State Regulations and Federally Mandated Benefits

The right to review the medical records that formed the basis for the trustees' decision that they were no longer permanently and totally disabled

The course describes a case where disability retirees were required to submit to physician examinations. When their pensions were terminated, the court ruled they had a right to review the medical records that formed the basis for the trustees' decision. The court relied on DOL regulations regarding participants' right in the claims appeal process.

Only a handful of cases have addressed the issue, resulting in mixed decisions, so preemption is arguable but not guaranteed

The course notes that ERISA does not specifically address privacy questions and that only a handful of cases have addressed whether ERISA preempts state privacy laws such as invasion of privacy. Those court cases have resulted in mixed decisions. There is an argument for preemption, but the result is not guaranteed.

Information reported in summarized or aggregate form where no particular individual is specifically identified

The course states that PHI includes information about plan benefits, individual enrollment data, and an individual's health condition or claims history. However, PHI does not include any information that is available or reported in summarized or aggregate manner so long as a particular individual is not specifically identified.

Government interest exceeds an employee's rights to privacy

The course lists several principles from court cases on medical confidentiality. One of these is that government interest in medical records for legitimate regulatory purposes exceeds an employee's rights to privacy.

Treatment, payment, or healthcare operations

The course states that PHI can be shared with third parties when disclosure is needed for treatment, payment, or healthcare operations purposes. If disclosure is not justified under those categories, the individual's authorization is required.

50 or more employees within a 75-mile radius in the previous year

The course states that a qualified FMLA employer is any employer with 50 or more employees within a 75-mile radius in the previous year, and need only have had 50 employees for 20 weeks the previous year.

Premiums as would be calculated under COBRA, excluding the 2% administrative fee

The course specifies that self-funded employers may only recover their share of allowable premiums as would be calculated under COBRA, excluding the 2% administrative fees. This is distinct from the full COBRA rate that includes the administrative charge.

30 days from the date the premium payment is due

The course states that failure to make a timely premium payment within a 30-day grace period will allow the employer to cease to maintain health coverage on the date the grace period ends.

The employee must have been given written notice at least 15 days prior to the termination of coverage

The course's FMLA regulations section specifies that for an employer to terminate health benefits for failure to make premium contributions, the premium must be more than 30 days overdue AND the employee must have been given written notice at least 15 days prior to the termination of coverage.

On the last day of FMLA leave

The course states explicitly that the COBRA qualifying event occurs on the last day of FMLA leave. The maximum COBRA coverage period is measured from that date.

The successor must consider the predecessor's FMLA coverage, eligibility, and other responsibilities and must restore employment after FMLA leave to the qualified employee

The course describes a successor-in-interest rule analogous to the COBRA successor employer rule. The employer is defined as any successor in interest, so the successor must consider the predecessor's FMLA coverage, eligibility, and other responsibilities when satisfying its own FMLA obligations, and must restore employment after leave.

Such employees are presumed to have met the hours requirement unless the employer can clearly demonstrate they did not work the requisite number of hours

The course states that for employees for whom the employer is not required to maintain records of hours worked (e.g., exempt employees under the FLSA), the final regulations provide that such individuals are presumed to have met the 1,250-hour requirement unless the employer can clearly demonstrate otherwise.

Group health benefits must be restored to at least the same level as when leave commenced

The course states that if the employee chooses no coverage during leave, when the employee returns, group health benefits must be restored to at least the same level as when leave commenced.

No; even if recovery of premiums is otherwise permitted under DOL rules, COBRA continuation coverage cannot be conditioned upon such reimbursement

The course explicitly states that even if recovery of premiums is permitted under DOL rules, the right to COBRA continuation coverage cannot be conditioned upon the employee's reimbursement of the employer for premiums paid during FMLA leave.

It includes conditions that may cause episodic rather than continuing periods of incapacity, such as asthma, cancer, arthritis, diabetes, and epilepsy

The course states that the definition of serious health condition was revised in the final regulations to cover chronic serious health conditions, including conditions that may cause episodic rather than continuing periods of incapacity, giving asthma, cancer, arthritis, diabetes, and epilepsy as examples.

Labor-Management Relations Act, National Labor Relations Act, Railway Labor Act, Labor-Management Reporting and Disclosure Act, and Welfare and Pension Plan Disclosure Act

The course lists five federal labor laws of significance when handling healthcare claims: LMRA, NLRA, Railway Labor Act, LMRDA, and WPPDA.

The collective bargaining agreement has expired and has not been renewed

The course lists three limited circumstances under which federal courts will intrude on arbitration under the LMRA: (1) arbitrator oversteps authority, (2) fraud or misconduct tainted arbitration, and (3) an injunction is required. Expiration of the collective bargaining agreement is not listed as a basis for court intervention.

