Register Now For 8/24 2010 Health Plan Update Briefing

July 30, 2010

Learn If Your Plan Will Be Grandfathered Plan & What You Must Do Now To Meet Key 2010/2011 Affordable Care Act & Other Federal Health Plan Compliance Deadlines

A Solutions Law Press Live Internet Broadcast Briefing

August 24, 2010

10:00 A.M.-12:30 P.M. Eastern

11:00 A.M.- 1:30 P.M. Central

9:00 A.M-11:30 A.M. Pacific

Solutions Law Press invites you to catch up on the latest guidance about the new group health plan mandates imposed under the Patient Protection and Affordable Care Act (Affordable Care Act) and other federal health plan regulations by participating in a live 2010 Health Plan Update” internet[*] broadcast briefing on Tuesday, August 24 2010.  The briefing will be conducted via live video broadcast from 11:00 A.M.-1:30 P.M. Central Time.  Register here for a registration fee of $150.00[†] per participant.   

Affordable Care Act Requires Prompt Action By Group Health Plans, Sponsors, Fiduciaries & Administrators

The Affordable Care Act and other impending federal health plan changes will require employment-based group health plans, their employer and other plan sponsors, plan fiduciaries, plan administrators and other service providers and insurers to make quick decisions and to act quickly to meet impending federal compliance deadlines while preserving flexibility.  All employer and other group health plan sponsors, fiduciaries, insurers and administrators must act quickly to update their health plan documents, communications, insurance and vendor agreements and other practices to comply with new federal requirements that become effective under the Affordable Care Act on the first day of the plan year beginning after September 22, 2010 and various other changes in federal health plan rules effective or scheduled to take effect during 2010 or 2011 plan years.  Many plan sponsors also may need to act quickly to cancel or revise plan design or vendor changes planned or already implemented since March 23, 2010 to position their health plan to qualify for grandfather status.  Quick action also may be needed to claim small employer tax credits, retiree medical subsidies or other benefits. 

Register Now To Get Key Information In August 24 Internet Briefing

The August 24, 2010 “2010 Health Plan Update” briefing will cover the latest guidance on Affordable Care Act and other federal health plan regulatory changes impacting employment-based group health plans and their sponsors for plan years beginning between September 23, 2010 and September 22, 2011 and other key information to help employers, group health plans, insurers, plan administrators, fiduciaries, broker and others working with these plans to understand and respond to these new requirements including:

  •  How to qualify your health plan as a grandfathered plan under Affordable Care act
  • How to decide if maintaining grandfathered plan status is worthwhile
  • Claims & appeals requirements for grandfathered & non-grandfathered plans
  • Preventive care coverage mandates & wellness program requirements & rules under Affordable Care Act & other federal regulations
  • Updated dependent child eligibility, pre-existing condition & other requirements for grandfathered & non-grandfathered plans
  • Special enrollment, preexisting condition & other eligibility mandates for grandfathered & non-grandfathered plans under new Affordable Care Act, new FMLA, COBRA, Michelle’s Law, HIPAA & other federal regulations
  • Mental health & substance abuse, provider choice & other benefit mandates under Affordable Care Act, Mental Health Parity & other federal rules
  • Update on other recent & pending Affordable Care Act group health plan rule guidance
  • Tips to review & update your plans, vendor agreements & processes to meet Affordable Care Act & other federal group health plan dictates
  • Expected future Affordable Care Act & other federal rule changes & tips for preparing
  • Practical strategies for responding to new requirements & changing rules
  • Participant questions

About The Presenter

The program will be conducted by attorney Cynthia Marcotte Stamer. With more than 23 years of experience advising employers, group health plans, plan fiduciaries, plan administrators and vendors, insurers and others about health plan and managed care matters, Ms. Stamer is nationally known for her work, publications and presentations on health plan and other employee benefit, health care and insurance matters. 

Current Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Committee, a Council Member of the ABA Joint Committee on Employee Benefits and Past Chair of the ABA Health Law Section Managed Care & Insurance  Interest Group, Ms. Stamer continuously advises employers, health plans, plan sponsors, fiduciaries, plan administrators, plan vendors, insurers and others about health program related legal, operational, documentation, public policy, enforcement, privacy, technology, litigation and risk management and other concerns. Ms. Stamer also publishes and speaks extensively on these and other health and managed care program concerns and practices.  Her insights on these and related topics have appeared in Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, Managed Healthcare, Health Leaders, various ABA publications and a many other national and local publications.  To contact Ms. Stamer or for additional information about Ms. Stamer, her experience, involvements, programs or publications, contact Ms. Stamer at (469) 767-8872 or via e-mail here, or see here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.  If you do not wish to receive these updates in the future, send an e-mail with the word   ©2010 Solutions Law Press.   All rights reserved. 


[*] A limited number of participants on a space available basis will have the opportunity to participate in the briefing as a member of the live studio audio audience in Plano, Texas.  Interested persons should e-mail support@solutionslawyer.net. 

[†] Discounts available for groups registering three or more participants.  Sponsorship opportunities also available.  For information, E-mail support@solutionslawyer.net.


Congress & Labor Department Considering Tightening of Retirement Plan Regulations

July 28, 2010

With health care reformed passed, Congressional leaders are considering the need to change federal retirement plan rules under the Employee Retirement Income Security Act or other laws.  Employer and other retirement plan sponsors, fiduciaries, administrators, advisors and vendors should keep a close eye out for legislation or regulation that would impose additional obligations on the administration of retirement plans in light of this new scrutiny.

In June 16, 2010 testimony before the Senate Special Committee on Aging, Assistant Secretary for the Employee Benefits Security Administration (EBSA) Phyllis Borzi discussed steps the Labor Department is taking to explore lifetime income options for participants and beneficiaries in private-sector retirement plans.  Her June 16 testimony, Ms. Borzi told Congress members the IRS and Labor Department are “committed to exploring what can be done through interpretation, regulation and legislation” to address the shift of financial risks of retirement to employees arising from the shift from defined benefit to defined contribution plans.

