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Medical Resident Stipend Ruling Shows Health Care, Other Employers Should Review Worker Classification, Payroll & Other Practices

January 12, 2011

Stipends paid to medical residents to provide on patient care and other medical services for 40 or more hours per week as part of an accredited graduate medical education program are wages paid to employees for Federal Insurance Contributions Act (FICA) payroll taxes purposes and do not qualify as exempt from FICA tax or withholding as student stipends according to January 11, 201 U.S. Supreme Court ruling in Mayo Foundation v. U.S. The decision is the latest reminder to health care providers and others of the need to critically review and update as necessary their organizations existing worker and wage characterization in light of evolving interpretations and the growing success of regulators and private plaintiffs in challenging these classifications.

In Mayo Foundation, the U.S. Supreme Court denied the plea of Mayo Foundation For Medical Education And Research (Mayo) that it overrule an Internal Revenue Service (IRS) Regulation that provides that medical students or others providing full-time services as part of their course of instruction do not qualify as “students” for purposes of the “student” exemption of Code § 3121(b)(10) regardless of whether “the services performed . . . may have an educational, instructional, or training aspect.” See Treas. Reg.§31.3121(b)(10)–2(d)(3)(iii). Mayo Foundation, the Supreme Court ruled against Mayo Foundation. It ruled the IRS’ regulation construing Code § 3121(b)(1) as inapplicable to medical students or other workers providing full-time services as part of a residency or other educational program should stand as Congress has not directly spoken to foreclose that interpretation and because the Treasury Department’s rule is a reasonable construction of what Congress has said.

Beyond its specific holding, the Mayo Foundation decision also serves as another reminder that health industry and other employers should not take the defensibility of their worker classification and associated income and payroll tax, employee benefit, employment and other practices for granted.

Recent developments send a clear message that health industry and other employers must remain constantly diligent about confirming and documenting the defensibility of their worker classifications and other associated practices in light of evolving rules and standards, enforcement, the growing frequency and success of regulators and private plaintiff challenges, and changing workforce practices. See e.g. Review of Worker Classification Needed As Classification Scrutiny Rises;Minimum Wage, Overtime Risks Highlighted By Labor Department Strike Force Targeting Residential Care & Group Homes; Review & Strengthen Defensibility of Existing Worker Classification Practices In Light of Rising Congressional & Regulatory Scrutiny; 250 New Investigators, Renewed DOL Enforcement Emphasis Signal Rising Wage & Hour Risks For Employers; Quest Diagnostics, Inc. To Pay $688,000 In Overtime Backpay.

The IRS, Department of Labor and other federal and state regulators are stepping up scrutiny of and enforcement of worker classifications and claims of exemption from applicable employment, tax and other requirements. In light of these and other developments, health industry and other employers should take reasonable steps to guard against these and other growing risks of worker misclassification and associated non-compliance. To minimize their potential exposure, health industry and other employers should consult with qualified legal counsel for advice within the scope of attorney-client privilege concerning the need to audit or otherwise act to strengthen the defensibility of their existing worker classification, employee benefit, fringe benefit, employment, wage and hour, and other workforce policies to mitigate exposures to potential IRS, Labor Department or other risks of worker misclassification or the handling of associated payroll, employment or other responsibilities.

For Help With Investigations, Policy Updates Or Other Needs

If you need assistance in conducting a risk assessment of or responding to an IRS, Labor Department or other legal challenges to your organization’s existing workforce classification or other labor and employment, employee benefit or compensation practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872 .

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 employers; employee benefit plans and their sponsors, administrators, fiduciaries; employee leasing, recruiting, staffing and other professional employment organizations; and others design, administer and defend innovative workforce, compensation, employee benefit and management policies and practices. 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 Managing Editor of Solutions Law Press HR & Benefits Update and other Solutions Law Press Publications, Ms. Stamer recently was a featured panelist on the ABA Joint Committee on Employee Benefits Teleconference on “Worker Classification & Alternative Workforce: Employee Plans & Employment Tax Challenges” and has worked, published and spoken extensively on worker classification and other related matters. She also is recognized for her publications, industry leadership, workshops and presentations on these and other human resources concerns and regularly speaks and conducts training on these matters. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, and many other national and local publications. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

About Solutions Law Press

THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TO U.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS. ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

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Posted by Cynthia Marcotte Stamer

CMS Physician Compare Web Site Offers Consumers New Provider Info Source

January 4, 2011

The Centers for Medicare & Medicaid Services (CMS) added a new “Physician Compare” feature to the CMS Healthcare Provider Directory on December 30, 2010. Regulators hope the new feature will help Medicare and non-Medicare patients and their families find and assess the quality of providers. While these and other similar resources can provide valuable information for patients and their families, like all provider directories, patients and their families should be cautioned to properly understand the benefits and limitations of the resource.

Required by the Patient Protection & Affordable Care Act (“Affordable Care Act”), the Physician Compare tool located here has information about Doctors of Medicine, Osteopathy, Optometry, Podiatric Medicine, and Chiropractic and certain other types of health care professionals participating in the Medicare Program, who routinely care for Medicare beneficiaries.

According to CMS, the Physician Compare Web Site is designed to be consumer friendly and help all patients—whether on Medicare or not—locate health professionals in their communities. The information on the site includes contact and address information for offices, the professional’s medical specialty, where the professional completed his or her degree as well as residency or other clinical training, whether the professional speaks a foreign language, and the professional’s gender. The tool can also help Medicare beneficiaries find out which physicians that see Medicare patients.

In addition to information about the physician’s practice, Physician Compare also shows consumers whether the practice reported certain data to CMS through the Physician Quality Reporting System, formerly known as the Physician Quality Reporting Initiative (PQRI). Currently, the PQRI reporting system is a voluntary reporting program that rewards physicians and other eligible healthcare professionals for reporting data on quality measures related to services furnished to Medicare beneficiaries. These quality measures are based on the best available medical evidence and designed to help professionals improve care for patients. In 2009, over 200,000 professionals reported data to CMS through the Physician Quality Reporting System.

According to CMS, it plans a second phase of the Web site which will indicate whether professionals chose to participate in a voluntary effort with the Agency to encourage doctors to prescribe medicines electronically, rather than through traditional paper-based prescription methods later in 2011.

In future years, the Physician Compare Web site will be expanded with information about the quality of care Medicare beneficiaries receive from physicians and the other healthcare professionals profiled on the site. The expansion will include information on quality of care and patient experience that can help consumers learn more about the care provided by Medicare-participating physicians. CMS is required by the Affordable Care Act to develop a plan to implement this expansion by 2013.

The new Physician Compare resource supplements a broad range of resources that patients and their families can use to gather information about an existing or proposed health care provider. Like all directories, however, patients and their families should keep in mind that no single resource or directory provides complete information about any one provider or should be used as a sole basis for selecting or assessing the quality or credentials of any health care provider.

For More Information Or Assistance

Learn more about other useful patient empowerment information and share your own insights to help other patients and their families develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources.

If you need help empowering your workforce or their families with new health care coping skills, updating your health benefit programs and contracts or with other employee benefit, compensation or employment regulations or other related matters please contact Cynthia Marcotte Stamer here or (469) 767-8872.

Management attorney and consultant, Ms. Stamer is nationally and internationally recognized for work experience, advocacy and leadership on health benefit and related matters. A practicing attorney, Ms. Stamer has more than 23 years experience advising and representing employers, employee benefit plans, their sponsors, fiduciaries, plan administrators, service providers, consultants, vendors, outsourcers, insurers, financial services providers, governments and others about health and other employee benefit, compensation, employment, insurance and financial services, and a wide range of other performance, legal and operational risk management practices and concerns. Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, 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 is nationally recognized for her work helping clients to design, document, administer and defend health and other employee benefit plans and other related financial and insurance products and to manage risks associated with the offering and administration of these arrangements. Her experience includes extensive work advising and representing employers, plans, plan fiduciaries, trustees, investors, and others about managing and resolving risks relating to fiduciary, contracting and other risks and responsibilities involved in the design, selection and administration of investments for employee benefit plans, and other fiduciary responsibility matters. She also has extensive experience assisting these and other clients to investigate and determine the appropriateness of retirement plan investment selections to comply with ERISA and other fiduciary responsibility rules, as well as to defend challenges to investment offerings or decisions against complaints or actions brought by private plaintiffs, the Labor Department, state and federal securities regulators, insurers and others. A prolific author and popular speaker, Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on employee benefit, compensation and human resources practices and concerns for the ABA, World At Work, SHRM, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, HCCA, Southwest Benefits Association and many other organizations. 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 learn more about Ms. Stamer, her experience, involvements, programs and publications, see here or contact Ms. Stamer.

Other Resources & Developments

If you found this information of interest, you also may be interested in reviewing other recent updates by Ms. Stamer about the tax credit on Code §45R or other benefits, compensation or human resources matters including:

If you or someone else you know would like to receive future updates and notices about upcoming programs and 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 about this communication click here.

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Posted by Cynthia Marcotte Stamer

Avoiding Post-Holiday Celebration Sexual Harassment & Discrimination Liability

December 29, 2010

With New Years Eve celebrations approaching and the Holiday Season wrapping up, businesses should take some common sense steps to decrease the risk of waking up in 2011 with a liability hangover. Participation of employees and clients in company sponsored and other social celebrations and activities can promote big rewards in relationship development and morale if properly managed. However, the music, food, game playing, toasting with alcohol and other aspects of the celebratory atmosphere at New Years Eve and other parties and social activities heighten the risk that certain employees or other business associates will engage in, or be subject to, risky or other inappropriate behavior that can create liability exposures or other business concerns for your business whether or not company sponsored. Read about other common Holiday Season-related celebration risks and management tips here.

Celebrations Raise Foreseeable Risks

Whether or not company-sponsored, holiday parties and other celebrations where employees celebrate with other employees or clients tend to fuel bad behavior by inviting fraternization, lowering inhibitions and obscuring the line between appropriate and inappropriate social and business behavior. The relaxation of the environment heightens the risk that certain employees or clients will make unwelcome sexual advances, make sexually suggestive or other inappropriate statements, or engage in other actions that expose the business to sexual harassment or other employment discrimination liability. Businesses also should use care to manage other discrimination exposures in the planning of holiday festivities, gift exchanges, and other activities. Businesses also should be vigilant in watching for signs of inappropriate patterns of discrimination in the selection of employees invited to participate in company-connected social events as well as off-duty holiday gatherings sponsored by managers and supervisors. In addition, businesses also should critically review their own plans for possible insensitivity. Business connected holiday parties, communications, gifts and other festivities should be designed to show appropriate sensitivity to religious and other cultural diversity.

To minimize these exposures, businesses should take steps to communicate and reinforce company policies and expectations about sexual harassment, discrimination, fraternization and other conduct viewed as inappropriate by the company and communicating reminders about these policies to employees and business associates during the Holiday Season.

Timely Investigation & Notification

Businesses faced with allegations of discrimination, sexual harassment or other misconduct also should act promptly to investigate any concerns and if necessary, take timely corrective action. Delay in investigation or redress of discrimination or other improprieties can increase the liability exposure of a business presented with a valid complaint and complicate the ability to defend charges that may arise against the business. Additionally, delay also increases the likelihood that a complaining party will contact governmental officials, plaintiff’s lawyers or others outside the corporation in the redress of his concern.

If a report of an accident, act of discrimination or sexual harassment or other liability related event arises, remember to consider as part of your response whether you need to report the event to any insurers or agencies. Injuries occurring at company related functions often qualify as occupational injuries subject to worker’s compensation and occupational safety laws. Likewise, automobile, employment practices liability, and general liability policies often require covered parties to tell the carrier promptly upon receipt of notice of an event or claim that may give rise to coverage, even though the carrier may not be obligated to tender a defense or coverage at that time.

For Help With Investigations, Policy Updates Or Other Needs

If your organization needs help investigating a reported concern, reviewing and updating its policies or assessing, managing or defending these or other labor and employment, compensation or benefit practices, or needs other assistance auditing, updating or defending its human resources, corporate ethics, and compliance practices, or responding to employment related or other charges or suits, please contact management attorney and consultant Cynthia Marcotte Stamer at cstamer@solutionslawyer.net, (468) 767-8872.

