles and
co-payments from ERISA HDHP, regardless who sponsored HSA or
whether a HSA (account) itself constitutes an ERISA
plan, such HSA fund
distribution, by claiming and satisfying or applying to high
deductibles in an ERISA HDHP,
has triggered ERISA jurisdiction
and obligations of the plan administrator of the employer-sponsored,
ERISA regulated, high deductible health plan.
Therefore a non-ERISA HSA
distribution can be an ERISA claim if HSA distribution is used to pay for covered
medical expenses to satisfy and supplement deductibles and copayments of
an ERISA plan, HDHP, which is the prerequisite for a HSA,
as HSA was mainly designed to do by the
President and Congress .
The
Honorable John W. Snow Prepared Remarks: Health Savings Accounts Events
(03/30/2004)
"Today we are issuing our next guidance in response
to those comments that we received. Issues covered by the new guidance
include a definition of preventive care and determining whether
prescription drugs can be covered on a first-dollar basis or be subject
to the high deductible under the high-deductible health plan that must
accompany an HSA."
If a HSA is set up with exemption of ERISA jurisdiction, and HSA fund
distribution is used to pay for qualified medical expenses under IRC 213
(d) without any interactions with an ERISA HDHP, such HSA will be
completely exempted from ERISA jurisdiction.
If a HSA is set up without exception of ERISA jurisdiction, and HSA fund
distribution can also be used for qualified medical expenses (QME),
instead of cover medical expenses of an ERISA HDHP, such HSA design and
set up will be subject to ERISA reporting and disclosure requirements,
but irrelevant to ERISA HDHP claim adjudication, as HSA fund
distribution adjudication is
"Between the Taxpayer, God, and the IRS".
However when such ERISA HSA fund distribution is used for covered medical
expenses of an ERISA HDHP, such HSA set up and distribution are
completely subject to ERISA regulation from beginning to the end.
HSA or ERISA, MORE EXPLANATIONS FROM DOL & IRS
IRS Notice 2004-2:
Q2 & A2 = HDHP & DOL
Bulletin 2004-1:
"The guidance makes clear that while
private-sector employer-sponsored HDHPs are group health plans
subject to ERISAs reporting, disclosure, fiduciary
responsibility and other requirements,...."
How many
employers will offer HSA's without High Deductible Health Plans (HDHP)
for health-care costs savings and control?
How many insurers will offer HSA products without health-insurance
policies?
How many employees will set up their own HSA Accounts without their
employers contributions and want $0.00 of medical expenses applied to
their annual deductibles of their health insurance?
How many HSA trustees or custodians would risk ERISA fiduciary
liabilities and the lawsuits by employers and employees if HSA claims
are actually dual HSA and ERISA Claims?
Qualified Medical Expenses
under HSA v. Cover Medical Expenses under ERISA Plans
Eligible medical expenses under HSA are governed
under IRC §213 (d) as "qualified medical expenses" while covered
medical expenses under ERISA health plans are determined by individual
plans SPD (Summary Plan Description) under ERISA. A claim for incurred
medical expenses could be qualified medical expenses under HSA but
noncovered medical expenses under High Deductible Health Plan (HDHP)
or both qualified medical expenses and covered medical expenses for
each individual, and every individual is intended to be reimbursed
from HSA and to apply that expenses to satisfy high deductibles under
HDHP/ health-care plan under ERISA, regardless of future determination
and outcomes.
A Claim of Incurred
Medical Expenses in connection with HSA for benefits or satisfaction
of deductibles under HDHP Triggers ERISA Jurisdiction
Although DOL has provided the following safe
harbors for HSA claims to be exempted from ERISA regulations,
practically speaking, every employee or eligible individual covered
under high deductible health plans would have to satisfy such high
deductible before benefits reimbursement can be made from the plan:
"Accordingly, we
would not find that employer contributions to HSAs give rise to an
ERISA-covered plan where the establishment of the HSAs is completely
voluntary on the part of the employees and the employer does not:
(i)
limit the ability of eligible individuals to move their funds to
another HSA beyond restrictions imposed by the Code; (ii) impose
conditions on utilization of HSA funds beyond those permitted under
the Code; (iii) make or influence the investment decisions with
respect to funds contributed to an HSA; (iv) represent that the HSAs
are an employee welfare benefit plan established or maintained by
the employer; or (v) receive any payment or compensation in
connection with an HSA.