Ms. Borzi indicated the Departments are looking at regulatory and other changes to provide better information and tools to require or encourage retirement plans to offer lifetime income options and communication and other tools to help workers better prepare to make their savings last throughout their retirement years.  She also reported that more than 800 comments were received in response to a Request for Information on lifetime income option alternatives jointly issued by the Labor Department and Internal Revenue Service.  Ms. Borzi indicated that the Request for Information is intended to start a national dialogue about the reforms needed in this area and how best to address those needs.

Public policy initiatives have primarily focused on the accumulation stage of retirement planning. Only recently has there been a greater focus on the decumulation stage of retirement, and what workers and retirees do upon receipt of their retirement savings. Given the potential utility of lifetime income to participants in efficiently constructing their personal retirement incomes, Ms. Borzi told Congress the Labor Department will be considering if additional information could assist participants in this regard, and what impediments exist to providing such information. Some policy makers believe that providing participants with both the lump sum value of their accounts and the value of an equivalent income stream would be very valuable to workers who have to figure out how to make their savings last throughout their retirement years.

While Ms. Borzi said the Labor Department is still evaluating options, her comments clearly reflect that the Labor Department’s emphasis will focus heavily on promoting greater security for a lifetime stream of income after retirement.  Her statements also signal that retirement plan sponsors, fiduciaries and vendors should expect to see changes in communication, funding and other retirement plan rules.  If you need assistance monitoring or responding to retirement plan or other employee benefits, employment or related regulations, or dealing with other employment or employee benefit concerns, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or cstamer@solutionslawyer.net.

About the Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer has more than 23 years experience working with employers, professional employment organizations, employee benefit plan sponsors and administrators and others on a wide range of labor and employment, employee benefits, and other management matters.  A featured speaker in the June 29 ABA JCEB Teleconference on Worker Classification, Ms. Stamer is The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, the editor of Solutions Law Press HR & Benefits Update.  Ms. Stamer also is recognized for her lengthy resume of publications, industry leadership, workshops and presentations on worker classification, and other employment, employee benefits, and related workforce and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience here. 

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.

©2010 Solutions Law Press. All rights reserved.


Testimony Highlights Growing Exposure of Businesses Misclassifying Workers; Businesses Should Act to Minimize Risks

July 27, 2010

Testimony by Deputy Secretary of Labor Seth Harris recently highlights the growing scrutiny by the U.S. Department of Labor on perceived abuses by employers in the misclassification as workers as independent contractors, exempt employees, or otherwise. This growing scrutiny makes it advisable that business review situations within their organizations where workers are treated as contractors, leased employees or exempt employees in light of existing labor, employment, tax and other regulations.

In his July 17, 2010 testimony to a Senate Committee on Health, Education, Labor and Pensions’ hearing on worker misclassification, Harris testified that the Labor Department worker misclassification has become an increasingly common problem.  According to Harris, employer misclassification of workers results in workers being denied benefits; gives an unfair advantage to employers who intentionally misclassify workers as independent contractors; and causes state and federal governments to lose tax revenue. In his testimony, Harris outlined the scope of the problem, as well as the Labor Department’s efforts to tackle the issue and its support of Congressional action to make misclassification illegal.  Read Harris’ Testimony.

Harris’ testimony highlights the significant expansion in governmental and private plaintiff awareness of worker classification practices as a weak point in many business operations.  The Congressional Hearing shows the increased interest by Congress in the adequacy of enforcement and regulation of worker classification relationships.  While Congress considers tighter regulation, federal and state agencies and private plaintiffs increasingly are using worker classification issues to strike out at businesses.  Since taking office, the Obama Administration has made review and enforcement of worker classification a priority in the Labor Department, Internal Revenue Service and other agencies.  Meanwhile, workers and others frequently are challenging the classification of workers as independent contractors, leased employees, salaried exempt employees or otherwise to recover valuable settlements or damages in wage and hour, worker’s compensation, employee benefit, employment discrimination, tort and other claims.

In light of the risks resulting from this growing scrutiny of worker classification practices, businesses should review situations within their organizations where workers are treated as independent contractors, leased employees, exempt employees or otherwise exempt from typical rules applicable to employees within the scope of attorney-client privilege.  When necessary, businesses should explore restructuring existing relationships if the review suggests the relationship might be difficult to defend against a government or other challenge.  When electing to continue to classify a worker as working in a capacity other than that of an employee, as an exempt employee, or both, organizations should carefully document the grounds under which the business.

For more information about worker classification rules and associated exposures under tax, employee benefit, labor and employment and certain other rules, concerned business leaders may want to listen to a recording of the June 29, 2010 Worker Classification: Employee Plans & Employment Tax teleconference sponsored by the American Bar Association Joint Committee on Employee Benefits.  Concerned business leaders also might be interested in other related articles by the author including:

If you need assistance with reviewing or defending your organization’s worker classification or other labor or other employment or employee benefit practices, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or cstamer@solutionslawyer.net.

About the Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer has more than 23 years experience working with employers, professional employment organizations, employee benefit plan sponsors and administrators and others on a wide range of labor and employment, employee benefits, and other management matters.  A featured speaker in the June 29 ABA JCEB Teleconference on Worker Classification, Ms. Stamer is The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, the editor of Solutions Law Press HR & Benefits Update.  Ms. Stamer also is recognized for her lengthy resume of publications, industry leadership, workshops and presentations on worker classification, and other employment, employee benefits, and related workforce and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience here. 

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.

©2010 Solutions Law Press. All rights reserved.