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization and Chair of the American Bar Association RPTE Employee Benefits & Other Compensation Group and a nationally recognized author and speaker, Ms. Stamer helps business manage people, operations and risk. She is experienced with advising and assisting employers with these and other labor and employment, employee benefit, compensation, risk management and internal controls matters. Her experience includes helping management both manage performance and manage legal risk and compliance. While helping businesses define and manage the conduct and performance of their employees, contractors and vendors, she also assists employers and others about compliance with federal and state equal employment opportunity, compensation, health and other employee benefit, workplace safety, and other labor and employment laws, advises and defends businesses against labor and employment, employee benefit, compensation, fraud and other regulatory compliance and other related audits, investigations and litigation, charges, audits, claims and investigations by the IRS, Department of Labor, Department of Justice, SEC, Federal Trade Commission, HUD, HHS, DOD, Departments of Insurance, and other federal and state regulators. She has counseled and represented businesses and their management on workforce and other internal controls and risk management matters for more than 23 years. Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to get access to other publications by Ms. Stamer see here or contact Ms. Stamer directly.

Other Helpful Resources & Information

If you found this article of interest, you also may be interested in reviewing other Breaking News, articles and other resources available CynthiaStamer.com or Solutions Law Press articles authored by Ms. Stamer including:

About Solutions Law Press

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. For important information concerning this communication click here. If you do not wish to receive these updates in the future, unsubscribe by updating your profile here.

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Posted by Cynthia Marcotte Stamer

Small Employers Should Weigh If Health Premium Tax Credit Justifies Changing Employee Leasing Arrangements

December 5, 2010

Accessing more affordable health care coverage often is a major driver behind the decision of many small businesses to enter into employee leasing arrangements. Many of these small businesses should consider if changing existing employee leasing practices makes sense to avoid unknowingly forfeiting or otherwise qualify to claim valuable health insurance premium tax credits under new Internal Revenue Code (Code) § 45R.

Enacted as part of the sweeping health care reforms included in the Patient Protection & Affordable Care Act (Affordable Care Act), Code § 45R generally offers a small employer that meets Code § 45R’s conditions (qualifying employer) to claim a tax credit for premiums that it pays for health insurance coverage to employees if:

The employer had fewer than 25 full-time equivalent employees (“FTEs”) for the tax year;
The average annual wages of its employees for the year must be less than $50,000 per FTE; and
The employer pays premiums to provide employee health care coverage under a “qualifying arrangement.”

For purposes of Code § 45R, “qualifying arrangement” is an arrangement under which an qualifying employer pays premiums for each employee enrolled in health insurance coverage offered by the employer in an amount equal to a uniform percentage (not less than 50 percent) of the premium cost of the coverage.

An analysis of an advance copy of Internal Revenue Service (IRS) Notice 2010-82, scheduled for official publication on December 20, 2010, reveals that a small business that leases rather than employs directly workers gives up the ability to claim a Code § 45R tax credit for amounts paid toward health insurance premiums charged for leased employees when the leasing organization employs the worker even though the business could have claimed those amounts if it employed the worker and paid the premiums directly.

According to Notice 2010-82, leased employees as defined in Code § 414(n) are counted in computing FTEs and average annual wages of businesses leasing their services (Service Recipient). This means that that the use of leased employees will disqualify the business for the Code § 45R tax credit if its total workforce exceeds 25 FTEs when leased employees are taken into account.

Although Service Recipients must count these leased employees when calculating FTEs, and compensation for purposes of determining if the business is a qualified employer, the IRS says Code § 45R does not allow a Service Recipient to claim the Code §45R credit for health insurance premiums paid by or through a leasing organization for coverage of leased employees. Since leasing organizations usually employ more than 25 FTEs, this means that neither business can claim any credit.

While the IRS won’t let Service Recipients claim credit for health premiums paid by a leasing company, Notice 2010-82 suggests that an otherwise qualifying small business can claim the tax credit for health premiums accessed through a leasing organization or other arrangement when the Service Recipient, and not the leasing organization, employs the workers and pays health premiums for coverage for the worker. Assuming a business otherwise is a qualifying employer, Notice 2010-82 suggests that the business may claim the tax credit for premiums it pays to purchases qualifying health insurance for individuals employed as the common law employee of the business directly to a licensed insurer or to obtain insured coverage from a multiemployer plan that otherwise meets the requirements of Code § 45R.

As with any decision about the use of leased employees, the feasibility and potential costs and benefits of structuring or restructuring the relationship with a worker who otherwise would be leased through a staffing company to claim the Code § 45R tax credit needs to be carefully evaluated before a business acts. Businesses should carefully evaluate both the change in insurance costs, if any, and how the structuring of the relationship will affect other costs and liabilities. Changing the relationship with a worker from employee to leased employee or visa versa can impact unemployment, employee benefit, employment liability, contractual, tort and other costs, obligations and other responsibilities. In some instances, increased health insurance or other costs and liabilities may outweigh the tax benefits that a small business otherwise could get by qualifying for the Code § 45R tax credit. Where the existing or contemplated relationship between business and the leasing organization already creates a co-employment relationship for many legal or financial purposes, however, restructuring the relationship to allow the business to directly employ workers but continue to use the payroll services of and access health coverage and other benefits for the worker under multiple employer benefit plans sponsored by the leasing organization may prove a viable and attractive option. Moreover, as many businesses misunderstand legal risks and benefits of their employee leasing and other contingent workforce relationships, businesses should consult with competent legal counsel within the scope of attorney-client privilege to ensure that they have an accurate understanding of the legal implications of their existing employee leasing arrangements when evaluating these potential costs and benefits to avoid making misinformed decisions.

Employers Urged To Seek Advice To Determine Tax Eligibility, Manage Legal Risks

Given the high cost of health insurance coverage, the Code § 45R credit may offers valuable savings for qualifying small employer. Before providing coverage or estimating tax liabilities in reliance on the expectation of claiming the credit, however, an employer interested in claiming the credit should seek guidance from qualified tax counsel familiar with the Code § 45R rules and guidance as well as other applicable federal mandates impacting employer provided coverage. The clarifications set forth in Notice 2010-82 illustrate that the rules for determining if an employer qualifies to claim a tax credit for health insurance premiums paid for employees under Code § 45R are anything but simple. In addition to meeting these conditions, employers offering or contributing to health coverage for employees can face a broad range of other legal and financial risk if they fail to properly understand and manage the organizational and personal responsibilities that can arise under applicable federal laws. Where it is contemplated that health coverage will be accessed or provided through an employee leasing, staffing or multiple employee plan arrangement, other additional considerations also will apply. Accordingly, small and other businesses that provide health coverage to employees or paying to lease the services of workers from a leasing organization that provides health coverage should review their options with experienced legal counsel within the scope of attorney-client privilege.

For More Information Or Assistance

You can learn more about these and other federal health plan mandates by listening to the recording of the 2010 Health Plan Update Briefing or reviewing other resources available here. If you need help with these or other employee benefit, compensation or employment regulations or other related matters please contact Cynthia Marcotte Stamer here or (469)767-8872.

Management attorney and consultant Cynthia Marcotte Stamer has more than 23 years experience advising and representing employers, employee benefit plans, their sponsors, fiduciaries, plan administrators, service providers, consultants, vendors, outsourcers, insurers, financial services providers, governments and others about health and other employee benefit, compensation, employment, insurance and financial services, and a wide range of other performance, legal and operational risk management practices and concerns. Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, 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 is nationally recognized for her work helping clients to design, document, administer and defend health and other employee benefit plans and other related financial and insurance products and to manage risks associated with the offering and administration of these arrangements. Her experience includes extensive work advising and representing employers, plans, plan fiduciaries, trustees, investors, and others about managing and resolving risks relating to fiduciary, contracting and other risks and responsibilities involved in the design, selection and administration of investments for employee benefit plans, and other fiduciary responsibility matters. She also has extensive experience assisting these and other clients to investigate and determine the appropriateness of retirement plan investment selections to comply with ERISA and other fiduciary responsibility rules, as well as to defend challenges to investment offerings or decisions against complaints or actions brought by private plaintiffs, the Labor Department, state and federal securities regulators, insurers and others. A prolific author and popular speaker, Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on employee benefit, compensation and human resources practices and concerns for the ABA, World At Work, SHRM, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, HCCA, Southwest Benefits Association and many other organizations. 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 learn more about Ms. Stamer, her experience, involvements, programs and publications, see here or contact Ms. Stamer.

Other Resources & Developments

If you or someone else you know would like to receive future updates and notices about upcoming programs and events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. To unsubscribe, send an e-mail with “Unsubscribe” in the subject here. For important information concerning this communication click here.

Comments Off on Small Employers Should Weigh If Health Premium Tax Credit Justifies Changing Employee Leasing Arrangements | Employee Benefits, Employers, ERISA, Health Plans, Human Resources, Insurance, Tax, Tax Credit, Tax Qualification | Tagged: 45R, Affordable Care Act, contingent workforce, employee leasing, health costs, Health Plan, health premium, small employer, tax credit | Permalink
Posted by Cynthia Marcotte Stamer

Affordable Care Act Grandfathered Plan Rules Loosened To Allow Insured Plans Making Some Insurance Changes To Qualify

November 17, 2010

A change to regulations implementing the “grandfathered plan” rules of the Patient Protection and Affordable Care Act (Affordable Care Act) announced yesterday has opened up the possibility that some insured group health plans changing insurers may continue to qualify as “grandfathered health plans” exempted from certain health care reform mandates. Because policy or insurer changes can create challenges in meeting other conditions required to get grandfathered plan status, however, sponsors and administrators of insured group health plans should prepare to timely comply with all applicable Affordable Care Act mandates unless they have verified their ability to prove that their program meets all requirements to qualify for grandfathered plan status will need to confirm that with or without the insurance-related change.

The Affordable Care Act generally requires that insured and self-insured group health plans and group and individual health insurance policies comply with many new federal mandates beginning with the first day of the plan or contract year that begins after September 22, 2010. If a group health plan or health insurance policy existed on March 23, 2010 and otherwise qualifies as a “grandfathered health plan,” however, it may qualify as exempted or for a delayed effective date from some but not these new mandates. By shaping the mandates applicable to group health plans, the grandfather rules will impact both the cost and the design of affected group health plans.

Original Rule About Insurance Changes

Interim Final Regulations issued by jointly by the Departments of Labor, Health & Human Services and Treasury (Agencies) last June established a series of detailed requirements that a group health plan or health insurance policy must meet to qualify as a grandfathered health plan or policy beyond merely existing on March 23, 2010. As part of these requirements, the Interim Final Regulations identified a number of changes and other events that would disqualify a group health plan or insurance policy as a grandfathered plan.

In the case of insured group health plans, changing insurance policies or insurers was not an allowable change for a plan desiring to qualify as grandfathered. As originally interpreted by the Agencies in the Interim Final Regulations, self-insured group health plans were permitted to change third-party administrators without forfeiting grandfathered health plan status as long as the change did not otherwise change the plan terms or design in a way that would disqualify the plan for grandfathered status. In contrast, however, the Agencies original interpretation stated that entering into a new policy, certificate, or contract of insurance for an insured non-collectively bargained group health plan in and of itself would disqualify the group health plan as a grandfathered health plan. The modified rule published on November 16, 2010 (Amended Rule) eliminates this distinction in response to public comments received since its publication of the original guidance.

Amended Rule About Insurance Changes

Under the Amended Rule, the same standards now will determine the effect of a change in vendor or contract on the grandfathered health plan status of a group health plan whether the plan is insured or self-insured. Accordingly, with respect to changes in group health coverage contracts, the Interim Regulations, as modified by the Amended Rule, now provides where insured or self-insured, a group health plan (including a group health plan that was self-insured on March 23, 2010) or its sponsor that enters into a enters into a new policy, certificate, or contract of insurance after March 23, 2010 that is effective before November 15, 2010 generally will cease to be a grandfathered health plan unless the plan meets certain specified conditions. The group health plan must provide to the new health insurance issuer (and the new health insurance issuer must require) documentation of plan terms (including benefits, cost sharing, employer contributions, and annual limits) under the prior health coverage sufficient to demonstrate that except for the contract change, the group health plan otherwise has not been modified or experienced any other event that would otherwise result in its disqualification for grandfathered health plan status under the Interim Final Regulations as modified by the Amended Rule.