(Field
Assistance Bulletin 2004-1)
Regardless whether a qualified medical expense
under HSA will ultimately qualify for covered medical expenses in
satisfying the plan's deductible in accordance with individual plan's
SPD (Summary Plan Description) under ERISA, a claim submitted to and
denied by an ERISA plan triggers ERISA jurisdiction under
DOL
FAQ C12:
"C-12: If a claimant submits medical bills to
a plan for reimbursement or payment, and the plan, applying the
plans limits on co-payment, deductibles, etc., pays less than 100%
of the medical bills, must the plan treat its decision as an adverse
benefit determination?
Under the regulation, an adverse benefit
determination generally includes any denial, reduction, or
termination of, or a failure to provide or make payment (in whole or
in part) for, a benefit. In any instance where
the plan pays less than the total amount of expenses submitted with
regard to a claim, while the plan is paying out the benefits to
which the claimant is entitled under its terms, the claimant is
nonetheless receiving less than full reimbursement of the submitted
expenses. Therefore, in order to permit the claimant to challenge
the plans calculation of how much it is required to pay, the
decision is treated as an adverse benefit determination under the
regulation. Providing the claimant with the required
notification of adverse benefit determination will give the claimant
the information necessary to understand why the plan has not paid
the unpaid portion of the expenses and to decide whether to
challenge the denial, e.g., the failure to pay in full. This
approach permits claimants to challenge whether, for example, the
plan applied the wrong co-payment requirement or deductible amount.
The fact that the plan believes that a
claimants appeal will prove to be without merit does not mean that
the claimant is not entitled to the procedural protections of the
rule. This approach to informing claimants of their benefit
entitlements with respect to specific claims, further, is consistent
with current practice, in which Explanation of Benefits forms
routinely describe both payable and non-payable portions of
claim-related expenses. See § 2560.503-1(m)(4)."
In addition
to plan SPD specific provisions in
defining covered medical expenses, a claimant must also comply with
plan provisions, as de facto control of HSA distribution by
employer/the plan, in managed-care environment, such as
pre-authorization, network provider limitations and utilization
reviews, in order to be eligible for benefits, even for covered medical
expenses.
In the course of such HSA ERISA exemption and ERISA
claim practice to establish that an HSA claim may not be eligible for
covered medical expenses in satisfying high deductibles under an ERISA
plan, a plan fiduciary has to access, disclose and possibly provide
for a copy of SPD, and to complete a full and fair review under ERISA
for such "adverse benefits determination" of "an ineligible ERISA claim"
of HSA expenses. In doing so, ERISA jurisdiction is inevitably
triggered and ERISA compliance requirement is evidenced.
Contrary to mainstream assertion and predictions,
this author believes that most HSA, up to 95%, will be ERISA claims
regardless of their merits under current crisis-cost shifting
managed-care environment. Failure in realizing this reality of ERISA
compliance requirement will eventually increase health-care costs and
managed-care litigations, and defeat entire purpose of timely medical
care and health care quality in cultivating health-care disasters.
HSA & ERISA law affect patients,
healthcare providers, insurance companies and TPA's as well as
employers.
We have received numerous comments
and feedback on our comprehensive chapters and pages on this web
site, requesting for a simplified "dummy version" of HSA's &/or ERISA page and a
roadmap of the ERISA basics in health care claim appeals.
We would like to try this
format to find out if we could accomplish this huge task.
Please e-mail your
questions and comments.
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BCBSA Approves Use Of Blue-Branded Debit Cards For
Tax-Favored Health Savings Accounts (BCBSA
Media Resources,
February 1,
2005)
Blues Plans Join the Health Savings Account Train (Reuters, UK -
Nov 17, 2004)
Blue Cross and Blue Shield Companies Offering
HSA-Compatible Health Plans Across the Country, New Products Expand the
Blues' Portfolio of Consumer-Directed Offerings (National
Desk, Health Reporter U.S.
Newswire (press release)
Most Blues Patients in Most States Will
Have Access to Health Savings Accounts by the End of 2005
(American Medical News)
Kaiser's New High-Deductible Plan Signals Switch for Group-Model HMOs
(MANAGED CARE WEEK via AISHealth.com)
Excerpt: "With Kaiser Permanente's decision this
month to enter the consumer-directed market with a high-deductible HMO
product, the managed care organization (MCO) becomes a highly visible
sign of the continuing transformation of staff- and group-model HMOs
toward fee-based products. HMO-focused plans are moving toward such
products in greater numbers in an effort to remain competitive with
employers seeking lower-cost plans."