Businesses Employing Children Should Review & Tighten Practices In Light of Tightened Rules & Increased Penalties

July 27, 2010

Employers violating child labor laws now face tighter rules and increased penalties under new regulations published last week by the Department of Labor.  These increased fines, coupled with important recent revisions to the child labor rules and reinvigorated enforcement by the Wage and Hour Division significantly increase the risks for employers that hire young workers that fail to follow these rules.   With summer the time that youth employment traditionally peaks, employers hiring workers under age 18 should review their practices for compliance with federal and state child labor laws to minimize exposures to these increased penalties.

Federal Regulation of Employment of Children

The federal Fair Labor Standards Act establishes strict rules governing the employment of children.  The Labor Department recently published final regulations updating protections for young employees in nonagricultural work. Under these regulations, for instance, key provisions prohibit the employment of individuals under age 18 in hazardous nonagricultural occupations. Individuals under age 16 may work only limited hours outside of school hours. Additionally, 14- and 15-year-olds may not work before 7 a.m. or later than 7 p.m. (9 p.m. from June 1 through Labor Day).  There are additional restrictions on the types of jobs and hours 14- and 15-year-olds may work.  

Special rules also apply to the employment of children in agriculture and the Obama Administration presently is reviewing these regulations to assess whether to further tighten these requirements.  In the meanwhile, federal rules regarding agricultural employment presently allow employment of individuals under age 12 with parental consent, but only on very small farms that are not subject to the federal minimum wage requirements. Individuals ages 12 and 13 may be employed in agricultural work on the same farm as a parent, or with a parent’s consent. Generally, no hired farm worker under age 16 years may perform hazardous work or be employed during school hours.

Increased Penalties for Violating Child Labor Rules

Under tough new penalties announced by the U.S. Department of Labor on July 16, 2010, employers who illegally employ individuals ages 12 or 13 will face a penalty of at least $6,000 per violation. If a worker is under 12 years of age and illegally employed, the penalty will be at least $8,000. Penalties for illegally employing workers under age 14 could be raised to $11,000 under certain conditions.

As summer traditionally is a time when youth employment peaks, summer employment practices of employers that hire young workers makes it particularly important that employers of these young workers take steps to review their current practices to confirm their compliance with these new rules to minimize penalty exposures. If you need assistance with reviewing your organization’s child labor or other employment or employee benefit practices, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or cstamer@solutionslawyer.net.

About the Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer has more than 23 years experience working with employers, professional employment organizations, employee benefit plan sponsors and administrators and others on a wide range of labor and employment, employee benefits, and other management matters.  The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, the editor of Solutions Law Press HR & Benefits Update and, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other health industry and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience here. 

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.   

©2010 Solutions Law Press. All rights reserved.


2010 Health Plan Update: Learn What You Must Do Now To Meet Key 2010/2011 Affordable Care Act & Other Federal Health Plan Deadlines

July 23, 2010

August 24, 2010

10:00 A.M.-12:30 P.M. Eastern ¨ 11:00 A.M.- 1:30 P.M. Central ¨ 9:00 A.M-11:30 A.M. Pacific

Solutions Law Press invites you to catch up on the latest guidance about the new group health plan mandates imposed under the Patient Protection and Affordable Care Act (Affordable Care Act) and other federal health plan regulations by participating in a live 2010 Health Plan Update” internet[*] broadcast briefing on Tuesday, August 24 2010.  The briefing will be conducted via live video broadcast from 11:00 A.M.-1:30 P.M. Central Time.  Register here for a registration fee of $150.00[†] per participant.   

Affordable Care Act Requires Prompt Action By Group Health Plans, Sponsors, Fiduciaries & Administrators

The Affordable Care Act and other impending federal health plan changes will require employment-based group health plans, their employer and other plan sponsors, plan fiduciaries, plan administrators and other service providers and insurers to make quick decisions and to act quickly to meet impending federal compliance deadlines while preserving flexibility.  All employer and other group health plan sponsors, fiduciaries, insurers and administrators must act quickly to update their health plan documents, communications, insurance and vendor agreements and other practices to comply with new federal requirements that become effective under the Affordable Care Act on the first day of the plan year beginning after September 22, 2010 and various other changes in federal health plan rules effective or scheduled to take effect during 2010 or 2011 plan years.  Many plan sponsors also may need to act quickly to cancel or revise plan design or vendor changes planned or already implemented since March 23, 2010 to position their health plan to qualify for grandfather status.  Quick action also may be needed to claim small employer tax credits, retiree medical subsidies or other benefits. 

August 24 Live Briefing Provides Key Information By Internet Broadcast

The August 24, 2010 “2010 Health Plan Update” briefing will cover the latest guidance on Affordable Care Act and other federal health plan regulatory changes impacting employment-based group health plans and their sponsors for plan years beginning between September 23, 2010 and September 22, 2011 and other key information to help employers, group health plans, insurers, plan administrators, fiduciaries, broker and others working with these plans to understand and respond to these new requirements.  The briefing will include:

  • How to qualify your health plan as a grandfathered plan under Affordable Care Act
  • How to decide if maintaining grandfathered plan status is worthwhile
  • Claims & appeals requirements for grandfathered & non-grandfathered plans
  • Preventive care coverage mandates & wellness program requirements & rules under Affordable Care Act & other federal regulations
  • Updated dependent child eligibility, pre-existing condition & other requirements for grandfathered & non-grandfathered plans
  • Special enrollment, preexisting condition & other eligibility mandates for grandfathered & non-grandfathered plans under new Affordable Care Act, new FMLA, COBRA, Michelle’s Law, HIPAA & other federal regulations
  • Mental health & substance abuse, provider choice & other benefit mandates under Affordable Care Act, Mental Health Parity & other federal rules
  • Update on other recent & pending Affordable Care Act group health plan rule guidance
  • Tips to review & update your plans, vendor agreements & processes to meet Affordable Care Act & other federal group health plan dictates
  • Expected future Affordable Care Act & other federal rule changes & tips for preparing
  • Practical strategies for responding to new requirements & changing rules
  • Participant questions

About The Presenter

The program will be conducted by attorney Cynthia Marcotte Stamer. With more than 23 years of experience advising employers, group health plans, plan fiduciaries, plan administrators and vendors, insurers and others about health plan and managed care matters, Ms. Stamer is nationally known for her work, publications and presentations on health plan and other employee benefit, health care and insurance matters. 