As currently drafted, the relief provided in the Amended Rule does not expressly apply to a change in insurer or insurance contract made by a non-collectively bargained group health plan after November 14, 2010 regardless of whether the change in made before deadline for the group health plan to begin complying with the Affordable Care Act (i.e., the first day of the first plan year beginning after March 22, 2010). Additionally, the relief set forth in the Amended Rule does not apply to individual health insurance policies. Where insured coverage is provided not through a group health plan but instead in the individual market, a change in issuer still remains a change in the health insurance coverage after March 22, 2010 that disqualifies the new individual policy, certificate, or contract of insurance for status as a grandfathered health plan for purposes of the Affordable Care Act.

For a more detailed discussion of the grandfathered plan rules and the changes made this week, see here.

For More Information Or Assistance

If you need help reviewing or responding to the grandfather regulations or other health benefit regulations or other related matters please contact Cynthia Marcotte Stamer here or (469) 767-8872.

About Ms. Stamer

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, a Council Member of the ABA Joint Committee on Employee Benefits, Past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, management attorney and consultant Cynthia Marcotte Stamer has more than 23 years experience advising and representing employers, health and other employee benefit plans, their sponsors, fiduciaries and plan administrators, consultants, vendors, outsourcers, insurers, governments and others about employment, employee benefit, compensation, and a wide range of other performance, legal and operational risk management practices and concerns. As a part of this work, Ms. Stamer has worked extensively with clients on health care reforms and regulations under the Affordable Care Act and other federal and state laws. A prolific author and popular speaker, Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on GINA and other employment and employee benefit risk management practices and concerns for the ABA, World At Work, SHRM, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, HCCA, Southwest Benefits Association and many other organizations. 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 learn more about Ms. Stamer, her experience, involvements, programs and publications, see here or contact Ms. Stamer.

Other Resources & Developments

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

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.

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Posted by Cynthia Marcotte Stamer

Update Employment Practices To Manage Genetic Info Discrimination Risks Under New EEOC Final GINA Regulations

November 9, 2010

The U.S. Equal Employment Opportunity Commission (EEOC) today issued final regulations (“Final Regulations”) implementing the employment provisions (Title II) of the Genetic Information Nondiscrimination Act of 2008 (GINA). Employers, employment agencies, labor organizations, joint labor-management committees, and others impacted by GINA should carefully review and update their hiring and background check, sick and family leave, disability accommodation, and other existing policies and practices to comply with the updated guidance provided by the Final Regulations to avoid liability under new GINA’s rules governing genetic information collection, use, protection and disclosure

Effective since November 21, 2009, Title II of GINA prohibits employers of 15 or more employees from discriminating in employment based on genetic information and restricts the acquisition and disclosure of genetic information by covered employers and certain other parties.

Under GINA, employers, employment agencies, labor organizations and joint labor-management committees face significant liability for violating the sweeping nondiscrimination and confidentiality requirements of GINA concerning their use, maintenance and disclosure of genetic information. Under GINA, employees and individuals can sue for damages and other relief like currently available under Title VII of the Civil Rights Act of 1964 and other nondiscrimination laws.

Meanwhile, Title I of GINA prohibits group health plans and health insurers from discriminating in eligibility or premium based on genetic information and requires these plans and insurers to protect the privacy of genetic information (Title I) for plan years beginning after May 20, 2009.

When assessing potential GINA risks and exposures, employers and others covered by its provisions must exercise care not to overlook or underestimate the genetic information collected or possessed by their organizations and the risks attendant to collecting or using this information. Many employers will be surprised by the breadth of the depth of “genetic information.” Because of GINA’s broad definition of “genetic information,” its provisions create potential liability concerns for a surprisingly wide range of employment and health plan practices.

The Final Regulations published today implement the employment discrimination rules of GINA Title II. The EEOC previously published proposed regulations interpreting Title II of GINA in March, 2009. Concurrent with its release of the Final Regulations, the Commission also issued two question-and-answer documents on the final GINA regulations. For links to today’s guidance and more details, see here.

Failing to properly address GINA compliance could expose employers to substantial risk. Violation of the employment provisions of Title II subjects an employer to potentially significant civil judgments like those that generally are available for race, sex, and other federal employment discrimination claims covered by the Civil Rights Act. Accordingly, employers and others who have not already done so should act quickly to review and update their policies and procedures to manage their new compliance and liability exposures under GINA. Employers and others covered by GINA also should assess their leave and other records and practices for data that could be considered genetic information and take appropriate steps to safeguard this information to comply with the confidentiality, nondiscrimination and anti-retaliation rules of GINA, the Americans with Disabilities Act and other applicable laws.

For More Information Or Assistance

If you need assistance evaluating or defending existing or proposed practices under GINA or with other workforce, employee benefit, compensation, internal controls or risk management practices, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

About Ms. Stamer

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, a Council Member of the ABA Joint Committee on Employee Benefits, Past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, management attorney and consultant Cynthia Marcotte Stamer has more than 23 years experience advising and representing employers, health and other employee benefit plans, their sponsors, fiduciaries and plan administrators, consultants, vendors, outsourcers, insurers, governments and others about employment, employee benefit, compensation, and a wide range of other performance, legal and operational risk management practices and concerns. As a part of this work, Ms. Stamer has worked extensively with client to manage risks and defend practices under GINA, the ADA and a wide range of employment discrimination, privacy and other laws. A prolific author and popular speaker, Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on GINA and other employment and employee benefit risk management practices and concerns for the ABA, World At Work, SHRM, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, HCCA, Southwest Benefits Association and many other organizations. 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 learn more about Ms. Stamer, her experience, involvements, programs and publications, see here or contact Ms. Stamer.

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Posted by Cynthia Marcotte Stamer

DOL Proposes To Expand Investment Related Services Giving Rise to ERISA Fiduciary Status As Investment Fiduciary

October 21, 2010

The U.S. Department of Labor Employee Benefit Security Administration (EBSA) today published a Proposed Regulation that would expand the circumstances when individuals giving investment advice to an employee benefit or employee benefit plan or individual retirement account participant for purposes of the fiduciary definition of Employee Retirement Income Security Act (ERISA) § 3(21) and the prohibited transaction provisions of Internal Revenue Code (Code) § 4975(e)(3)(B).

If adopted as proposed, the Proposed Regulation would broaden the persons considered fiduciaries based on their provision of investment related advice or services to plans, participants or beneficiaries. Additionally, the restatement of these standards also likely will necessitate that both plan fiduciaries and providers of these services tighten agreements and other practices and procedures governing the engagement and delivery of services in order to maintain or protect desired allocations of fiduciary responsibility over these activities.

The deadline for individuals and organizations to comment on the proposed rule is January 19, 2011. Plan sponsors, fiduciaries, service providers and others concerned about the potential impact of the proposed changes should assess the potential implications of the rule and timely submit any comments or concern to the EBSA by this date.

To learn more about the Proposed Rule and its implications, see the more detailed article here.

If your organization needs assistance to evaluate or respond to the Proposed Regulation or reviewing, updating, administering or defending your employee benefit, human resources, compensation or internal control and risk management procedures, documentation, or policies or procedures, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Other Resources

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

About Ms. Stamer

Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, 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, Cynthia Marcotte Stamer is nationally recognized for her extensive work helping clients develop, implement and defend innovative, practical, legally defensible solutions to their particular health and other employee benefit, employment and insurance needs. Ms. Stamer has more than 23 years experience advising and representing employer, association and other plan sponsors, health and other employee benefit plans, their fiduciaries, plan administrators, consultants, vendors, outsourcers, insurers, governments and others about health plan and product design; administration, legal and operational risk management, vendor and fiduciary credentialing, managed care and vendor contracting, cost-containment, documentation, public policy, enforcement, privacy, technology, litigation and other concerns. Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on these and other health and managed care program concerns and practices for the ABA, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, HCCA, Southwest Benefits Association and many other organizations. 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 learn more about Ms. Stamer, her experience, involvements, programs and publications, see here or contact Ms. Stamer.

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Posted by Cynthia Marcotte Stamer

EEOC Attacks Medical Leave Denials As Prohibited Disability Discrimination

October 19, 2010

Two new Equal Employment Opportunity Commission (EEOC) lawsuits filed against a Texas concrete manufacturer and Los Angeles garment manufacturer highlight the need for U.S. employers with more than 14 employees to consider and prepare to defend against potential disability discrimination exposures when dealing with medical leave requests by employees who might be considered disabled under the Americans with Disabilities Act (ADA) as well as other expanding ADA enforcement exposures. Read more.

The lawsuits reflect that employers considering an employee’s request for medical leave should evaluate if the ADA requires the employer to grant the requested medical leave in addition to considering any otherwise applicable leave entitlement the requesting employee qualifies for under the Family & Medical Leave Act, state leave laws or otherwise applicable employer policies. As a result, all employers of 15 or more employees generally should review and tighten their policies and processes for evaluating requests for medical leave to minimize their exposure to claims that the denial of a requested medical leave violated the ADA.

Furthermore, employers also should consider the advisability of other more generalized policy or procedure updates to strengthen their defensibility against potential ADA and other disability claims generally in light of stepped up enforcement by the EEOC and private plaintiffs changes to the ADA made by the ADA Amendments Act of 2008 (ADAAA) that makes it easier for employees to win ADA suits. To mitigate growing exposures to these claims, employers covered by the ADA and/or the Rehabilitation Act of 1973 should review and strengthen their existing hiring and other employment practices and documentation to strengthen their defensibility in the face of these new challenges.

If you need assistance responding an employee’s request for medical leave or other accommodations, or otherwise to review, update or defend your disability discrimination or other employment, compensation, benefits or other workforce, internal controls or risk management practices, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Other Resources

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About Ms. Stamer

Management attorney and consultant Cynthia Marcotte Stamer helps businesses, governments and associations solve problems, develop and implement strategies to manage people, processes, and regulatory exposures to achieve their business and operational objectives and manage legal, operational and other risks. When working with clients, Ms. Stamer combines a client-oriented approach with an extensive practical and technical knowledge of human resources, insurance, employee benefits, health care, privacy & security, corporate compliance and other legal matters to assist clients to formulate and administer pragmatic operational and risk management strategies and effective internal controls taking into account the financial, operational, political, legal and other realities confronting the client.

Recognized in the International Who’s Who of Professionals and bearing the Martindale Hubble Premier AV-Rating, Ms. Stamer also is a highly regarded author and speaker who serves in the leadership of many professional and civil organizations. She regularly conducts management and other training on a wide range of workforce management, employee benefits, compensation, risk management internal controls, and other related matters for businesses, trade and professional associations and others. Her insights on human resources risk management matters appear in The Wall Street Journal, various publications of The Bureau of National Affairs and Aspen Publishing, the Dallas Morning News, Spencer Publications, Health Leaders, Business Insurance, the Dallas and Houston Business Journals and a host of other publications. To request Ms. Stamer’s assistance, for information about arranging for Ms. Stamer to provide workshops and other training, to access other publications or resources or for more details about Ms. Stamer’s experience and other credentials, contact Ms. Stamer at via telephone at 469.767.8872 or via e-mail at cstamer@solutionslawyer.net or see CynthiaStamer.com.

If you or someone else you know would like to receive future updates and notices about upcoming programs and events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. To unsubscribe, send an e-mail with “Unsubscribe” in the subject here. For important information concerning this communication see here.

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Posted by Cynthia Marcotte Stamer

Annual Benefit Limitation Waiver Guidance Offers Fast Acting Employers, Insurers Expanded Options To Meet Affordable Care Act Health Plan Rule

October 3, 2010

Many employers and insurers that act quickly may qualify for a temporary reprieve from the obligation to redesign their group health plans and health insurance policies to comply with the annual benefit limitations on health plan benefits imposed under the Patient Protection and Affordable Care Act (Affordable Care Act) applicable to most health insurance plans and policies beginning with post-September 22, 2010 plan years.