Employees Do Not Think They Can Control Health
Care Costs Survey Results Show
(BenefitNews Connect via BenefitNews.com)
Excerpt: "Employees are willing to take more
control of their health care decisions, but are not quite sure how to
do so, a Hewitt Associates poll of 39,000 employees shows. Among the
consulting firm's findings: More than 80% of employees don't estimate
their health care expenses each year. Nearly as many (79%) don't think
they can do anything to control health care costs. More than half
(57%) have never researched provider costs or quality."
Three Employers Compare Consumer-Directed Health
Plan Design Notes During Audioconference
(INSIDE CONSUMER-DIRECTED CARE via AISHealth.com)
Patients Cutting Health Care Usage: Higher Costs
Force Workers to Make Difficult Decisions (The
Mercury News; one-time registration required)
" Nearly
six out of 10 workers say they are avoiding their doctors until they
experience serious symptoms -- a decision that could lead to costly
bills that could have been avoided with preventive care."
Poor
health, not lack of insurance,
drives ED visits ... American
Medical News
"The
study published online Oct. 19 by
the Annals of Emergency
Medicine found that 85% of
emergency patients had health
insurance and 83% of ED visits
were made by people who had a
usual source of care such as a
primary care physician. People
without insurance were no more
likely to visit the emergency
department than people with
insurance."
Does lack of a usual source of
care or health insurance increase
the likelihood of an emergency
department visit? Results of a
national population-based study,"
Annals of
Emergency Medicine
Comments on and Excepts from Recent Articles on
the Implementation of Health Savings Accounts
(Attorney B. Janell Grenier via Benefitsblog.com)
Excerpt: "Generally, payment
with HSAs should work the same way payments generally work for
patients with insurance. The doctor informs the insurer of the
charges, the insurer sends the patient a statement explaining how much
the patient owes, and the patient then has to pay the doctor that
amount. Patients using HSAs should wait to pay until the doctor
submits the information to their insurer, says Mr. Engel of Mellon
Financial. . ... Some insurers, like UnitedHealthcare, are already
working to minimize this hassle, for example, by allowing consumers to
authorize the insurer to deduct directly from their HSAs to pay
medical bills."
Wall Street Journal Looks at Use of and Confusion
with Health Savings Accounts (Kaiser Family
Foundation)
Excerpt: "The Wall Street Journal on [November 30]
examined some of the challenges facing consumers, insurers and banks
as the health care industry works out the details of health savings
accounts. One 'potential are[a] of confusion' is
'when and how much' patients with HSAs should pay providers, the
Journal reports. According to the Journal, some providers and
consumers 'are confusing HSAs with direct, full-price payments' made
by the uninsured. In fact, consumers with HSAs are expected ...."
HSA Adjudication Is "Between the Taxpayer, God,
and the IRS" (Spencer Benefits Reports)
"Health savings account owners may use HSA funds to pay for their
spouse's and/or dependents' medical expenses, even if the spouse or
dependents are not enrolled in the employee's high-deductible plan or
have coverage under another employer's plan, said Kevin Knopf, attorney
adviser in the Treasury Department's Office of Benefits Tax Counsel. Mr.
Knopf spoke and answered questions at a January 13 teleconference
sponsored by the American Bar Association's joint committee on employee
benefits."
Predicting the Future of Health Savings Accounts
(PDF) (International
Society of Certified Employee Benefit Specialists)
"The Department of Labor (DOL) has issued guidance
as to the circumstances under which HSAs will or will not be subject
to ERISA. In order to avoid ERISA, employer involvement with HSAs must
be limited. While 58% of survey participants indicated that it would
be somewhat or very likely that their organization would choose to
avoid ERISA, a sizable minority (35%) said it was not very likely they
would structure an HSA so as to avoid ERISA."
Half of Insured Adults with High-Deductible Health Plans Experience
Medical Bill or Debt Problems (The Commonwealth Fund)
Excerpt: "About half of insured adults with a
high-deductible health plan have medical bill problems or debts,
compared with less than one-third (31%) of those with lower-deductible
plans, according to new research from The Commonwealth Fund.
Individuals with high-deductible plans are also more likely than those
with lower-deductible plans to experience access problems such as not
filling a prescription, or skipping a medical test, treatment, or
follow-up when needed, due to cost."
Half
of bankruptcy due to medical bills-US study (Reuters AlertNet)
"WASHINGTON, Feb 2 (Reuters) -
Half of all U.S. bankruptcies are caused by soaring medical bills
and most people sent into debt by illness are middle-class workers
with health insurance, researchers said on Wednesday."