Current Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Committee, a Council Member of the ABA Joint Committee on Employee Benefits and Past Chair of the ABA Health Law Section Managed Care & Insurance  Interest Group, Ms. Stamer continuously advises employers, health plans, plan sponsors, fiduciaries, plan administrators, plan vendors, insurers and others about health program related legal, operational, documentation, public policy, enforcement, privacy, technology, litigation and risk management and other concerns. Ms. Stamer also publishes and speaks extensively on these and other health and managed care program concerns and practices.  Her insights on these and related topics have appeared in Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, Managed Healthcare, Health Leaders, various ABA publications and a many other national and local publications.  To contact Ms. Stamer or for additional information about Ms. Stamer, her experience, involvements, programs or publications, contact Ms. Stamer at (469) 767-8872 or via e-mail here, or see here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.  If you do not wish to receive these updates in the future, send an e-mail with the word   ©2010 Solutions Law Press.   All rights reserved. 


[*] A limited number of participants on a space available basis will have the opportunity to participate in the briefing as a member of the live studio audio audience in Plano, Texas.  Interested persons should e-mail support@solutionslawyer.net.

[†] Discounts available for groups registering three or more participants.  E-mail support@solutionslawyer.net.


New Affordable Care Act Health Plan Appeals Regulations Require Health Plan Updates

July 23, 2010

Register For August 24th 2010 Health Plan Update To Catch Up On Latest Federal Health Plan Regulations

Employer and other plan sponsors, administrators, and fiduciaries of non-grandfathered group health plans must move quickly to update their plan documents, administrative procedures and agreements, claims and other communications and other processes and procedures to comply with new regulations (Appeals Rules) implementing tightened health plan claims and appeals rules enacted under the Patient Protection & Affordable Care Act (Affordable Care Act) jointly published by the U.S. Departments of Health & Human Services (HHS), Labor (DOL) and Treasury yesterday (July 23, 2010).  The new Appeals Rules are the latest in a wave of new Affordable Care Act and other federal regulations that require quick action by employment based health plans, their employer and other sponsors, fiduciaries, administrators and insurers.  Regulations issued in previous weeks by the Departments define when health plans and health insurance policies qualify as “grandfathered” under the Affordable Care Act and interpret and implement many other federal health plan rule changes enacted by the Affordable Care Act.  In addition to responding to these Affordable Care Act changes, most group health plans also will require updates in response to other federal health plan rule changes beyond those enacted under the Affordable Care Act.  To assist concerned business leaders, plan fiduciaries and plan administrators to understand and cope with these new rules, Solutions Law Press invites you to participate in the live “2010 Health Plan Update,” internet workshop on August 24, 2010 from 11:00 a.m.-1:30 p.m. Central Time.  To register or for other details, see here.

Affordable Care Act Appeals Rules & Other Federal Claims & Appeals Regulations Make Prompt Plan Review & Update Advisable

Currently, all group health plans covered by the Employee Retirement Income Security Act (ERISA) must prudently process and administer claims and appeals using reasonable claims and appeals procedures that comply with detailed Labor Department regulations.  Recent Supreme Court and other decisions send a strong signal that many group health plans, their insurers, and administrators need to tighten their existing documentation and practices to promote the defensibility of claims and appeal decision making under the existing requirements of ERISA and the existing Labor Department regulations implementing these requirements.  These existing claims and appeals requirements generally will continue to apply to all ERISA-covered group health plans without regard to whether the group health plan qualifies as grandfathered or non-grandfathered for purposes of the affordable care act. 

The new requirements generally will apply to claims denials and coverage rescissions made by non-grandfathered health plans beginning with the first plan year beginning after September 22, 2010.  Furthermore, non-grandfathered group and individual health policies subject to the Appeals Rules also may continue to be required to comply with state-mandated external and/or independent review and other state-imposed claims and appeals procedures.   

In addition to complying with existing claims and appeals requirements, the new Appeals Rules also will require that non-grandfathered health plans modify existing claims and appeals procedures to comply with new federal appeals protections mandated under the Affordable Care Act.  The Appeals Rules requirements for internal claims and appeals processes generally will apply to any denial, reduction, or termination of, or failure to provide or make a payment (in whole or in part) for a benefit, including any:

  • Rescission of coverage as defined in the regulations restricting rescissions
  • Determination of an individual’s eligibility to participate in a plan or health insurance coverage
  • Determination that a benefit is not a covered benefit
  • Imposition of a preexisting condition exclusion, source-of-injury exclusion, network exclusion, or other limitation on otherwise covered benefits
  • Determination that a benefit is experimental, investigational, or not medically necessary or appropriate
  • Other denial, reduction, or termination of, or a failure to provide or make a payment (in whole or in part) for a benefit can include both pre-service claims (for example, a claim resulting from the application of any utilization review), as well as post-service claims and
  • Any other instance where a plan pays less than the total amount of expenses submitted with regard to a claim, including a denial of part of the claim due to the terms of a plan or health insurance coverage regarding co-payments, deductibles, or other cost-sharing requirements.