On September 3, 2010, the U.S. Department of Health & Human Service published rules that enable qualifying employers and insurers to obtain a waiver of the application of ACA’s annual limits to their health plan for 2011 (Annual Limit Waiver). In addition to the Annual Limit Waiver relief, HHS on October 1, 2010 also announced plans in the near future to publish additional guidance to provide some relief for mini-meds and certain other plans from the medical loss ratio rules of ACA. Plan sponsors and insurers struggling to redesign their benefit programs to meet ACA’s annual limit and medical loss ration mandates for their 2011 plan year should act quickly to evaluate and where applicable take advantage of the added flexibility that this new guidance may afford regarding their 2011 plan design.

With compliance deadlines impending, however, plan sponsors and insurers must act quickly to leverage these opportunities and make other necessary arrangements to update their health programs to meet new federal requirements. When deciding how to respond to ACA and other new federal health plan rules, plan sponsors and insurers who maintain plans that can qualify as grandfathered plans under ACA should carefully consider all alternatives before deciding to forego this status. Many plan sponsors and insurers feel soaring health coverage costs require that they make cost-saving plan design changes that preclude them from maintaining a grandfathered plan. Creative use of the new Annual Benefit Limitation Waiver, grandfathered plan and other guidance may help mitigate the cost and other challenges of complying with these new federal rules. Read more details.

If your organization needs assistance to apply for an ACA Annual Limit Waiver, reviewing or updating your heath care program design, documentation, policies or procedures in response to ACA or other requirements or with other employee benefit, insurance or human resources matters, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

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About Ms. Stamer

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Posted by Cynthia Marcotte Stamer

New Insured Group Health Plan Non-Discrimination Rules Create Significant Liability For Employers & Insurers; Prompt IRS Also To Review Self-Insured Group Health Plan Rules

September 20, 2010

Non-grandfathered insured group health plans that impermissibly discriminate in favor of highly compensated employees in post-September 22, 2010 plan years face significant liability under new rules enacted as part of the Patient Protection and Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act (the Reconciliation Act), Pub. L. 111-152 (collectively the “Affordable Care Act”). Given these significant new liability exposures, employers and insurers that presently sponsor insured group health plans that discriminate in favor of highly compensated employees must quickly redesign their programs to comply with the Affordable Care Act’s new nondiscrimination rules unless the program qualifies as exempt from the new rules as a “grandfathered plan.”

Concurrently, sponsors of insured and self-insured group health plans alike will want to keep a close eye out for anticipated changes in the Internal Revenue Service’s (IRS’) regulations interpreting the non-discrimination rules under Internal Revenue Code section 105. In connection with the implementation of the Affordable Care Act’s new nondiscrimination requirements for insured group health plans, the Internal Revenue Service has announced that it both is evaluating the regulatory guidance needed regarding the new rules, as well as reviewing the adequacy of its guidance concerning the self-insured group health plan nondiscrimination requirements under Code section 105(h). Employers and others concerned about the content of these new regulations should consider sharing their input with the IRS in response to the invitation for public comment set forth in Notice 2010-63, which is scheduled for official publication in Internal Revenue Bulletin 2010-41 on October 12. Read more here.

Because of the significant liability exposures that result if an insured group health plan violates the new Affordable Care Act nondiscrimination rules, employers and insurers should act quickly to review all insured group health plan arrangements for possible prohibited discrimination in favor of highly compensated employees under the new Affordable Care Act rules. Unless the program will qualify as a grandfathered plan for purposes of the Affordable Care Act, employers or other sponsors, insurers, and administrators of these programs should take prompt action either to terminate or redesign the program as necessary to avoid violation of the new rule before the first post-September 22, 2010 plan year begins. With prompt action, it may be possible to preserve the ability to continue to maintain certain discriminatory insured group health plans by demonstrating that the arrangement existed before March 23, 2010 and otherwise qualifies as a grandfathered plan for purposes of the Affordable Care Act. Where it is not possible to demonstrate that the plan qualifies as an exempt grandfathered plan, however, employers will want to take quick action to appropriately terminate or amend the arrangement and to timely communicate these changes to affected participants and beneficiaries.

For Assistance or More Information

If your organization needs assistance reviewing or updating your heath care program design, documentation, policies or procedures in response to the Affordable Care Act or other requirements or with other employee benefit, insurance or human resources matters, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Current Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, 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 and other employee benefit 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, conducts client and other training, speaks and consults extensively on these and other health and managed care program concerns and practices. She regularly speaks and conducts training for the ABA, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations. 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 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:

About Solutions Law Press

Comments Off on New Insured Group Health Plan Non-Discrimination Rules Create Significant Liability For Employers & Insurers; Prompt IRS Also To Review Self-Insured Group Health Plan Rules | Employee Benefits, ERISA, Health Plans, Human Resources, Labor Management Relations | Tagged: Affordablel Care Act, Health Plans, highly compensated employees, Insurers | Permalink
Posted by Cynthia Marcotte Stamer

NLRB To Review, Invites Briefs In Cases Involving Voluntary Recognition Agreements & Successor Employers

August 31, 2010

A newly constituted National Labor Relations Board in a narrow 3-to-2 vote has granted review and is inviting interested parties to file briefs in two sets of cases that question when a labor union’s support among employees can be challenged.

In one set of cases, the newly-constituted Board will reconsider the Board’s 2007 ruling that an employer that agrees to voluntarily recognize a union based on signed authorization cards must post a notice advising the employees that they have a right within 45 days of the notice to file a petition for an election to decertify the union or in support of a rival union, if they so desire.

In the second set of cases, Board is set to reconsider the Board’s rulings that a successor employer duty to recognize and bargain with a union recognized by its predecessor can be challenged by the employer, employees, or a rival union.

Get more details here.

The decisions made by the Board could have significant impacts on the responsibilities of employers to recognize and deal with unions. Employers and others concerned with labor-management relations should monitor, and if appropriate, consider sharing their perspective through a timely submitted brief in these matters.

For Assistance or More Information

If your organization needs assistance reviewing or responding to the request for comments or otherwise dealing with labor or other human resources compliance concerns, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Ms. Stamer has more than 23 years experience advising employers and others about union organizing and certification, collective bargaining and other labor and employment, employee benefits, compensation and other workforce compliance, risk management and defense matters. She continuously advises employers about these and other related regulatory compliance, workforce management, operational, public policy, enforcement, litigation and risk management and other concerns. Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on these and other concerns and practices. She regularly speaks and conducts training for the ABA, American Health Lawyers Association, Institute of Internal Auditors, and many other organizations. 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 Publishers of her many highly regarded writings on labor, human resources and other workforce management 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.

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Posted by Cynthia Marcotte Stamer

ICE Invites Comments On Information Required For IMAGE Program Employers

August 31, 2010

September 30, 2010 now is the deadline for employers and others wishing to comment on the information that the Department of Homeland Security, U.S. Immigration and Customs Enforcement (ICE) plans to require employers to supply when completing the “Form 73–028, IMAGE Information Request and Membership Application/ICE Mutual Agreement between Government and Employers” (IMAGE Form) required to participate in the IMAGE program originally announced by ICE in the June 11, 2010 Federal Register here. In a notice published in the August 31, 2010 Federal Register, ICE announced that it is extending the period for commenting on its proposed information collection requirements for an additional 30 days after having received no response to its June 11, 2011 request for comments. Read more here.

For Assistance or More Information

If your organization needs assistance reviewing or responding to the request for comments or otherwise designing, defending or administering I-9 or other human resources compliance concerns, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Ms. Stamer has more than 23 years experience advising employers and others about I-9 and other labor and employment, employee benefits, compensation and other workforce compliance, risk management and defense matters. She continuously advises employers about these and other related regulatory compliance, workforce management, operational, public policy, enforcement, litigation and risk management and other concerns. Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on these and other health and managed care program concerns and practices. She regularly speaks and conducts training for the ABA, American Health Lawyers Association, Institute of Internal Auditors, and many other organizations. 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 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.

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Posted by Cynthia Marcotte Stamer

Affordable Care Act’s Health Plan External & Internal Review Safe Harbor & Other Regulations Require Health Plan Updates

August 26, 2010

The Patient Protection & Affordable Care Act (Affordable Care Act) generally mandates that all group and individual health plans and policies comply with these mandates no later than the first plan or policy year beginning after September 22, 2010 unless the plan or policy qualifies as a “grandfathered plan” under the Affordable Care Act. Employer and other health plan sponsors, insurers, fiduciaries and administrators of all federally-regulated employment-based health plans should move quickly to update plan documents, administrative procedures and agreements, decisional criteria, investigation and decision-making documentation, and claims and appeals-related notification and other communications to comply with a series of new Federal guidance governing health plan claims and appeals published in the Federal Register on July 23, 2010 as further supplemented by additional “safe harbor” external review procedures published in the Federal Register today (August 26, 2010) (collectively the ACA Appeals Rules”).

Although the ACA Appeals Rules technically apply only to non-grandfathered plans, Agency commentary about existing Labor Department health plan claims and appeals procedures published along with the ACA Appeals rules sends a strong signal that the adequacy of all health plan claims and appeals procedures is warranted. As many health plan sponsors and health insurers are deciding that compliance with Affordable Care Act mandates is more cost effective than meeting the conditions that federal regulations require for a health plan to maintain grandfathered plan status, most group health plans and policies will need to be updated to comply with these new rules quickly. Even if a plan qualifies as a grandfathered plan, however, comments contained included the preamble to the July 23, 2010 guidance and recent court decisions send a strong signal that a review and update of existing claims and appeals procedures and practices is warranted. Read more.

For assistance to review and update your health or other employee benefit claims and appeals or other terms, processes, notices and communication or other processes and procedures, please contact the author of this update, attorney Cynthia Marcotte Stamer at (469) 767-8872 or cstamer@solutionslawyer.net.

Learn More About Affordable Care Act Mandates: Order Recording of August 24 “2010 Health Plan Update”

Details of recently released guidance about federal health plan rules applicable to employment-based health plans under the Affordable Care Act and other federal health plan regulations were among the topics covered in a “2010 Health Plan Update” internet broadcast briefing on Tuesday, August 24 2010. For more information about this briefing, see here. If you are interested in purchasing a recording of this briefing, e-mail here.

For Assistance or More Information

If your organization needs assistance updating your heath care program documentation, policies or procedures in response to these or other requirements or with other employee benefit, insurance or human resources matters, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

Health Care Reform: What You Need To Know To Build Your Family’s Healthcare Survival Plan

August 13, 2010

Health Care Reform: What You Need To Know To Build Your Family’s Healthcare Survival Plan

August 26, 2010

6:30-8:00 PM

Sunrise of Plano Center

4800 West Parker Road

Plano, Texas 75093

Sunrise Senior Living is inviting members of the public to learn from attorney and author Cynthia Marcotte Stamer about health care reform and learn practical tips to help senior and other patients and their caregivers plan their family’s healthcare survival plan.

The program will be held on August 26, 2010 from 6:30 PM-8:00 PM at the Sunrise of Plano Center located at 4800 West Parker Road, Plano, TX 75093.

During the program, Ms. Stamer will overview the impending health care reforms recently enacted by Congress and share some practical tools and information to help patients and their families, caregivers, employer and others plan for and prepare to deal with various challenges that commonly arise when caring for an elderly or ill person.

For more details about the program, see here. To RSVP, contact Sunrise Director of Community Relations Loretta Ressler by telephone at 972-985-9181 or by fax to 866-898-9748.

About Ms. Stamer

Cynthia Marcotte Stamer is a leader on the development of practical strategies for helping patients and their families, health care providers, employers, insurers, and others help patients and their families better handle health care and disability related challenges. The founder and President of the Project COPE: The Coalition On Patient Empowerment and author of the “Health Care Toolkit” and the many other highly regarded publications and works on patient empowerment and related matters, “Cindy” is nationally and locally recognized for her activism in developing practical solutions for common health, disability and other employment challenges for employers, insurers and others.