Wall Street Journal Examines Concerns about Medical Evidence
Used for Best-Practice Guidelines (The National
Journal Group, Limited via The BlueCross BlueShield Association)
Opinion: Risks and Benefits: Health Savings Accounts and
Employee Ability to Handle Risk and Costs (CFO.com)
Bush Promotes Health Savings Accounts: Plan Would Cut Costs and
Increase Patient Responsibility (The Washington Post;
one-time registration required)
Early Response Suggests Health Savings Accounts Products Are Popular
in the Individual Market (American Medical News)
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Employee Benefits Security Administration Issues Field
Assistance Bulletin on Health Savings
"The guidance makes clear that while
private-sector employer-sponsored HDHPs are group health plans
subject to ERISAs reporting, disclosure, fiduciary
responsibility and other requirements, HSAs generally will not
constitute ERISA-covered employee benefit plans. The guidance
also clarifies that an employer can make contributions to the HSA of an eligible individual without being considered to have
established or maintained the HSA as an ERISA-covered plan,
provided that the employers involvement with the HSA is
limited."
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?"
"Conclusion
HSAs generally will not
constitute "employee welfare benefit plans" for purposes of the
provisions of Title I of ERISA. Employer contributions to the
HSA of an eligible individual will not result in Title I
coverage where, as discussed above, employer involvement with
the HSA is limited. Finding that an HSA established by an
employee is not covered by ERISA does not,
however, affect whether an HDHP sponsored by the employer
is itself a group health plan subject to Title I. In fact,
unless otherwise exempt from Title I (e.g., governmental plans,
church plans) employer-sponsored HDHPs
will be employee welfare benefit plans within the meaning of
ERISA section 3(1) subject to Title I."
Text of
IRS Notice 2004-2: Guidance on Health Savings Accounts (PDF)
(Internal Revenue Service)
(Selected)
Q-1. What is an HSA?
A-1. An HSA is a tax-exempt trust or
custodial account established exclusively for the purpose of
paying qualified medical expenses of the account beneficiary
who, for the months for which contributions are made to an HSA,
is covered under a high-deductible health plan.
Q-26. What are the qualified medical expenses that are
eligible for tax-free distributions?
A-26. The term qualified medical
expenses are expenses paid by the account beneficiary, his or
her spouse or dependents for medical care as defined in section
213(d) (including nonprescription drugs as described in Rev. Rul.
2003-102, 2003-38 I.R.B. 559), but only to the extent the
expenses are not covered by insurance or otherwise. The
qualified medical expenses must be incurred only after the HSA
has been established. For purposes of determining the itemized
deduction for medical expenses, medical expenses paid or
reimbursed by distributions from an HSA are not treated as
expenses paid for medical care under section 213.
Q-29. Must HSA trustees or custodians determine whether HSA
distributions are used exclusively for qualified medical
expenses?
A-29. No. HSA trustees or custodians
are not required to determine whether HSA distributions are used
for qualified medical expenses. Individuals who establish HSAs
make that determination and should maintain records of their
medical expenses sufficient to show that the distributions have
been made exclusively for qualified medical expenses and are
therefore excludable from gross income."
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JS-2112: Treasury and IRS Issue Indexed
Amounts for Health Savings Accounts
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November 19, 2004
JS-2112
Treasury and IRS Issue Indexed Amounts
for Health Savings Accounts
The Treasury Department and IRS today
issued new guidance on the maximum contribution levels for
Health Savings Accounts (HSAs) and out-of-pocket spending
limits for High Deductible Health Plans (HDHPs) that must be
used in conjunction with HSAs. These amounts have been indexed
for cost-of-living adjustments for 2005 and are included in
Revenue Procedure 2004-71, which announces changes in several
indexed amounts for purposes of the federal income tax. The
minimum deductible required for HDHPs did not change.
"Today's guidance will help consumers and
employers who wish to participate in HSAs in 2005 to plan
accordingly," said Treasury's Acting Assistant Secretary for
Tax Policy Greg Jenner. "Knowing the dollar limits for these
accounts, and for the high deductible insurance that goes with
them, is critical for those who want to get the maximum
benefit out of this revolutionary health care coverage option
one that puts health care spending decisions back in the
hands of individuals."
The new levels are as follows:
New Annual Contribution Levels for HSAs:
- For 2005, the maximum annual HSA
contribution for an eligible individual with self-only
coverage is $2650. (Note: for any individual, the maximum
contribution is the lesser of the indexed amount or the
deductible of the HDHP.)
- For family coverage the maximum annual
HSA contribution is $5250.
- Catch up contributions for individuals
who are 55 or older is increased by statute from $500 to
$600 for 2005.