When applicable, the new Appeals Rules among other things will require that non-grandfathered group health plans and insurers issuing non-grandfathered health insurance plans and policies:

  • Implement specified internal and external review procedures
  • Must continue to provide continued coverage pending the outcome of an internal appeal
  • Comply with the Appeals Rules’ additional criteria for ensuring that a claimant receives a full and fair review in addition to complying with the requirements of existing Labor Department claims and appeals procedures.

Highlights of some of these fair review requirements include:

  • Timely allowing a claimant to review the claim file and to present evidence and testimony as part of the internal claims and appeals process
  • Before issuing a final internal adverse benefit determination based on a new or additional rationale, timely proving the claimant free of charge, with the rationale
  • Complying with the Appeals Rules’ requirements for ensuring that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision
  • Providing certain notifications regarding appeals and other rights as required by the Appeals Rules

The Appeals Rules also state that if a plan or issuer that fails to strictly adhere to all of its requirements with respect to a claim, the claimant may initiate an external review and pursue any available remedies under applicable law, such as judicial review regardless of whether the plan or issuer asserts that it substantially complied with these requirements or that any error it committed was de minimis.

Both Grandfathered & Non-Grandfathered Plans Should Review Existing Claims & Appeals Procedures For Compliance With Existing Labor Department Regulations

Grandfathered health plans will not be required to comply with the new Appeals Rules. Like non-grandfathered plans, however, grandfathered plans will remain covered by the current claims and appeals requirements of ERISA and the existing Labor Department regulations.  Along the Labor Department updated its existing claims and appeals regulations a decade ago, many plan fiduciaries, administrators and insurers have failed to fully update their plan documentation, processes and notifications to comply with these highly specific and detailed requirements. Furthermore, most grandfathered health plan sponsors and administrators also will want to consider whether any tightening of their health plan’s claims and appeals processes is warranted by language contained in the preamble to the Appeals Rules that that clarifies the Labor Department’s interpretation of existing claims and appeals procedures.

Other Affordable Care Act & Other Health Plan Rule Changes Require Prompt Action By Group Health Plans, Sponsors, Fiduciaries & Administrators

The Appeals Rules are the latest in a series of recently-issued guidance implementing various health coverage requirements of the Affordable Care Act.  It follows closely the publication by the Agencies of regulations about when group health plans and insurance qualify as “grandfathered plans” for purposes of determining deadlines for complying with certain health care reform requirements imposed under the Affordable Care Act and a series of other regulations construing and implementing various other Affordable Care Act requirements.  For additional information about these other Affordable Care Act requirements, see here.

These Affordable Care Act and other impending federal health plan changes will require employment-based group health plans, their employer and other plan sponsors, plan fiduciaries, plan administrators and other service providers and insurers to make quick decisions and to act quickly to meet impending federal compliance deadlines while preserving flexibility.

All employer and other group health plan sponsors, fiduciaries, insurers and administrators should be prepared to act quickly to update their health plan documents, communications, insurance and vendor agreements and other practices to comply with new federal requirements that become effective under the Affordable Care Act on the first day of the plan year beginning after September 22, 2010 and various other changes in federal health plan rules effective or scheduled to take effect during 2010 or 2011 plan years.  Many plan sponsors also may need to act quickly to cancel or revise certain design or vendor changes planned or already implemented since March 23, 2010 to position their health plan to qualify for grandfather status.  Quick action also may be needed to preserve options to claim small employer tax credits, retiree medical subsidies or other opportunities. 

August 24  “2010 Health Plan Update” Internet Workshop Provides Key Information

The August 24, 2010 “2010 Health Plan Update” briefing will cover the latest guidance on Affordable Care Act and other federal health plan regulatory changes impacting employment-based group health plans and their sponsors for plan years beginning between September 23, 2010 and September 22, 2011 and other key information to help employers, group health plans, insurers, plan administrators, fiduciaries, broker and others working with these plans to understand and respond to these new requirements including:

  • How to qualify your health plan as a grandfathered plan under Affordable Care act
  • How to decide if maintaining grandfathered plan status is worthwhile
  • Claims & appeals requirements for grandfathered & non-grandfathered plans
  • Preventive care coverage mandates & wellness program requirements & rules under Affordable Care Act & other federal regulations
  • Updated dependent child eligibility, pre-existing condition & other requirements for grandfathered & non-grandfathered plans
  • Special enrollment, preexisting condition & other eligibility mandates for grandfathered & non-grandfathered plans under new Affordable Care Act, new FMLA, COBRA, Michelle’s Law, HIPAA & other federal regulations
  • Mental health & substance abuse, provider choice & other benefit mandates under Affordable Care Act, Mental Health Parity & other federal rules
  • Update on other recent & pending Affordable Care Act group health plan rule guidance
  • Tips to review & update your plans, vendor agreements & processes to meet Affordable Care Act & other federal group health plan dictates
  • Expected future Affordable Care Act & other federal rule changes & tips for preparing
  • Practical strategies for responding to new requirements & changing rules
  • Participant questions

To register or get additional information, see here.

About The Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer is nationally and internationally recognized for more than 23 years of work helping employer and other plan sponsors, insurers, administrators, fiduciaries, governments and others design, administer and defend innovative health and other employee benefit programs and other human resources, compensation and management policies and practices.  Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other health industry and human resources concerns. You can review other highlights of Ms. Stamer’s experience hereIf you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Solutions Law Press & Other Solutions Law Press Resources

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns.  

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.    If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject to here.

©2010 Solutions Law Press. All rights reserved.


Blockbuster & Health Delivery Disability Discrimination Settlements Highlight Need For Tightened Disability Discrimination Risk Management

July 19, 2010

A public accommodation disabilities charge settlement agreement with Blockbuster Inc. announced by the U.S. Department of Justice and an employment disability discrimination settlement agreement with Health Delivery, Inc. highlight the advisability for U.S. businesses to check and strengthen their disability and other nondiscrimination policies, training and risk management efforts.