Health plans were deemed 'other conditions of employment' for collective bargaining purposes, spurring the growth of collectively bargained health plans

The course states that the landmark decision of Inland Steel Corp. v. NLRB resulted in health plans being deemed 'other conditions of employment' for collective bargaining purposes. This important decision spurred the growth of collective bargaining health plans.

A neutral person or umpire must decide, and if the dispute remains unresolved, the nearest federal district court shall adjudicate

The course describes the conditions for Taft-Hartley trusts, including that if trustees deadlock, a neutral person or umpire must decide. If the dispute remains unresolved, the nearest federal district court shall adjudicate.

It did not mandate any benefit or funding minimum

The course states that the WPPDA was the pre-ERISA version of mandated reporting and disclosure. Its purpose was to combat abuses by requiring full disclosure to the DOL. Significantly, this act did not mandate any benefit or funding minimum.

The qualified domestic relations orders established by the Retirement Equity Act of 1984

The course states that QMCSOs are modeled after the qualified domestic relations orders brought on for retirement plans by the Retirement Equity Act of 1984.

Bob should be shown as a separate single-coverage participant in his own right with assignment rights to Mary, not as a dependent of John

The course states that by force of ERISA, Bob is to be a plan participant in his own right, not merely as a special dependent of John. Bob should be designated as a special participant with assignment rights to Mary, the one financially responsible. John should be shown as single coverage, and Bob should be shown as single coverage separately.

The child was born out of wedlock, is not claimed as a dependent on the parent's tax return, or does not reside with the parent

The course states that SSA §1908 prohibits any plan, insurer, or HMO from denying enrollment to a dependent child because the child was born out of wedlock, is not claimed as a dependent on the parent's income tax return, or does not reside with the parent.

50% of the employee's disposable income, as set by Section 303(b) of the Consumer Protection Act

The course states that the plan must permit the employer to do a payroll deduction for the healthcare costs from the employee's pay, subject to the limits of Section 303(b) of the Consumer Protection Act, which is generally capped at 50% of the employee's disposable income.

When a state medical support statute is more liberal than SSA §1908 demands, whether the additional benefit is preempted by ERISA §514 is unclear

The course identifies the troublesome preemption question: ERISA §514 preempts state statutes affecting employee benefit plans but now excepts state medical child support or domestic order statutes. The difficult question is whether additional benefits mandated by a state statute that exceed SSA §1908 requirements are preempted.

Pre-existing condition limitations may not be applied any differently than to newborns who are timely enrolled

The course states that pre-existing condition limitations may not be applied to adopted children who are timely enrolled any differently than to newborns who are timely enrolled.

Adopted children of retirees must be covered, and the participant is not required to pay back plan benefits if the adoption is never finalized

The course lists several DOL guidance points: adopted children of retirees must be covered; only if the parent is a party to a legally enforceable agreement for full or partial support will such adoption be recognized; the participant is not required to pay back plan benefits if the adoption is never finalized; and birth expenses of the natural mother are not covered.

The number of employees on each working day during 20 or more calendar weeks in either the current or prior calendar year

The course states that the under-20-employees test measures the number of employees (each working day) of 20 or more calendar weeks in either the current or prior calendar year. Below 20 employees, the employer plan will always be secondary to Medicare, except for the first 18 months of ESRD.

Being on the payroll for FICA purposes, which includes sick leave, short-term disability, leave of absence, or vacation where there is an expectation of return to work

The course defines 'active' as being on the payroll for FICA purposes. It does not mean being long-term disabled or retired. It does mean being on sick leave, short-term disability, leave of absence, or vacation where there is an expectation of return to work, even if temporarily off the payroll.

The first 18 months of Medicare eligibility or entitlement because of ESRD

The course states that for covered persons who have Medicare entitlement or eligibility because of permanent kidney failure, during the first 18 months of the eligibility or entitlement, the plan must be the primary payer.

Imposing higher premiums, higher deductibles or coinsurance, longer waiting periods, lower annual or lifetime benefits, or more restrictive preexisting illness conditions than for those under 65

The course provides an extensive list of prohibitions for working aged plans, including that they must not impose higher premiums, higher deductibles or coinsurance, longer waiting periods, lower annual or lifetime benefits, or more restrictive preexisting illness conditions for those 65 or over compared to those under 65.

The determination of ESRD after Medicare has assumed a primary position has no effect; Medicare continues to be primary

The course explains that with dual entitlement, the order matters. Under Order 1 (age/disability entitlement first, then ESRD), the determination of ESRD after Medicare has assumed a primary position has no effect—Medicare continues to be primary.

Either apply the same aggregate limit to mental health benefits without distinguishing between medical/surgical and mental health, or not impose any aggregate limit on mental health benefits that is less than the medical/surgical limit

The course states that if the plan includes an aggregate limit on substantially all medical and surgical benefits, the plan must either apply the limit to mental health benefits without distinguishing between medical/surgical and mental health benefits, or not include any aggregate limit on mental health benefits that is less than the plan's aggregate limit on substantially all medical and surgical benefits.