An AV-rated attorney Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization and recognized in International Who’s Who, “Cindy” regularly helps put these and other solutions in effect in her day-to-day practice of advising health care providers, employers, health care organizations, insurers, and others about the design and implementation of patient and employee communications and consumer directed health care, patient empowerment, patient education and “patient centric” care strategies and other health care, employee benefits, disability management, human resources, insurance, and related matters.

A popular speaker nationally recognized for her legal and practical experience with patient empowerment and consumer driven health care, health care quality, and other human resources, employee benefit, and health matters, Cindy works extensively on a wide range of efforts to improve health care domestically and international. Past President and the founding Chair of the Alliance for Health Care Excellence’s Patient Empowerment Project, the current Chair of the American Bar Association (ABA) Real Property Trusts and Estate Section Employee Benefit and Other Compensation Programs Group Chair and Past Chair of the ABA Health Law Section Managed Care and Insurance Interest Group A widely published author, Cindy is the author of a diverse array of employee benefit, human resources and health law publications and tools for The Bureau of National Affairs, Aspen Publishers, the Thompson Publishing Group, and Spencer Publications. Her insights on patient empowerment and consumer directed health care have been quoted in the publications of BNA, Business Insurance, World At Work, the American Bar Association, the American Health Lawyers Association, Health Leaders, the Wall Street Journal, Aging Magazine, Spencer Publications, Health Care Report, the Dallas and Houston Business Journal, the Dallas Morning News and a host of other publications.

You can get more information about Ms. Stamer and her experiences, publications, programs, community service, and professional activities here. If you need assistance with these or concerns or wish to inquire about arranging for Ms. Stamer to speak on this or another topic, please contact Ms. Stamer at (469) 767-8872 or via e-mail here. =

About Project COPE

Project COPE works together with employers, health care providers, insurers and other payers, community leaders, patients and others to develop, educate and share practical strategies, information and tools that help empower patients to use health care resources and payers, providers and communities to provide access to quality affordable care.

The most overlooked opportunities for quality and cost improvements rests with the people in health care:

The patients, their families and friends
Health care providers
Employers, churches, social organizations and other community organizations and resources that deal with patients and their families;
Health plans, insurers, and others that administer care; and
Others that encounter patients and their families.

The best opportunity to improve access to quality, affordable health care for every American and every employer, insurer, and community organization to understand their role in the health care system and to get and share the education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, caring for elderly, disabled or ill Americans people requires the human touch. Americans can best improve health care by not waiting for someone else to step up: Speak up, step up and help bridge the gap when you or your organization can do so by extending yourself a little bit. Speak up to help communicate and facilitate when you can. Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process. Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist. The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye. Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families. While reimbursement is an important element, money is not the only issue. Improving and maintaining quality health care requires that Americans and American employers, health care providers, government and community leaders and others understand, and share education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others.

If you or someone else is interested in learning more about Project Cope, e-mail cstamer@solutionslawyer.net or register to participate in the COPE linked in group here.

To stay in touch with these and other activities and developments of Ms. Stamer, 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.

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Posted by Cynthia Marcotte Stamer

Assess Your Health Plan Compliance 8/24: Register Now!

August 12, 2010

Get a Health Plan Compliance Checkup

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

2010 Health Plan Update

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

Earn 2 Hours of Texas Insurance Continuing Education Credit, WorldAtWork or HRCI Credit!

Solutions Law Press invites you to catch up on the latest guidance on 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 the “2010 Health Plan Update” briefing on Tuesday, August 24, 2010. The briefing will be held via a live internet broadcast from 11:00 to 1:30 P.M. Central Time. Registrants can elect to participate in person or watch via the Internet for a registration fee of $150.00. To register click here.

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

Health benefit costs and legal risks continue to grow for U.S. businesses. The Affordable Care Act and other impending federal health plan regulatory changes will require employment-based group health plans, their employer and other plan sponsors, insurers 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 practices to comply with new federal requirements that become effective under the Affordable Care Act on the first day of the next 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 qualify for small employer tax credits, retiree medical subsidies or other benefits.

August 24 Briefing 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 the Affordable Care Act
How to decide if maintaining grandfathered plan status is worthwhile
Claims & appeals requirements for grandfathered & non-grandfathered plans
Preventive care coverage & wellness program rules under Affordable Care Act, GINA, ADA & other federal regulations
Updated dependent child eligibility, pre-existing condition & other dependent coverage rules for grandfathered & non-grandfathered plans
Special enrollment, preexisting condition & other eligibility mandates for grandfathered & non-grandfathered plans under new Affordable Care Act, FMLA, Michelle’s Law, HIPAA & other regulations
Mental health & substance abuse, provider choice & other benefit mandates under new Affordable Care Act, Mental Health Parity & other federal rules
New HIPAA Privacy Rules
Update on other recent & pending Affordable Care Act group health plan rule guidance
Cafeteria plan implications
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. Ms. Stamer is nationally known for her more than 23 years of 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 Group, 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 group health plans, insurers, employer and other plan sponsors, plan fiduciaries, plan administrators and vendors, and others about health plan design, administration, defense, contracting and related legal compliance, 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. Texas Insurance Department Continuing Education Provider Number 3544.

About Solutions Law Press

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

Solutions Law Press ™ Thanks Our Sponsors

Benefit HR Productions is a producer of enrollment and employee benefit and human resources orientation and on boarding enrollment and other human resources video communications for employers and their service providers. For more information, contact Bill at (972) 267-8410.

NFC offers supplemental insurance benefits to individuals and families that pay benefits directly to the insured and offers cafeteria plan administration services at no cost to employers including a Debit Card feature. To learn more about NFC cafeteria plan services or its supplemental insurance products contact Art Mueller at National Family Care Life Insurance Company, 13530 Inwood Rd, Dallas, Tx 75244. 800-527-0996. acmnfc@flash.net

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.

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Posted by Cynthia Marcotte Stamer

New Regulations & Court Decisions Require Health Plan Claims & Appeal Updates & Strengthening

August 8, 2010

Register Now For 8/24 Health Plan Update Briefing

Employer and other health plan sponsors, insurers, fiduciaries and administrators should move quickly to review, update and tighten their plan documents, administrative procedures and agreements, decisional criteria, investigation and decision-making documentation, and claims and appeals-related notification and other communications in response to new requirements and guidance in recently proposed Labor Department Regulations and the increased willingness of Federal courts to scrutinize and overturn benefit denials.

New regulations (ACA Appeals Rules) implementing tighter health plan claims and appeals rules enacted under the Patient Protection & Affordable Care Act (Affordable Care Act) are the latest in a wave of new Affordable Care Act and other federal regulations that require quick updates to employment-based health plans.

The new ACA Appeals rules published July 23, 2010 primarily focus on additional claims and appeals standards that group health plans not “grandfathered” under the Affordable Care Act must meet by the first plan year beginning after September 22, 2010. However, clarifications of the Labor Department’s interpretation of existing claims and appeals rules for employment-based group health plans shared with the ACA Appeals Rules make clear grandfathered plans also have work to do. Therefore, group health plan sponsors, insurers, fiduciaries and administrators of all group health plans should review and tighten their claims and appeals procedures in response to the guidance recently published in connection with the ACA Appeals Rules.

Beyond responding to the Labor Department’s ACA Appeals Rules, employer and other health and employee benefit plan sponsors, insurers, fiduciaries and administrators also should consider tightening and strengthening their claims and appeals decision-making, documentation and notice processes and procedures to reduce the risk that the courts will overturn benefit denials to guard against the growing willingness of federal courts to overturn benefit denials based upon their findings of process, documentation, notification, conflict of interest or other deficiencies that make the decision “arbitrary or capricious” or otherwise unsustainable under ERISA. Read more.

Many Other Changing Federal Rules Require Other Plan Updates

Changing claims and appeals standards are only a small part of the sweeping range of developments that employer and other plan sponsors, administrators, and fiduciaries of group health plans must deal with as the struggle to design and administer legally defensible plans this year.

The new ACA 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 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.

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.

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. 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 and managing costs.

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

Solutions Law Press invites you to catch up on the latest guidance about the new group health plan 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 & Get More Details.

Learn the tests that will decide if your group health plan will qualify as “grandfathered” from key Affordable Care Act requirements and assess what updates you should consider making to meet critical 2010/2011 Affordable Care Act & other federal health plan compliance deadlines.

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.

For Assistance or More Information

Other Resources

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

About Solutions Law Press

Comments Off on New Regulations & Court Decisions Require Health Plan Claims & Appeal Updates & Strengthening | Affordable Care Act, Claims Administration, Disability Plans, Employee Benefits, Employers, ERISA, Fiduciary Responsibility, Health Plans, Human Resources, Insurance, Preemption, Reporting & Disclosure | Tagged: Affordable Care Act, Appeals, Claims, ERISA, Health Plans | Permalink
Posted by Cynthia Marcotte Stamer

Free 8/13 ABA RPTE Study Group Call On Affordable Care Act Claims & Grandfathered Plan Regulations

August 8, 2010

On August 13, 2010, at 1 PM Eastern, Noon Central, 11 AM Mountain and 10 AM Pacific, the RPTE Employee Benefits Group will host a free one hour “Study Group” conference call led by the Welfare Plan Committee to discuss the interim regulations under the Patient Protection and Affordable Care Act (PPACA) regarding claims adjudication and grandfather plan status. This timely discussion has immediate impact on practitioners and their clients dealing with group health plans, since the new rules generally apply to plan years beginning on or after September 23, 2010.

Key topics will include:

Mandatory Claims Processing and Appeals Process Requirements
Impact on 2001 ERISA Claims Regulations
Impact on Plan Designs and Plan Administration
Determining Grandfather Status
Impact of Future Plan Actions on Grandfather Status

In addition, the topics for possible future calls in September and October regarding health care reform, as well as the current ABA projects to provide comments to the DOL, IRS and Department of HHS with respect to guidance under PPACA and opportunities for involvement also will be discussed.

The conference call will be moderated by:

Cynthia Marcotte Stamer, Cynthia Marcotte Stamer, PC, Dallas, TX;
Elizabeth Leight, Society of Professional Benefit Administrators, Washington, DC; and
Scott Douglas Marquardt, Total Plan Services, Inc., Dallas, TX

The phone number and passcode for the call are:

(866) 646-6488

Pass code: 5380700259

Given the scope of the changes wrought by PPACA, and the numerous interpretations being offered in the legal and insurance communities as well as the media, this promises to be a lively discussion. Multiple views and comments are encouraged.