On July 19, 2010, the Justice Department announced that an agreement with Blockbuster Inc. to settle a complaint (DOJ Complaint #202-35-231) that charged Blockbuster Inc with violating Title III of the Americans with Disabilities Act of 1990 (“ADA”), 42 U.S.C. §§ 12181-12189.

Retail stores like those owned and operated by Blockbuster generally are places of public accommodation covered by Title III of the ADA. The ADA generally prohibits places of public accommodation, including those operating retail stores, from discriminating against an individual on the basis of disability in the full and equal enjoyment of its goods, services, facilities, and accommodations.  Furthermore, the ADA specifically requires public accommodations to make reasonable changes in policies, practices, and procedures to permit the use of service animals by persons with disabilities.

The settlement resolves a complaint filed by a disabled individual who complained Blockbuster denied her an equal opportunity to enjoy its goods, services, and facilities at several stores because the complainant was accompanied by her service animal. According to the complaint, Blockbuster Inc. employees refused to allow her to access the store with her service animal even after she had contacted Blockbuster management to ensure that she and her service animal would be allowed in Blockbuster stores and had been assured that such access problems would be properly addressed.

Although Blockbuster contended in the course of the investigation of the complaint that it already had policies and training in place about Title III of the ADA, the Justice Department and the complainant contended that these steps failed to adequately achieve the necessary ADA compliance.

While Blockbuster Inc. did not admit wrongdoing, it agreed under the settlement agreement:

  • Consistent with the requirements of Title III of the ADA, not discriminate against any individual on the basis of disability in the full and equal enjoyment of any of its goods, services, facilities, privileges, advantages, or accommodations;
  • Not to refuse to make reasonable modifications to policies, practices, and procedures to afford equal access to the goods, services, facilities, privileges, advantages, and accommodations of its Blockbuster stores by persons with disabilities or when otherwise necessary to avoid discrimination against individuals with disabilities, including but not limited to persons who use service animals;
  • To pay $12,000.00 to the complainant and $10,000.00 to the United States;
  • To distribute to employees with contact with the public and conspicuously where employees can read an-agreed upon  Service Animal Policy that will ensure equal access for persons with disabilities who use service animals to all facilities that it operates;
  • To keep on hand in all stores for any store customers who wish to, upon request, read the Policy and post under the “Stores” link on its website (http://www.blockbuster.com) in an accessible format (e.g., HTML) the terms of the Service Animal Policy consistent with the requirements of Title III of the ADA;
  • To conduct Justice Department-approved employee training as specified in the settlement agreement;
  • To post in a conspicuous location in the public entryways of all Blockbuster stores a “Service Animals Welcome” sign with information about how to access a required ADA Complaint Line and other agreed upon content; and
  • To establish and administer a grievance program through which it will receive and investigate customer complaints of alleged ADA Title III violations.

Rising Employment Discrimination Exposures

The Blockbuster Inc. settlement is one of many signs of the rising discrimination exposures businesses face under federal discrimination public accommodation and employment laws.  The Justice Department under the Obama Administration is devoting significant resources to the investigation and prosecution of claims that businesses are violating the public accommodation provisions of the ADA.  This heightened enforcement emphasis has resulted in the Justice Department’s announcement of more than 20 ADA public accommodation claims since January 1, 2010. See here.

Meanwhile, Equal Employment Opportunity Commission (EEOC) also continues to vigorously pursue disability and other discrimination charges.  On July 9, 2010, for example, the EEOC announced that Health Delivery, Inc. had agreed to pay $45,000 to settle charges that engaged in prohibited disability based employment discrimination by refusing to hire an employee with a record of a disability.  Health Delivery, Inc., a Saginaw, Mich.-based health services provider had been charged with violating the ADA by unlawfully refusing to return to work an employee with a record of depression even though she had completed a course of treatment and had been approved to return to work.  In addition to the paying the required settlement, Health Delivery, Inc. also agreed to make disability discrimination policy changes and to provide training to all of its management and supervisory employees regarding the ADA.

Businesses Must Act To Manage Risks

In light of this continuing emphasis on investigation and prosecution of disabilities claims, businesses should review and update their existing policies and practices prohibiting unlawful discrimination in employment and the provision of services based on race, color, religion, sex, familial status, national origin, disability, veteran status or other basis prohibited by law and other steps to be prepared to demonstrate their compliance in operation as well as form. While adopting and communicating appropriate policies prohibiting unlawful discrimination in the provisions of goods, services, and employment is an important element of compliance, businesses also need to take necessary steps to ensure that their customers, workforce and operations comply with these policies in practice.  Businesses should not assume that the usual recital of their equal employment and services policies alone will suffice.  Businesses also need to have and administer well-documented practices and procedures governing the report, investigation and disposition of complaints.  These procedures should include clearly written and well communicated procedures to be used to report suspected violations.  Businesses also must take appropriate, well-documented steps to communicate and train workforce members regarding the policy, establish and communicate clear procedures requiring employees both to comply with these rules and to report known or suspected violations.  Businesses also should consider establishing compliance hotlines and using other compliance audit processes to monitor and address possible violations.  They should be prepared to demonstrate they take seriously and take appropriate action to investigate suspected violations, to rectify confirmed violations, and to appropriately discipline employees or others that participate in prohibited violations.   

About the Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer has more than 23 years experience working with employers, professional employment organizations, employee benefit plan sponsors and administrators and others on a wide range of labor and employment, employee benefits, and other management matters.  The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, the editor of Solutions Law Press HR & Benefits Update and, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other health industry and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience here. 

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 


Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication, see here.    If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject to here.

©2010 Solutions Law Press. All rights reserved.


CMS & ONC To Co-Host 7/22 ONC Certification & Medicare/Medicaid EHR Incentive Program Audio Training

July 19, 2010

The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) will co-host an Audio Training on the Final Rules for ONC Certification and Medicare and Medicaid EHR Incentive Programs on July 22, 2010 from 2:00-3:30 pm EST. 