- Both the HSA contribution and catch up
contribution apply pro rata based on the number of the
months of the year a taxpayer is an eligible individual,
and, with respect to the catch up contribution, the number
of months of the year that the taxpayer is age 55 and over.
New Amounts for Out-of-Pocket Spending on
HSA-Compatible HDHPs:
- The maximum annual out-of-pocket amount
for HDHP self-coverage increases to $5,100 and the maximum
annual out-of-pocket amount for HDHP family coverage is
twice that, $10,200.
Minimum Deductible Amounts for HSA-Compatible HDHPs:
- For 2005, the minimum deductible for HDHP
is unchanged, remaining at $1,000 for self-only coverage and
$2,000 for family coverage.
REPORTS
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Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (pdf) (415) (A full text of the H.R. 1)
The corrected
2005 Publication 15-B, Employers Tax Guide to Fringe Benefits
(PDF) (or
HTML
version), is now available for download. --04-FEB-2005
If you downloaded the 2005 version of
Publication 15-B before February 3, 2005, please make a note
of the following correction.
The discussion of cafeteria plans on
pages 2 and 3 of the publication incorrectly indicated that
health savings accounts could
not be included in cafeteria plans. Previous references to
health savings accounts have been deleted from the text
under "Qualified benefits" and "Benefits not allowed" in
that discussion.
"Mission
Health Savings Accounts (HSAs) were created
by the Medicare bill signed by President Bush on December 8,
2003 and are designed to help individuals save for future
qualified medical and retiree health expenses on a tax-free
basis."
Contents
All About HSAs
JS-1061: Treasury Issues Guidance To Encourage Use Of New
Innovative Health Savings Accounts ("HSAs")
Text of
IRS Notice 2004-2: Guidance on Health Savings Accounts (PDF)
(Internal Revenue Service)
13 pages. Excerpt: "This notice provides
certain basic information about HSAs in question and answer
format, without attempting to enumerate all of the specific
rules that apply under section 223. The notice is divided into
five parts. Part I of the notice explains what HSAs are and
who can have them. Part II describes how HSAs can be
established. Parts III and IV cover contributions to HSAs and
distributions from HSAs. Part V discusses other matters
relating to HSAs."
IRS Modifies
HSA Eligibility Rule for 2004, 2005 for Individuals Covered by
Prescription Drug Plan (PDF) (Internal Revenue Service)
Rev. Rul.
2004-38 Clarifies HSA Eligibility Rule for Individuals Covered by
Prescription Drug Plans (PDF) (Internal Revenue Service)
IRS Provides
Safe Harbor for Preventive Care Benefits Under High-Deductible Health
Plan (PDF) (Internal Revenue Service)
HSAs
Established Before April 15, 2005 Can Cover Expenses Incurred On or
After January 1, 2004 (PDF) (Internal Revenue Service)
Frequently Asked Questions About Health Savings Accounts (HSAs)
(U.S. Treasury Department)
Text of Rev.
Rul. 2004-45 on Interaction of Health Savings Accounts with Other
Health Arrangements (PDF) (Internal Revenue Service)
JS-1535: Treasury Clarifies Interaction Of Health Savings Accounts
With Other Employer-Provided Health Reimbursement Plans
Draft Form Issued
by IRS: Model Health Savings Account for Use by Trustees (PDF)
(Internal Revenue Service)
Draft Form Issued
by IRS: Model Health Savings Account for Use by Custodians (PDF)
(Internal Revenue Service)
Text of Notice
2004-50 Providing 88 Q&As on Health Savings Accounts (PDF)
(Internal Revenue Service)
30 pages. Excerpt: "This notice provides guidance on Health
Savings Accounts.... Notice 2004-2, 2004-2 I.R.B. 269,
provides certain basic information on HSAs in question and
answer format. This notice addresses additional questions
relating to HSAs."
Text of Notice
2004-50 Providing 88 Q&As on Health Savings Accounts (PDF)
(Internal Revenue Service) (Revised and corrected--Aug. 9, 2004)
32 pages
IRS Announcement 2004-67 (Sept. 7, 2004) (page 54 of 57)
CORRECTIONS
"The last sentence in A14 of Notice 20042 which currently
reads, After an individual has attained age 65 (the Medicare
eligibility age), contributions, including catch-up
contributions, cannot be made to an individuals HSA, is
corrected to read as follows: After an individual has
attained age 65 and becomes enrolled in Medicare benefits,
contributions, including catch-up contributions, cannot be
made to an individuals HSA. Additionally, the terms becomes
eligible for in the first sentence of the Example in A14 of
Notice 20042 are replaced by becomes enrolled in.