Other Resources

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

ü Small Employers Sponsoring Health Coverage May Qualify For New Tax Credit, Must Act Quickly To Comply With Other New Federal Health Plan Mandates Under Affordable Care Act & Other Laws

ü Rite Aid Pays $1 Million HIPAA Privacy Settlement As OCR Tightens HIPAA Regulations

ü New Affordable Care Act Mandated High Risk Pre-Existing Condition Insurance Pool Program Regulations Prohibit Plan Dumping of High Risk Members, Set Other Rules

ü Register Now For 8/24 2010 Health Plan Update Briefing

ü Congress & Labor Department Considering Tightening of Retirement Plan Regulations

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

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

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

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

ü Agencies Release Regulations Implementing Affordable Care Act Health Plan Preventative Care Mandates

ü New Retirement Plan Resource To Help Spanish-Speaking Participants With Retirement Planning

ü Office of Civil Rights Proposes Changes To HIPAA Privacy, Security & Civil Sanctions Rules

ü St. Louis Employer’s OSHA Violations Trigger Contempt Order and Penalties

ü Review & Strengthen Defensibility of Existing Worker Classification Practices In Light of Rising Congressional & Regulatory Scrutiny

ü Key Affordable Care Act Health Plan Coverage Mandates Guidance Issued June 28; Apply ASAP For Early Retirement Reinsurance Program

ü HHS, DOL & IRS Rules Define “Grandfathered” Group Health Plans & Health Insurance Coverage under the Patient Protection and Affordable Care Act

ü New Rule Requires Federal Government Contractors To Post New “Employee Rights Under The National Labor” Poster

ü Defined Contribution Plans Investing In Publically Traded Employer Securities Face New Requirements

ü CBO Raises Estimated Cost of Health Care Reforms As Employers, Health Plans Brace Costs Of Newly Effective & Impending Mandates

ü Certain Workforce Reductions Trigger Plant Closing Notice & Other Obligations

ü Mishandling Employee Benefit Obligations Creates Big Liabilities For Distressed Businesses & Their Business Leaders

ü DOL Plans To Tighten Employment Protections For Disabled Veterans & Other Disabled Employees Signals Need For Businesses To Tighten Defenses

ü COBRA, HIPAA, GINA, Mental Health Parity or Other Group Health Plan Rule Violations Trigger New Excise Tax Self-Assessment & Reporting Obligations

About Solutions Law Press

Comments Off on Free 8/13 ABA RPTE Study Group Call On Affordable Care Act Claims & Grandfathered Plan Regulations | Affordable Care Act, Claims Administration, Employee Benefits, ERISA, Fiduciary Responsibility, Health Plans, Human Resources, Insurance, Reporting & Disclosure | Tagged: Affordable Care Act, Benefit Denials, Claims Regulations, Grandfathered Plans, Health Plans | Permalink
Posted by Cynthia Marcotte Stamer

Stamer To Conduct“Health Plan Eligibility Update” Teleconference For NBI October 13, 2010

August 5, 2010

Register Now For 8/24 2010 Health Plan Update Briefing

Employer and other group health plan sponsors and insurers, fiduciaries and administrators of group health must update their health plans and practices to comply with new federal rules imposed by the Affordable Care Act and a host of other evolving federal health plan rules. In the meantime, health plan sponsors, fiduciaries, insurers and administrators looking to catch up on the most significant new requirements for employer and union sponsored health plans for the upcoming year also should consider registering to participate in the Solutions Law Press Health Plan Update Briefing scheduled for August 24, 2010.

October 13 NBI Teleconference Focuses On Eligibility Requirements

Catch up on the evolving federal health plan eligibility rules that employer and union sponsored group health plans must meet by listening in as attorney Cynthia Marcotte Stamer speaks about “Health Plan Eligibility Update”” on a live teleconference to be hosted by National Business Institutes on Wednesday, October 13, 2010 from 1:00 p.m.- 2:30 Central Time. To register or for additional information on the October 13 NBI Teleconference , visit http://www.nbi-sems.com.

During the October 13, 2010 Health Plan Eligibility Teleconference, Ms. Stamer will share:

ü Core Requirements Of Federal Group Health Plan Eligibility Rules Including Evolving Requirements of:

The Affordable Care Act
COBRA
HIPAA
GINA
Family Leave
Military Leave
Michelle’s Law & Other Dependent Coverage
Medicare Secondary Payer

ü Implications On Cafeteria Plan & Other Common Enrollment Strategies

ü Tips to Keep Health Plans Complaint

August 24 SLP Internet Briefing Overviews Latest Core Federal Rules For Group Health Plans Generally

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[i] 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. 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. Register/Get Details Here!

About The Presenter

Both programs 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

If you found this of interest, you also may be interested in the following recent Solutions Law Press publications by Ms. Stamer:

Comments Off on Stamer To Conduct“Health Plan Eligibility Update” Teleconference For NBI October 13, 2010 | ADA, CHIP, COBRA, Employee Benefits, Employers, ERISA, family leave, Fiduciary Responsibility, FMLA, GINA, Health Plans, HIPAA, Human Resources, Insurance, Leave, medical leave, Medicare Part D, Mental Health, Mental Health Parity, Patient Protection and Affordable Care Act | Tagged: Affordable Care Act, Emploeyrs, GINA, Group Health plans, Health Plans, HIPAA, Insurers | Permalink
Posted by Cynthia Marcotte Stamer

Small Employers Sponsoring Health Coverage May Qualify For New Tax Credit, Must Act Quickly To Comply With Other New Federal Health Plan Mandates Under Affordable Care Act & Other Laws

August 4, 2010

Register for August 24 Health Law Update Briefing To Catch Up On Latest Affordable Care Act & Other Federal Health Plan Rules

The Affordable Care Act and other impending federal health plan changes will require employment-based group health plans, their employer and other plan sponsors – large and small, 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.

Information provided by the Internal Revenue Service (IRS) in April provides helpful insights about how the small employer tax credit works currently. These tax credit rules generally will apply from 2010-2013. An enhanced version of the credit will be effective beginning in 2014.

The tax credit generally is available to qualified employers who provide health care coverage for employees and meet certain requirements (“qualified employers”) generally are eligible for a Federal income tax credit for health insurance premiums they pay for certain employees. I

The employer must have fewer than 25 full-time equivalent employees (“FTEs”) for the tax year;
The average annual wages of its employees for the year must be less than $50,000 per FTE,
The employer must provide employees health care coverage by paying premiums under a “qualifying arrangement” within the meaning of the Act and regulations.

Either a for-profit or non-profit employer that meet these conditions generally can qualify as “qualifying employer.” However, special rules apply in calculating the credit for a tax-exempt qualified employer.

Calculation of the Credit

For purposes of the calculating the credit, the IRS Q&As indicate that only premiums paid by the employer under an arrangement meeting certain requirements (a “qualifying arrangement”) generally are counted in calculating the credit. Under a qualifying arrangement, the employer pays premiums for each employee enrolled in health care coverage offered by the employer in an amount equal to a uniform percentage (not less than 50 percent) of the premium cost of the coverage. Special transition rules apply for tax years beginning in 2010 with respect to the requirements for a qualifying arrangement.

If an employer pays only a portion of the premiums for the coverage provided to employees under the arrangement (with employees paying the rest), the amount of premiums counted in calculating the credit is only the portion paid by the employer. For example, if an employer pays 80 percent of the premiums for employees’ coverage (with employees paying the other 20 percent), the 80 percent premium amount paid by the employer counts in calculating the credit. For purposes of the credit (including the 50-percent requirement), any premium paid pursuant to a salary reduction arrangement under a section 125 cafeteria plan is not treated as paid by the employer.

In addition, the amount of an employer’s premium payments that counts for purposes of the credit is capped by the premium payments the employer would have made under the same arrangement if the average premium for the small group market in the State (or an area within the State) in which the employer offers coverage were substituted for the actual premium. If the employer pays only a portion of the premium for the coverage provided to employees (for example, under the terms of the plan the employer pays 80 percent of the premiums and the employees pay the other 20 percent), the premium amount that counts for purposes of the credit is the same portion (80 percent in the example) of the premiums that would have been paid for the coverage if the average premium for the small group market in the State were substituted for the actual premium.

The Q&As also indicate that the average premium for the small group market in a State (or an area within the State) will be determined by the Department of Health and Human Services (HHS) and published by the IRS. HHS and the IRS expect to publish the average premium for the small group market on a State-by-State basis is expected to be posted on the IRS website by the end of April.

Maximum Credit For A Qualified Employer

For tax years beginning in 2010 through 2013, the maximum credit is 35 percent of the employer’s premium expenses that count towards the credit unless the employer is a non-profit employer.

For a non-profit employer, the maximum credit for a tax-exempt qualified employer for 2010 to 2013 tax years is 25 percent of the employer’s premium expenses that count towards the credit. However, the amount of the credit cannot exceed the total amount of income and Medicare (i.e., Hospital Insurance) tax the employer is required to withhold from employees’ wages for the year and the employer share of Medicare tax on employees’ wages.

Reductions Of Tax Credit

The available tax credit declines if the number of FTEs of an employer exceeds 10 or if average annual wages exceed $25,000, the amount of the credit is reduced as follows (but not below zero). If the number of FTEs exceeds 10, the reduction is determined by multiplying the otherwise applicable credit amount by a fraction, the numerator of which is the number of FTEs in excess of 10 and the denominator of which is 15. If average annual wages exceed $25,000, the reduction is determined by multiplying the otherwise applicable credit amount by a fraction, the numerator of which is the amount by which average annual wages exceed $25,000 and the denominator of which is $25,000. In both cases, the result of the calculation is subtracted from the otherwise applicable credit to determine the credit to which the employer is entitled. For an employer with both more than 10 FTEs and average annual wages exceeding $25,000, the reduction is the sum of the amount of the two reductions. This sum may reduce the credit to zero for some employers with fewer than 25 FTEs and average annual wages of less than $50,000. The Regulations provide guidance for calculating the amount of the actual credit and claiming that amount.

Certain workers are not counted for purposes of determining the number of FTEs or average annual wages.

Qualifying small employers with taxable income for the year claim the credit on their e employer’s annual income tax return. For a tax-exempt employer, special rules apply. Since employers qualifying for the credit can consider the credit in determining estimated tax payments for the year to which the credit applies in accordance with regular estimated tax rules, employers qualifying for and planning to claim the credit may want to recalculate their quarterly income taxes taking into their projected tax credit. When taking the credit, an employer should keep in mind that claiming the credit does affect an employer’s deduction for health insurance premiums. by reducing the amount of premiums that can be deducted by the amount of the credit.

Other Health Plan Changes Require Prompt Action By All Sponsoring Employers Including Small Employers

The Small Employer Tax Credit is only one of many changes in federal health plan compliance requirements enacted under the Affordable Care Act. Narrowly passed by Congress in March after a year of contentious debate, the comprehensive health care reform legislation imposes a complex array of reforms impacting employment based health plans, employers, and the insurers and other vendors and administrators of these programs.

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

The program will be conducted by the author of this update, 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. For additional information about Ms. Stamer and her experience, see here.

If you need assistance with these or other employee benefits, employment, compensation insurance or other management concerns, wish to inquire about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here,

About Solutions Law Press

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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 by registering to participate in the distribution of these and other updates on our Solutions Law Press distributions in blog form 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 “Remove” in the Subject to here.

[i] 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.

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

Comments Off on Small Employers Sponsoring Health Coverage May Qualify For New Tax Credit, Must Act Quickly To Comply With Other New Federal Health Plan Mandates Under Affordable Care Act & Other Laws | Employee Benefits, Employers, Health Plans, Human Resources, Income Tax, Tax | Permalink
Posted by Cynthia Marcotte Stamer

Rite Aid Pays $1 Million HIPAA Privacy Settlement As OCR Tightens HIPAA Regulations

August 3, 2010

Drug store chain Rite Aid Corporation and its 40 affiliated entities (Rite Aid) will pay $1 million to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. Although targeting a health care provider, employers, health plan sponsors, administrators, and service providers should recognise the the Rite Aid settlement as a strong reminder of the importance of reviewing and tightening their own human resources, employee benefits, adn other policies and processes to better safeguard protected health information, personal financial information and other sensitve data.

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights announcement of the HIPAA resolution agreement with Rite Aid and the concurrent negotiation of a separate consent order of potential FTC Act violations between Rite Aid and the Federal Trade Commission (FTC) follows HHS’ announcement of proposed changes to its HIPAA Privacy Rules and associated penalties in response to changes enacted under the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act). The Rite Aid settlement and the proposed Privacy Rule changes illustrate the growing penalty risks that health plans, health care providers, healthcare clearinghouses and their business associates (Covered Entities) face for violating the Privacy Rules. Read more details.

Additionally, the Rite Aid decision also serves as a reminder to employers, health plans and their administrators, insurers and finance and finance departments to tighten their controls over the use, access and disposal of sensitive information. A walk through of almost most employee benefit, human resources and finance department typically reveals that at any given time a wide range of personal health and other sensitve information is handled and disposed of in a manner that leaves it open to improper or unnecessary use or disclosure. Additionally, while situations like those in Rite Aid and CVS draw big press, Secret Service, FBI, DOL and other statistics show that most wrongful access and damage comes from the improper use of access of information gained through credentials as an employee, contractor or customer. Rite Aid, CVS, and other HIPAA, FTC and personal identity breach statistics, settlements and judgments are a reminder to all of the advisability of cleaning up their policies and controls to better protect this data.

For Assistance or More Information

If your organization needs assistance updating or defending your privacy, data security or other health plan design, documentation policies or procedures in response to these or other requirements or with other employee benefit, insurance or human resources matters, please contact the author of this update, Board Certified Labor & Employment attorney Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here.