During the training, the Agencies plan to discuss:

  • Benefits of HIT
  • Summary of the final rules
  • ONC temporary certification process
  • ONC initial set of standards and implementation specifications
  • Medicare and Medicaid EHR Incentives Programs including the initial definition of meaningful Use

To join the audio training, dial 1-877-251-0301 and enter the Conference ID pass code: 87841621

Materials will be made available prior to the training at the following web address here

For more information about CMS EMR incentives, see here. 

About The Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer is nationally and internationally recognized for more than 23 years of work helping employer and other plan sponsors, insurers, administrators, fiduciaries, governments and others design, administer and defend innovative health and other employee benefit programs and other human resources and health care IT, human resources, compensation and management policies and practices.

The author of numerous highly regarding publications on HIPAA and other health care IT related matters, Ms. Stamer works extensively with employer and other health plan sponsors, fiduciaries, administrative and other service providers, insurers, and other clients on health benefit program and product design, documentation, administration, compliance, risk management, and public policy matters.  The publisher of Solutions Law Press, Ms. Stamer also publishes, conducts training and speaks extensively on these and related concerns for the ABA, the Bureau of National Affairs and many other organizations.

The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, and the editor and publisher of Solutions Law Press HR & Benefits Update and other Solutions Law Press Publications, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other HIPAA, EMR and other health technology, health industry and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience hereHer insights on these and other matters appear in Managed Care Executive, Modern Health Care, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, MDNews, Kentucky Physician, and many other national and local publications. 

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.


Free 7/22 Study Group Teleconference Call on Self Correction, Determination Letters & Other Administrative Practices

July 19, 2010

Beginning at Noon Central on July 22, 2010, the American Bar Association (ABA) Real Property Probate & Trust (RPTE) Section Employee Benefits & Other Compensation Group and ABA Tax Section Subcommittee on Self Correction, Determination Letters and other Administrative Practice will host a special one hour telephone conference call on questions regarding the tax-qualified employee benefit plan determination letter program and interim amendments. 

Slated to begin at 1 PM Eastern, Noon Central, 11 AM Mountain and 10 AM Pacific Time, Ingrid Grinde, Manager, Group 1, EP Technical Guidance and Quality Assurance of the IRS will is expected to be joined by Michael Spaid, an actuary in the Employee Plans, Tax Exempt and Government Entities Division, IRS for this second “study group” session, which follows up on a study group session hosted by the RPTE Section in March, 2010.

The July 22 program is in lieu of the regular bimonthly RPTE Employee Benefits Group conference call, which typically are held at 1  PM Eastern, Noon Central on the first Monday of every other month

The call will again be lead by members of the RPTE Employee Benefits & Other Compensation Group Leadership, Joy Mercer, Frank Palmieri  and  Lisa Tavares.

The phone number and passcode for the special call are:

(866 ) 603 – 1269

Conference ID # 85693340

Company Name: American Bar Association

Leader Name: Robert Miller

As this is an operator assisted call with a limited number of lines available, organizers recommend persons planning to join the call dial in approximately 10 minutes early, to avoid any delay and to reserve a line.

About the Author

This information is provided by author Cynthia Marcotte Stamer.  If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872. 

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer has more than 23 years experience working with employers, professional employment organizations, employee benefit plan sponsors and administrators and others on a wide range of labor and employment, employee benefits, and other management matters.  The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, the editor of Solutions Law Press HR & Benefits Update and, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other health industry and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience here. 

Other Resources

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.


Labor Department FMLA Guidance Signals Need For Employer Care Determining Who Qualifies As Child

July 19, 2010

Employers and employee benefit plan administrators deciding whether to approve the request of an employee for leave or other rights under the Family and Medical Leave Act (FMLA) due to the serious illness, birth, adoption or placement of a child with no legal or biological relationship with the employee  should not underestimate the scope of the FMLA’s reach based on recent guidance.  Employers and plan administrators also need to be sure that their policies are properly drafted and administered to apply right definition of child based on the class of leave requested as the family-status-relevant definitions under the FMLA and other laws continue to proliferate.

Recent Department of Labor Wage & Hour Division Wage and Hour Division (WHD) guidance reveals the WHD adopts a very broad view of the circumstances under which a when a child with no legal or biological relationship to an employee can qualify as a “son or daughter” for purposes of determining rights of the employee under the FMLA based on the birth , adoption, placement for adoption or need to care for the  child during a serious illness and a narrow view of the documentation that an employer may require an employee to provide to prove such a relationship exists.[i] 

Background 

The FMLA entitles an employee to 12 work weeks of leave for the birth or placement of a son or daughter, to bond with a newborn or newly placed son or daughter, or to care for a son or daughter with a serious health condition.[ii] 

The definition of “son or daughter” under the FMLA includes not only a biological or adopted child, but also a “foster child, a stepchild, a legal ward, or a child of a person standing in loco parentis” who is either: 

  • Under 18 years of age; or
  • 18 years of age or older and incapable of self-care because of a mental or physical disability.”[iii]

In Loco Parentis

The FMLA regulations define in loco parentis as including those relationships between an employee and a child where the facts and circumstances show that the employee has undertaken day-to-day responsibilities to care for and financially support a child.[iv] 

Administrator’s Interpretation No. 2010-3 (June 22, 2010) (WHD Interpretation) clarifies the definition of “son or daughter” under Section 101(12) of the FMLA as it applies to an employee standing “in loco parentis” to a child taking FMLA-protected leave for the birth or placement of a child, to care for a newborn or newly placed child, or to care for a child with a serious health condition.  The WHD Interpretation does not address an employee’s entitlement to take military FMLA leave for a son or daughter, which is determined by separate definitions. 