Final Versions of Combined HSA/Archer
MSA Reporting Forms and Instructions for Trustees and
Custodians:
Form
1099-SA and
Instructions
Form
5498-SA
Text of Proposed Regs for Medicare Prescription Drug Benefit
(PDF)
233 pages. (Centers for Medicare & Medicaid Services,
Department of Health and Human Services)
Overview of Health Savings Accounts With Chart Comparison to
Archer MSAs, HRAs and FSAs (PDF) (Miller &
Chevalier Chartered)
How
Health Savings Accounts Compare To FSAs and HRAs (Groom Law
Group)
Overview:
Health Savings Accounts-- Favorable IRS and DOL Guidance (Groom
Law Group)
Analysis: Comprehensive HSA Guidance Clarifies Many Issues,
Sets Forth Several New Rules (Groom Law Group)
ERIC Summary Outline for Employer Sections (Title 1; J & R) of
the Medicare Regulations (ERISA Industry Committee)
ABA Joint Committee on Employee Benefits
Agency Q-As
ABA Reports Various Employee Benefit Regulators' Views on
Health Issues (Deloitte's Washington Bulletin)
Overview: 2005 Medicare Premiums, Deductibles and Coinsurance
(The Segal Company)
HSA Adjudication Is "Between the Taxpayer, God, and the IRS"
(Spencer Benefits Reports)
Overview: Irs, Treasury Resolve Key HSA Issues
(Business Insurance)
American Benefits Council Comments on IRS HSA Guidance (PDF)
(American Benefits Council)
Not Everyone Sees Health Savings Accounts as a Panacea -- Wait and
See Attitude Reported (Workforce Management)
AMA's 'Health Savings Accounts at a Glance' Brochure Explains How
Health Savings Accounts Work (PDF) (American Medical
Association)
Chart: 2005 Minimums and Maximums for High-Deductible Health
Plans, HSAs and MSAs (The Segal Company)
Excerpt: "The Internal Revenue Service (IRS)
recently released Revenue Procedure 2004-71, which announced
various inflation-adjusted amounts for 2005.1 The new numbers
for high-deductible health plans (HDHPs), Health Savings
Accounts (HSAs) and Archer medical savings accounts (MSAs) are
shown in the first of the two charts below. The second chart
notes the maximum annual HSA contributions for 2005."
Three Employers
Compare Consumer-Directed Health Plan Design Notes During
Audioconference (INSIDE CONSUMER-DIRECTED CARE via
AISHealth.com)
Excerpt: "Although their plan designs are
different, three benefits leaders who helped launch
consumer-directed health (CDH) plans for their employers agree
that their core reasons for implementing a CDH plan are the
same: provide an incentive for employees to be better consumers
of health care. Employee benefits leaders representing three CDH
strategies -- from three different administrators -- discussed
the design elements of their plans during a Nov. 10
audioconference sponsored by AIS."
HSA Road Rules for Consumers, Employers, Insurers, Banks, Credit
Unions and Administrators (PDF) (HSA Coalition)
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U.S. Health-care Crisis & ERISA Criminal Enforcement
950,000 MD's Settled With
Aetna & Cigna on ERISA
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Happy or Sad
30th Birthday To ERISA?
(Copyright
© 2004
by
Jin Zhou, ERISAclaim.com)
Sept. 2, 2004
On Sept. 2, 1974, exactly 30
years ago today, ERISA, The Employee Retirement Income Security Act,
was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to protect employees in pension and
welfare plans, to provide uniform federal protections in response to
the failure of the Studebaker Co. in December 1963, with thousands
of long-service employees cheated out off their promised pensions,
and to preempt any state laws when the employees pension and welfare
benefits were threatened. 30 years later, ERISA Failure in its
compliance and enforcement left thousands of retirees without
medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout.
ERISA Failure Syndrome
U.S. Healthcare Crisis
Trilogy
Jin Zhou Identifies "ERISA Failure" That Killed
U.S. Healthcare
"Failure of Imagination"
Again?
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ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension
Insurance Program (Spencer Benefits Reports)
Excerpt: "The seed for ERISA
was planted with the failure of the Studebaker Company in December
1963, leaving thousands of long-service employees without their
promised pensions."
A Hard-to-Swallow Lesson on Pensions
and Promises and ERISA
(The New York Times; one-time
registration required)
Excerpt: "Hundreds of people
here in western New York, all
closing in on retirement, have
learned a bitter lesson about
pensions and the law that
guarantees them. Two years ago,
their employer, ... unexpectedly
started urging them to take their
pensions early, warning that they
would otherwise lose their right
to take their benefits in a single
check. The workers signed up to
receive their money right away,
but the money was much less than
they had earlier been told they
had coming."