Current Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, 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, Stamer continuously advises employers, health and other employee benefit 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, conducts client and other training, speaks and consults extensively on these and other health and managed care program concerns and practices. She regularly speaks and conducts training for the ABA, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, Southwest Benefits Association and many other organizations. Her extensive publications include numerous highly regarding works on HIPAA and other health plan matters published by the Bureau of National Affairs, the ABA, and others. 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 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:

About Solutions Law Press

Comments Off on Rite Aid Pays $1 Million HIPAA Privacy Settlement As OCR Tightens HIPAA Regulations | Corporate Compliance, Data Security, Employee Benefits, Employers, ERISA, Fiduciary Responsibility, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Internal Investigations, Medicare Part D, Risk Management | Tagged: Data Security, HIPAA, HITECH Act, Privacy, Privacy Rules, Rite Aid, Security Rules, Security Standards | Permalink
Posted by Cynthia Marcotte Stamer

New Affordable Care Act Mandated High Risk Pre-Existing Condition Insurance Pool Program Regulations Prohibit Plan Dumping of High Risk Members, Set Other Rules

August 1, 2010

Register Now For 8/24 Health Plan Update Briefing

Group health plans and insurers risk are prohibited from dumping or engaging in other actions designed to drive individuals with pre-existing high risk conditions to enroll in coverage under high risk pool plans established under the “Pre-Existing Condition Insurance Plan” (PCIP) program established by the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act) in lieu of maintaining existing private coverage.

Section 1101 of the Affordable Care Act requires HHS to set up the PCIP program to ensure that a temporary high risk health insurance pool program exists to provide affordable health insurance coverage to uninsured individuals with pre-existing conditions until January 1, 2014, when Exchanges established under sections 1311 and 1321 of the Affordable Care Act take effect.

Interim final rules implementing the PCIP program (Regulations) issued by the Department of Human Services on Friday, July 30, 2010 prohibit group health plans and insurers from dumping individuals with high risk conditions from coverage. The Regulations also identify the individuals that will qualify for enrollment in PCIP plans and detail the rules governing the establishment, implementation and administration of the PCIP program.

Dumping High Risk Patients Prohibited

In addition to already-existing liability for any violation of existing prohibitions against discrimination based on health history under the Health Insurance Portability & Accountability Act, the Genetic Information Nondiscrimination Act, and the Affordable Care Act, the Regulations provide that a health insurance issuer or group health plan found to have illegally discouraged an individual from remaining enrolled in its coverage or engaging in other actions considered “dumping” based on the individual’s health status will be responsible for any medical expenses incurred by the PCIP to provide coverage for a dumped individual who subsequently enrolls in the PCIP plan. Additionally, HHS also may refer the insurer or the plan to Federal and State authorities for other enforcement actions that may be warranted based on the behavior at issue. In light of these exposures, group health plans and insurers should review and tighten their eligibility terms, processes and procedures to avoid prohibited conduct. In this respect, plans and insurer should pay particular attention to managing the conduct of individuals involved in communicating with members or prospective members. Insurers and plans should adopt policies clearly prohibiting eligibility discrimination in violation of these and other rules and back up these rules by clear operating policies and training that makes clear to individuals involved in enrollment and other enrollment activities what conduct is prohibited.

More OnThe PCIP Program & Regulations

The Regulations provide an individual will be eligible to enroll in a PCIP if he or she:

Is a citizen or national of the United States or lawfully present in the United States;
Has not been covered under creditable coverage for a continuous 6-month period of time prior to the date on which such individual is applying for PCIP;
Has a pre-existing condition within the meaning of the Affordable Care Act;
Is a current resident of one of the 50 States or the District of Columbia which constitutes or is within the service area of the PCIP; and
Meets other criteria established by the PCIP with HHS approval.
PCIP Plans will be required to cover eligible individuals without any pre-existing condition limitation or waiting period.

The Regulations outline the process that a State or nonprofit private entity to pursue and enter into a contract with HHS to set up and run a PCIP program. The PCIP program generally anticipates that each State will contract with HHS to maintain a qualifying PCIP program directly or by subcontracting with another party. If a State elects not to or fails to maintain a PCIP program, however, the Regulation states HHS will contract with a nonprofit private entity to offer a PCIP program in that State.

PCIP program operates must have enrollment and disenrollment rules and processes that meet the applicable standards in the Regulations. The Regulations dictate that as part of this process, a PCIP verify that an individual is a United States citizen or national or lawfully present in the United States in accordance with the Regulations. The Regulations also allow PCIPS to employ certain strategies to manage enrollment over the course of the program that may include enrollment capacity limits, phased-in (delayed) enrollment, and other measures, as defined by the PCIP and approved by HHS to manage the PCIP program’s compliance with funding and other allowable requirements.

The Regulations specify that each benefit plan offered by a PCIP cover at least the following categories and the items and services:

Hospital inpatient services
Hospital outpatient services
Mental health and substance abuse services
Professional services for the diagnosis or treatment of injury, illness, or condition
Non-custodial skilled nursing services
Home health services
Durable medical equipment and supplies
Diagnostic x-rays and laboratory tests
Physical therapy services (occupational therapy, physical therapy, speech therapy)
Hospice
Emergency services and ambulance services
Prescription drugs
Preventive care
Maternity care

The Regulations also prohibit PCIP Plans from offering certain benefits. Benefit plans offered by a PCIP cannot cover the following services:

Cosmetic surgery or other treatment for cosmetic purposes except to restore bodily function or correct deformity resulting from disease.
Custodial care except for hospice care associated with the palliation of terminal illness.
In vitro fertilization, artificial insemination or any other artificial means used to cause pregnancy.
Abortion services except when the life of the woman would be endangered or when the pregnancy is the result of an act of rape or incest.
Experimental care except as part of an FDA-approved clinical trial.

The Regulations regulate the premiums and cost sharing that PCIP programs can use. The Regulations limit the premium a PCIP may charge to 100 percent of the premium for the applicable standard risk rate that would apply to the coverage offered in the State determined in accordance with the Regulations using HHS-approved reasonable actuarial techniques. Premiums charged to enrollees in the PCIP may vary on the basis of age by a factor not greater than 4 to 1. Also, the PCIP program’s average share of the total allowed costs of the PCIP benefits must be at least 65 percent of such costs. Furthermore, the out-of-pocket limit of coverage for cost-sharing for covered services under the PCIP cannot exceed the Internal Revenue Code § 223(c)(2) limit. If the plan uses a network of providers, this limit may be applied only for in-network providers, consistent with the terms of PCIP benefit package.

The Regulations allow a PCIP program to require that covered persons use network providers for non-emergency services if that the PCIP has sufficient providers to ensure that all covered services are reasonably available and accessible to its enrollees. Out-of-network coverage for emergency services will be required under certain conditions. The Regulations also will require PCIPst o process and administer claims and appeals in compliance with the Regulations.

The Regulations also require PCIPs to develop and apply operating procedures to prevent, detect, report to HHS and law enforcement and recover (when applicable or allowable) incidences of waste, fraud, and abuse and to cooperate with Federal law enforcement and oversight authorities in cases involving waste, fraud and abuse.

Register For 8/24 Internet Briefing To Learn If Your Plan Will Be Grandfathered Plan & What Health Plan Updates Your Plan Will Require To Meet 2010/2011 Affordable Care Act & Other Federal Health Plan Compliance Deadlines

For Assistance or More Information

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:

About Solutions Law Press

Comments Off on New Affordable Care Act Mandated High Risk Pre-Existing Condition Insurance Pool Program Regulations Prohibit Plan Dumping of High Risk Members, Set Other Rules | Affordable Care Act, Corporate Compliance, Employee Benefits, Employers, ERISA, Fiduciary Responsibility, GINA, Health Plans, Human Resources, Insurance | Permalink
Posted by Cynthia Marcotte Stamer

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

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

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.

About Solutions Law Press

[*] 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.

Comments Off on Register Now For 8/24 2010 Health Plan Update Briefing | ADA, Affordable Care Act, COBRA, Disease Management, Employee Benefits, Employers, ERISA, Excise Tax, family leave, Fiduciary Responsibility, FMLA, GINA, HIPAA, Human Resources, Insurance, Internal Controls, Leave, medical leave, Mental Health, Patient Protection and Affordable Care Act, Payroll Tax, Privacy, Protected Health Information, Risk Management, Tax, Wellness | Tagged: Affordable Care Act, COBRA, FLSA, GINA, grandfathered plan, Health Plan, HIPAA, Mental Health Parity, Michelle's Law | Permalink
Posted by Cynthia Marcotte Stamer

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.

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.

Comments Off on Testimony Highlights Growing Exposure of Businesses Misclassifying Workers; Businesses Should Act to Minimize Risks | Employers, Employment Tax, ERISA, Health Plans, Human Resources, Immigration, Insurance | Permalink
Posted by Cynthia Marcotte Stamer

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.

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.

Comments Off on Businesses Employing Children Should Review & Tighten Practices In Light of Tightened Rules & Increased Penalties | Child Labor, Corporate Compliance, Employers, Human Resources, Internal Controls, Wage & Hour | Permalink
Posted by Cynthia Marcotte Stamer

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

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

August 24 Live Briefing Provides Key Information By Internet Broadcast

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

About Solutions Law Press

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

Comments Off on 2010 Health Plan Update: Learn What You Must Do Now To Meet Key 2010/2011 Affordable Care Act & Other Federal Health Plan Deadlines | ADA, Affordable Care Act, Disease Management, EEOC, Employee Benefits, Employers, ERISA, Excise Tax, family leave, Fiduciary Responsibility, FMLA, GINA, H.R. 4872, Health Care Reform, Health Plans, HIPAA, Human Resources, Insurance, Leave, medical leave, Medicare Part D, Mental Health, Mental Health Parity, Military Leave, Patient Protection and Affordable Care Act, Payroll Tax, Prescription Drugs, Public Policy, Reporting & Disclosure, Union, USERRA, Wellness, Wellness Programs | Tagged: Affordable Care Act, broker, Employers, grandfathered plan, Group Health plans, health coverage, Health Plans, Insurer, Mental Health Parity, Patient Protection and Affordable Care Act, plan sponsor, pre-existing conditions, preventive care | Permalink
Posted by Cynthia Marcotte Stamer

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

July 23, 2010

Register For August 24^th 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.

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

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

Solutions Law Press & Other Solutions Law Press 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.

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Posted by Cynthia Marcotte Stamer

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.

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.

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Posted by Cynthia Marcotte Stamer

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

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 here. Her 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.

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.

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Posted by Cynthia Marcotte Stamer

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.

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.

[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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Posted by Cynthia Marcotte Stamer

Agencies Release Regulations Implementing Affordable Care Act Health Plan Preventative Care Mandates

July 15, 2010

The Departments of Health and Human Services (HHS), Labor, and the Treasury yesterday (July 14, 2010) issued new Interim Final Regulations requiring private health plans that do not qualified as grandfathered under the Patient Protection and Affordable Care Act (Affordable Care Act) to cover evidence-based preventive services and eliminate cost sharing requirements for such services.

Preventive Care Interim Final Regulations

The Regulations interpret and implement a new federal health plan mandate that non-grandfathered employer-sponsored group health plans and health insurers provide 100% coverage for certain preventive care that the Affordable Care Act for plan years beginning after September 22, 2010.

Under the regulations, non-grandfathered plans beginning with the first plan year beginning after September 22, 2010 must cover preventive services that have strong scientific evidence of their health benefits and may no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider. Specifically, the Interim Final Regulations interim final regulations require that a group health plan and a health insurance issuer offering group or individual health insurance coverage provide benefits for and prohibit the imposition of cost-sharing requirements with respect to “recommended preventive services.” Under the Interim Final Regulations, “recommended preventive services include:

Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (Task Force) with respect to the individual involved.
Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (Advisory Committee) with respect to the individual involved. A recommendation of the Advisory Committee is considered to be “in effect” after it has been adopted by the Director of the Centers for Disease Control and Prevention. A recommendation is considered to be for routine use if it appears on the Immunization Schedules of the Centers for Disease Control and Prevention.
With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force). The Department of HHS is developing these guidelines and expects to issue them no later than August 1, 2011.