The WHD Interpretation states that the FMLA does not require an employee who intends to assume the responsibilities of a parent to prove that he or she provides both day-to-day care and financial support to be found to stand in loco parentis to a child. 

According to the WHD Interpretation, the determination of when an employee has an in loco parentis relationship with a child is fact specific question based on the facts and circumstances with no particular factor being dispositive. . The WHD Interpretation adds that the fact that a child has a biological parent in the home, or has both a mother and a father, does not prevent a finding that the child is the “son or daughter” of an employee who lacks a biological or legal relationship with the child for purposes of taking FMLA leave.    

“The key in determining whether the relationship of in loco parentis is established is found in the intention of the person allegedly in loco parentis to assume the status of a parent toward the child.  The intent to assume such parental status can be inferred from the acts of the parties” taking into account a variety of factors including the age of the child; the degree to which the child is dependent on the person claiming to stand in loco parentis; the amount of support, if any, provided; and the extent to which duties commonly associated with parenthood are exercised. 

Noting Congress intended  the phrase “in loco parentis” to ensure that an employee who actually has day-to-day responsibility for caring for a child is entitled to leave even if the employee does not have a biological or legal relationship to that child, the WHD Interpretation states the phrase is commonly understood to refer to “a person who has put himself in the situation of a lawful parent by assuming the obligations incident to the parental relation without going through the formalities necessary to legal adoption.  It embodies the two ideas of assuming the parental status and discharging the parental duties.”  

Applying these principles, the WHD Interpretation identifies various situations where the WHD perceives that relationship in loco parentis might exist for purposes of the FMLA based on the assumption of the employee of either responsibility to care for a child or financial responsibility for the child in the absence of a biological or legal relationship including: 

  • Where an employee provides day-to-day care for his or her unmarried partner’s child (with whom there is no legal or biological relationship) but does not financially support the child;
  • Where an employee who will share equally in the raising of a  newborn or adopted child with the child’s biological parent;
  • Where a grandparent takes in a grandchild and assumes ongoing responsibility for raising the child because the parents are incapable of providing care,;
  • Where an aunt assumes responsibility for raising a child after the death of the child’s parents.

In contrast, the WHD Interpretation notes that an employee who cares for a child while the child’s parents are on vacation would not be considered to be in loco parentis to the child. 

When determining whether to approve a FMLA Leave request of an employee seeking time off due to the birth, adoption, placement for adoption or serious illness of a child with whom the employee has no biological or legal relationship, the WHD Interpretation makes clear that the WHD construes the phrase “in loco parentis” broadly.  Furthermore, the WHD Interpretation also signals the need for employers to exercise caution when requiring documentation of the existence of such a claimed relationship. While acknowledging that the FMLA allows an employer to require an employee claiming a relationship in loco parentis with child to require the employee to provide reasonable documentation or statement of the family relationship, the WHD Interpretation raises questions about the degree of documentation that the employer may require.  According to the WHD Interpretation, “[a] simple statement asserting that the requisite family relationship exists is all that is needed in situations such as in loco parentis where there is no legal or biological relationship.”[v] 

Drafting Policies & Using the Right Standard for the Right Circumstances

When drafting and applying FMLA and other legally mandated policies, it’s important that employers, employee benefit plan sponsors and administrators and others use the correct standard for the circumstance prevented.  The FMLA definition of child from the WHD Interpretation applies only to determinations of the status of a person as a son or daughter for purposes of the FMLA’s leave provisions regarding leaves requested due to the serious illness, birth or adoption of a child of an employee and not for military related FMLA leaves.  Different standards apply for military related FMLA leaves.  Similarly, the standards used to determine who qualifies as a child for purposes of FMLA may not necessarily be the same as legally required to decide when an individual qualifies as a child for other legal purposes.  For instance, recent changes to federal health plan rules enacted as part of the Patient Protection & Affordable Care Act may require that group health plans and insurers use different standards to decide when an individual qualifies for enrollment as the child of an employee in dependent coverage beyond those applicable under the FMLA.  It is highly advisable that employers and employee benefit plan sponsors and administrators carefully review and update their existing policies, plan documents and practices for compliance with the appropriate and currently applicable standards and exercise care in the administration of these practices to avoid costly mistakes. 

About the Author

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, management attorney and consultant Ms. Stamer has more than 23 years experience working with employers, professional employment organizations, employee benefit plan sponsors and administrators and others on a wide range of labor and employment, employee benefits, and other management matters.  The Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, Government Affairs Committee Legislative Chair for the Dallas Human Resources Management Association, the editor of Solutions Law Press HR & Benefits Update and, Ms. Stamer also is recognized for her publications, industry leadership, workshops and presentations on these and other health industry and human resources concerns. She regularly speaks and conducts training for the ABA, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations.  Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Aspen Publishers, Schneider Publications, Spencer Publications, World At Work, SHRM, HCCA, State Bar of Texas, Business Insurance, James Publishing and many others.  You can review other highlights of Ms. Stamer’s experience here.  

If you need help with human resources or other management, concerns, wish to ask about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer here or (469)767-8872.  

Other Resources 

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including: 

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive our Solutions Law Press distributions here. For important information about this communication click here.    If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject to here. 

©2010 Solutions Law Press. All rights reserved. 
 


[i] See 29 C.F.R. § 825.122(g), (h). 

[ii] See 29 U.S.C. § 2612(a)(1)(A) – (C); 29 C.F.R. § 825.200. 

[iii] 29 U.S.C. § 2611(12).  See also 29 C.F.R. §§ 825.122(c), 825.800.[1]. 

[iv] 29 C.F.R. § 825.122(c)(3). 

[v] See 29 C.F.R. § 825.122(j); 73 Fed. Reg. 67,952 (Nov. 17, 2008).


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