The private plans should be ordered as primary/secondary as though Medicare did not exist, and Medicare will be tertiary

The course cites Perry v. Food and Commercial Workers Trust Fund and Baptist Memorial Hospital v. Pan American Life Insurance Company, stating that the private plans should be primary/secondary, determined as though Medicare did not exist; Medicare will be tertiary.

The plan remains primary for the first 18 months of ESRD, even when the participant or spouse later became eligible for Medicare because of disability or age

The course describes Order 2 (ESRD first, then age/disability entitlement): the plan remains primary for the first 18 months of ESRD, even when the participant or spouse later became eligible for Medicare because of disability or age.

Offering, facilitating, or subsidizing a plan intended to supplement only Medicare's benefits

The course states that participants and their spouses entitled to Medicare must be informed they may reject plan coverage and choose Medicare as primary. However, if they reject coverage, the employer may not offer them, facilitate, or subsidize a plan intended to supplement only Medicare's benefits.

Medicare secondary-payer provisions, end-stage renal provisions, and pediatric vaccine provisions

The course defines a nonconforming group health plan as one that fails to meet requirements relating to Medicare secondary-payer provisions, end-stage renal provisions, and pediatric vaccine provisions.

A tax equal to 25% of the employer's or employee organization's expenses incurred during the calendar year for each nonconforming group health plan

The course states that the CFR imposes on any employer or employee organization that contributes to a nonconforming group health plan a tax equal to 25% of the employer's or employee organization's expenses incurred during the calendar year for each group health plan to which they contribute.

Prevent employees on military leave from losing employer-sponsored healthcare, and prevent returning military personnel from having to satisfy new waiting and/or preexisting conditions

The course states the purpose of the act was twofold: (1) prevent employees on military leave from losing their employer-sponsored healthcare, and (2) prevent returning military personnel from having to satisfy new waiting and/or preexisting conditions.

Amend the plan to grant an extended leave of absence with no COBRA; terminate employment and not deny COBRA if requested; or do neither, meaning the employee is off the plan and primary to CHAMPUS while COBRA must be offered due to hours reduction

The course lists three employer options: (1) amend the plan giving the employee an extended leave of absence with no COBRA involved; (2) terminate employment and not deny COBRA if requested; or (3) do neither, meaning the employee is off the plan and primary to CHAMPUS, with COBRA offered due to the hours reduction qualifying event.

Five years

The course states that the cumulative length of an employee's absences from a position cannot exceed five years. This was extended from four to five years by changes made since the act was passed.

Reemployed persons are guaranteed pension plan benefits that accrued during military service, regardless of whether the plan is a defined benefit or defined contribution plan

The course lists significant changes since the act was passed, including that reemployed persons are guaranteed pension plan benefits that accrued during military service, regardless of whether a plan is a defined benefit plan or a defined contribution plan.

31 or more days

The course notes as a significant change since the act was passed that reemployment eligibility documentation may be required of employees who are absent for military service lasting 31 or more days.

18 months

The course lists COBRA-like health benefit continuation for up to 18 months during military service as one of the significant changes to existing rules and regulations since USERRA was passed.

Non-service-related treatment provided in or by VA facilities

The course states that the Consolidated Omnibus Budget Reconciliation Act of 1985 requires the VA to bill private-sector employee benefit plans for services rendered for non-service-related treatment in or by VA facilities.

VA bills could make such a plan primary to Medicare because VA is prohibited from billing Medicare; the solution is to encourage Medicare-age veterans to use non-VA facilities

The course states that VA is prohibited from billing Medicare by federal law. Retiree health plans that pay secondary to Medicare should be on guard for VA bills that could make such plan primary to Medicare. The only way to avoid paying primary to Medicare is to encourage Medicare-age veterans to use non-VA facilities.

96 hours

The course states that self-funded health plans may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child following a Caesarean section to less than 96 hours.

Imposing deductibles, coinsurance, or other cost sharing for hospital stays in connection with childbirth, provided the same level applies throughout the entire stay

The course states the act does not prevent a group health plan from imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital stays in connection with childbirth, except that the same level must apply throughout the stay. The plan may not require prior authorization, offer monetary incentives for early discharge, or provide less favorable benefits for any portion of the stay.

No aggregate limit may be imposed on mental health benefits

The course states that if the plan doesn't include an aggregate limit on substantially all medical and surgical benefits, no limit may be imposed on mental health benefits.

Plans were required to conduct a written assessment of whether the plan imposes nonquantitative treatment limitations more stringently upon mental health or substance use disorder benefits compared to medical/surgical benefits

The course states that starting in 2021, self-funded group health plans were required to conduct a written assessment of whether the plan imposes nonquantitative treatment limitations more stringently upon mental health or substance use disorder benefits compared to medical/surgical benefits.