The Economic Downturn and Changes in Health Insurance Coverage,
2000-2003, (Kaiser
Commission on Medicaid and the Uninsured)
 Executive
Summary (.pdf)
 Report
(.pdf)
"EXECUTIVE SUMMARY
The number of uninsured Americans under age 65
increased by 5.1million between 2000-2003 largely driven by continuing
declines in employer sponsored insurance. ....."
The Supreme Court and Employee Health
Insurance (FindLaw's
Writ - Sebok)
"What Americans
generally don't know, however, is
that this issue isn't restricted to
the Congress or the Executive. To
the contrary, the U.S. Supreme Court
has been nationalizing one important
aspect of health care in this
country: the administration of
medical health insurance offered by
employers to their employees.
This creeping
nationalization has been achieved
slowly and surely by the expansion
of the court's interpretation of an
important federal law: the Employee
Retirement Income Security Act
(ERISA)."
Inquiry on Medicare Finds Improper Limits on
Choices of Health Care Providers (The New York Times;
one-time registration required)
Excerpt: "Federal investigators
said Monday that the Bush
administration had improperly allowed
some private health plans to limit
Medicare patients' choice of health
care providers, including doctors,
nursing homes and home care agencies."
Medicare Demonstration PPOs: Financial and Other
Advantages for Plans, Few Advantages for Beneficiaries
GAO-04-960, September 27, 2004
Abstract
Highlights-PDF
PDF
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Brief Summary Of
the
New Regulation
for Physicians and
ERISA Plans/TPAs |
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Effective Date: January 01, 2003 |
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For
Physicians and Health-care Providers |
For
Insurance Companies
ERISA Plans/TPAs |
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ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1
(f)(i),
Page 70267-9] |
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1 (f)(i), Page 70267-9] |
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New Assignment of Benefit Form Required for
Appeals and Claim Dispute
(DOL
FAQ, B2-B3) |
No New Legal Assignment of Benefit Form, No
Obligations to Physicians and Health-care Service Providers
(DOL
FAQ B2),
otherwise Obligations to Disclose to Both Patients and Providers
(DOL FAQ B-3) |
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No written appeal, no rights, except for claims
involved with urgent care.
[Page 70255 & 70271] |
In claims involved with urgent care,
physicians/health-care providers are to be considered by default as
authorized representatives.
[Page 70255 & 70271] |
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The regulation clarifies for the first time since 1977 and
prohibits anti-assignment provisions in ERISA plans & (footnote 36).
[page 70255 ]
[29 CFR § 2560.503-1 (b) (4) Page 70266] |
Assignments by patients must be absolutely
clear as to what extent and capacity, verifications are permitted &
(footnote 36).
(DOL FAQ B-3)
[page 70255 & 70266]
[29 CFR § 2560.503-1 (b) (4), Page 70266] |
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Must complete required two levels of appeals,
with legal assignment of benefits and specific written request for
disclosure of specific plan documents.
[Page 70253] |
No legal assignment of benefits, no response
required; no specific written request, no disclosure obligated,
however failure to establish and comply with claim procedures,
administrative remedies are considered to be exhausted. Lawsuit may
follow.
[Page 70271] |
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New protections for pre-service claims and
urgent care claims against improper pre-authorization,
pre-certification and utilization review as well as urgent cares.
[Page 70248 & 70271] |
Understanding of differences in pre-service,
urgent care and post-service claims will save big money in fiduciary
breach liability claims and
POSSIBLE
medical malpractice claims. [Page
70248 & 70271] |
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New definitions of relevant documents and
disclosure obligations, no more medical necessity secrets, UCR fee
schedule confidential
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
No legal assignment of benefits, no obligation
to disclose to an assignee, assignment verification by the plan is
allowed and protected.
Update SPD and any guidelines, only use disclosable and
qualified medical claim reviewers.
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
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A Full and Fair Review with new definitions and
protection requires de novo reviews on two appeals by at least four
different people, two different fiduciaries with ERISA plan, and
two different Health-care professionals independent to the ERISA
plan.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
Update
SPDs with New Standards and compliance, specify and designate
only qualified fiduciaries for appeals, establish new complaint
appeal procedures, use only disclosable and licensed as well as
certified health-care professionals for medical reviews,
pre-certification and prior authorizations in every case.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
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New clarifications on state law preemptions and
"independent" medical reviews. No preemption for state laws unless
prevention of the application of the new regulation
[Page 70254] |
Comply with both
the regulation and state laws in claims involving mixed
treatment and eligibility determinations and pure medical treatment
decision-makings.
[Page 70254] |
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New clarifications with new definitions claim
denial/an adverse benefit determination (payment<100% claimed)
or Overpayment, and new protections.
(DOL FAQ C-12) |
Overpayment vs. an adverse benefit
determination, recoupment vs. appeal procedures.
(DOL FAQ C-12) |
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SPDs must
describe...... |
No SPDs, No
decision making |
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Insurance company's decision-making power and
disclosure obligations must be described in SPD
[29 CFR 2520.102-3 (q), Page 70242] |
Fully-insured plans with a health insurance
issuer being wholly or partially responsible for administering the
plan (e.g. payment of claims) must describe insurer's role in SPD.
[29 CFR 2520.102-3 (q), Page 70242] |
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Claim fiduciary, whoever makes denial
appeal decisions, has duties to disclose
SPD and relevant document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan
Fiduciaries" and "Enforce Your Rights."
[29 CFR § 2520.102-3, Page 70243] |
Claim fiduciaries or plan fiduciaries
have new duties to disclose, without charge,
SPD and relevant
document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for
benefits is denied or delayed, or may face up to $110 a day penalty
under "Prudent Actions by Plan Fiduciaries" and "Enforce Your
Rights."
[29 CFR § 2520.102-3, Page 70243] |
|
Failure to timely
make benefit determination and review decisions by the plan
administrator will constitute "deemed denied" review/appeal and
"deemed exhaustion of administrative remedy" under
§ 2560.503-1(l), ("a decision on the
merits of the claim" = de novo judicial review, instead of
deferential judicial review) that will forfeit or preclude
the plan from "deferential review standard" on judicial review in
federal court,
the most important part of "ERISA Shield" on ERISA land.
Gilbertson v Allied Signal Inc |
DOL interprets
§
2560.503-1(l) through CFR accompanying supplementary information on
page 70255: The Departments intentions in including this
provision in the proposal were to clarify that the procedural
minimums of the regulation are essential to procedural fairness and
that
a
decision made in the absence of the mandated procedural protections
should not be entitled to any judicial
deference. |
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More.... |
More.... |
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And
many more new and
important
provisions and protections for health-care providers and
insurance companies/ERISA plans/TPA's, as well as patients and
employers. |
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Kaiser statehealthfacts.org
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Due to the recent demand
from the
ERISA plans and TPA's, we're pleased to announce
that we also provide educational and consulting services to the ERISA plans,
TPA's and managed care organizations on
New
Federal Claim/ERISA Regulations and
Compliance, however we do not provide any services involving actual claim
dispute or legal advice for any legal matter or disputes. |
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Codified in Title 29 of the
Code of Federal Regulations:
Regulations
Selected links:
2520.102-3 Contents of summary plan description.
2560.503-1 Claims procedure. |
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ERISA Laws/Rules
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DOL
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HIPPA Final
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$10,600 ERISA Claim
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| Recent Federal Court Ruling in a Case with
$10,600 medical claim, insurance Co. refused to pay, provider
made numerous demand for payment in almost one year, but no
appeals filed, the court dismissed the lawsuit because provider
failed to exhaust administrative remedy, as required under ERISA,
by filing ERISA claim appeals. This situation is so popular
in health-care community.
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$37,350 ERISA Claim
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| Health-care provider alleged medical claims
submitted to Aetna for reimbursement, Aetna asserted no receipt
of medical claims, no written denials. Health-care
provider failed to present proof of claim submission, claim
denial and ERISA claim appeals. This case was dismissed. ERISA
health-care claims are handled in federal court, state law is
generally not applicable.
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Opinion: Cutting Costs in Half Through Better Management is
Fantasy But Health Care Debate Is Real (The Hartford
Courant)
Excerpt: "If a
talk on economics can have a $650 billion throwaway line,
Treasury Secretary Paul O'Neill delivered it.... "
"O'Neill
insists the problem is not with people, but systems - systems
that invite medical errors, systems that penalize health care
professionals for making honest mistakes, systems that create
the mind-numbing complexity of reimbursement for providers,
systems that reward too much treatment and punish efficiency." |
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ctnow.com
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Health
Cost Trends Shift
"The study said managed care probably has squeezed out all the
savings it can from the nation's health care system and that
employers are turning to other familiar devices such as
increasing premiums and co-payments to trim their costs" |
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