The complete list of recommendations and guidelines required to be covered under these interim final regulations can be found here. Non-grandfathered health plans and policies, their sponsors, insurers, fiduciaries and administrators will need to monitor this list for periodic updates. The Affordable Care Act provides for updates in the required preventive services. The Affordable Care Act requires that the Departments establish an interval of not less than one year between when new recommendations or guidelines are issued, and the plan year (in the individual market, policy year) for which coverage of the services addressed in such recommendations or guidelines must be in effect. The Interim Final Regulations provide that non-grandfathered group health plans and insurance policies will be required to update their preventive care coverage in response to changes in these standards for plan years (in the individual market, policy years) beginning on or after the later of September 22, 2010, or one year after the date the recommendation or guideline is issued. This means that non-grandfathered plans will be required to comply with recommendations and guidelines issued prior to September 23, 2009 for plan years (in the individual market, policy years) beginning after September 22, 2010. For recommendations and guidelines adopted after September 23, 2009, information at here will be updated on an ongoing basis and will include the date on which the recommendation or guideline was accepted or adopted.

With respect to a plan or health insurance coverage that has a network of providers, the Interim Final Regulations make clear that a plan or issuer is not required to provide coverage for recommended preventive services delivered by an out-of-network provider and may impose cost-sharing requirements for recommended preventive services delivered by an out-of-network provider.

The Interim Final Regulations also address and clarify various other concerns relating to the application of the new preventive care mandate including:

The cost-sharing requirements when a recommended preventive service is provided during an office visit;
That a plan or issuer may rely on established techniques and the relevant evidence base to determine the frequency, method, treatment, or setting for which a recommended preventive service will be available without cost-sharing requirements to the extent not specified in a recommendation or guideline;
That a plan or issuer continues to have the option to cover preventive services in addition to those required to be covered and may impose cost-sharing requirements on these additionally covered preventive services at its discretion;
That a plan or issuer may impose cost-sharing requirements for a treatment that is not a recommended preventive service even if the treatment results from a recommended preventive service; and
That a plan or issuer is not required to provide coverage or waive cost-sharing requirements for any item or service that has ceased to be a recommended preventive service provided other provisions of law don’t independently require coverage of that requirement and appropriate advance notice is provided in accordance with the Affordable Care Act and other provisions of law.

The Affordable Care Act gives authority to the Departments to develop guidelines for group health plans and health insurance issuers offering group or individual health insurance coverage to utilize value-based insurance designs as part of their offering of preventive health services. Value-based insurance designs include the provision of information and incentives for consumers that promote access to and use of higher value providers, treatments, and services. In recognition of the role that value-based insurance design can play in promoting the use of appropriate preventive services, the Interim Final Regulations authorize the use of certain value-based design features by non-grandfathered group health plans and health insurance policies. The preamble accompanying the Interim Final Regulations states that the Departments are developing additional guidelines regarding the utilization of value-based insurance designs by group health plans and health insurance issuers with respect to preventive benefits and invites public comment on this and certain other matters.

Plans & Policies Exempt As Grandfathered Plans

Regulations previously published by the agencies on June 14, 2010 define the conditions when a plan or policy qualifies as exempt from this and certain other Affordable Care Act mandates as a “grandfathered plan.” Whether or not a health plan or policy qualifies as grandfathered under the Affordable Care Act, fiduciaries, administrators, insurers and sponsors of health plans and policies should keep in mind that in addition to the requirements of the Interim Final Regulations, their program separately may be required to cover certain preventive services by other provisions of Federal or State law.

Catch Up On Guidance On Other Affordable Care Mandates

The Interim Final Regulations are the latest of a series of guidance implementing various Affordable Care Act health plan mandates issued by the Regulations in May, June and July. For information about purchasing a recording of the July 9, 2010 Solutions Law Press-sponsored briefing on regulations issued through July 8, 2010 by the Departments interpreting the Affordable Care Act’s rules about when plans and policies qualify as grandfathered plans, and its impending mandates about pre-existing conditions, patient protections and various other Affordable Care Act health plan mandates, e-mail your request here.

About Ms. Stamer

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 employer and other plan sponsors, insurers, Managing Editor of Solutions Law Press and a member of the editorial advisory board of many other industry publications and programs. 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 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. Her 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.

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.

Comments Off on Agencies Release Regulations Implementing Affordable Care Act Health Plan Preventative Care Mandates | Affordable Care Act, Health Plans, Human Resources, Patient Protection and Affordable Care Act, Wellness Programs | Permalink
Posted by Cynthia Marcotte Stamer

Review & Strengthen Defensibility of Existing Worker Classification Practices In Light of Rising Congressional & Regulatory Scrutiny

June 29, 2010

Employers using independent contractors, leased employees or other non-employee workers should carefully review the defensibility of their existing classification and treatment of those workers under tax, labor, employment, employee benefit and other laws in light of stepped up interest and scrutiny by Congress and regulators.

On June 17, 2010, the Senate Committee on Health, Education, Labor, and Pensions held hearings on pending legislation intended to prevent employers from misclassifying workers as independent contractors to avoid paying minimum wage or overtime or other legal protections due employees under the Fair Labor Standards Act (FLSA).

The Employee Misclassification Prevention Act S.3254/H.R.5107 seeks to reduce misclassification errors by amending the Fair Labor Standards Act:

Requiring employers to keep accurate records of each workers’ status;
Clarifying it’s a violation of the Fair Labor FLSA to misclassify workers;
Increasing fines for misclassification under the FLSA;
Requiring employers to notify workers if the employer classifies them as an employee or independent contractor;
Creating an “employee’s rights website” containing relevant information concerning state and federal wage and hour issues; and
Protecting workers against discrimination or retaliation for requesting proper classification will be protected.

In addition to proposed changes to the FLSA, Congress also is looking at legislation that would tighten worker classification rules under other laws. For instance, the Taxpayer Responsibility, Accountability and Consistency Act of 2009 H.R.3408/ S.2882 would target perceived worker misclassification employment and income tax withholding and reporting abuses by amending the Internal Revenue Code to:

Require reporting to the Internal Revenue Service (IRS) of payments of $600 or more made to corporations;
Define criteria and rules relating to the treatment of workers as employees or independent contractors;
Increase penalties for failure to file correct tax return information or comply with other information reporting requirements; and
Require the Secretary of the Treasury to issue an annual report on worker misclassification.

Other proposed legislation would tighten requirements and oversight of the use of independent contractors and other non-employee workers under OSHA and various other federal laws.

While Congress tightens even tighter requirements, regulators are stepping up their scrutiny of employer practices for classifying workers under existing laws. Under a National Research Program announced last September, the Internal Revenue Service has begun conducting the first of approximately 6,000 payroll tax audits that it plans to complete over a three-year period focusing on the appropriateness of employer worker classification and other payroll tax practices.

To guard against these and other growing risks of worker classification, employers should review within the scope of attorney-client privilege the defensibility of their existing worker classification, employee benefit, fringe benefit, employment, wage and hour, and other workforce policies and consult with qualified legal counsel about the advisability to adjust these practices to mitigate exposures to potential IRS, Labor Department or other penalties associated with worker misclassification.

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 employers; employee benefit plans and their sponsors, administrators, fiduciaries; employee leasing, recruiting, staffing and other professional employment organizations; and others design, administer and defend innovative workforce, compensation, employee benefit and management policies and practices. 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 recently was a featured panelist on the ABA Joint Committee on Employee Benefits Teleconference on “Worker Classification & Alternative Workforce: Employee Plans & Employment Tax Challenges” and has worked, published and spoken extensively on worker classification and other related matters. She also is recognized for her publications, industry leadership, workshops and presentations on these and other human resources concerns and regularly speaks and conducts training on these matters. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, and many other national and local publications. 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. 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.

Comments Off on Review & Strengthen Defensibility of Existing Worker Classification Practices In Light of Rising Congressional & Regulatory Scrutiny | ADA, Affirmative Action, Corporate Compliance, E-Verify, EEOC, Employee Benefits, Employers, Employment Tax, Government Contractors, Health Plans, Human Resources, I-9, Immigration, Income Tax, Internal Controls, Internal Investigations, Leave, Military Leave, OFCCP, OSHA, Payroll Tax, Rehabilitation Act, Retaliation, Safety, Tax, Unemployment Benefits, USERRA, VEVRRA, Wage & Hour, Whistleblower | Tagged: Employee, Employment, Employment Tax, Fair Labor Standards Act, Independent Contractor, Minimum Wage, Tax, Worker Classification | Permalink
Posted by Cynthia Marcotte Stamer

Key Affordable Care Act Health Plan Coverage Mandates Guidance Issued June 28; Apply ASAP For Early Retirement Reinsurance Program

June 29, 2010

The Department of Health and Human Services (HHS) Office of Consumer Information and Insurance Oversight (OCIIO) today (June 29, 2010) began accepting applications for the Early Retiree Reinsurance Program (ERRP) established under the Patient Protection and Affordable Care Act (“Affordable Care Act”). Meanwhile, HHS and the Departments of Treasury and Labor Monday published new interim regulations implementing the Affordable Care Act’s group health plan preexisting condition, lifetime and annual limits, rescissions, and patient protections mandates (the “Rules”). These two key developments follow the Agencies release of guidance about the Affordable Care Act’s grandfather provisions and other guidance on the Affordable Care Act’s group health plan rules.

To assist concerned business leaders, plan fiduciaries and plan administrators to understand and cope with these new rules, Solutions Law Press author Cynthia Marcotte Stamer will host a teleconference briefing on these new regulations and other Affordable Care Act health plan guidance on July 9, 2010 from Noon. to 1:30 p.m. Central Time. To register or for other details, see here.

Early Retiree Reinsurance Program

Created by the Affordable Care Act as a bridge to the new health insurance marketplace established by the Exchanges in 2014, this $5 billion program temporarily will reimburse employers, unions, state and local governments, and nonprofits admitted to the program for a portion of claims paid for early retirees.

The Early Retiree Reinsurance Program will reimburse employers admitted to the program for 80 percent of medical claims costs between $15,000 and $90,000 paid for retirees age 55 and older who are not eligible for Medicare, and their spouses, surviving spouses, and dependents. Employers, including state and local governments and unions, who provide health coverage for early retirees are eligible to apply. Program participants will be able to submit claims for medical care going back to June 1, 2010.

Today is the first day HHS is accepting applications. Applications for the program, as well as fact sheets and application assistance can be found here.

Key Guidance On Affordable Care Act Health Plan Coverage Mandates Issued Monday

On Monday, June 28, 2010 HHS, Labor and Treasury (the “Agencies”) jointly published interim final rules implementing the Affordable Care Act’s Rules on preexisting conditions, coverage rescissions, lifetime and annual dollar limits for essential benefits, and patient choice/access of providers. See Regulation, Fact Sheet, Patient Protection Model Notice, Lifetime Limits Model Notice and Dependents Model Notice

The Rule implements and interprets the Affordable Care Act’s restrictions on the use by that group health plans and individual and group health insurance coverage (“health plans”) which generally:

Prohibit preexisting condition exclusions and limitations for children under age 19;
Prohibit arbitrary insurance coverage rescissions;
Prohibit lifetime dollar limits on essential benefits;
Restrict annual dollar limits on essential benefits;
Protect certain choice of physician rights of plan members; and
Prohibit certain restrictions on emergency services.

Certain plans qualifying as “grandfathered” for purposes of the Affordable Care Act may qualify as exempt from these requirements.

The Rule is 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 Patient Protection & Affordable Care Act (Affordable Care Act). See Fact Sheet, Regulation, FAQs, Table, and Model Notice;
Extension of Coverage For Adult Children see Fact Sheet, Regulation, FAQs and IRS Guidance; and IRS Guidance on Tax-Free Employer-Provided Health Coverage Now Available for Children under Age 27, see here;
FAQs on Health Care Reform and COBRA;
IRS Issues Regulations on 10-Percent Tax on Tanning Services Effective July 1, see here;
IRS Guidance On Special Tax Incentives for Small Businesses to Provide Health Care, Hire New Workers, see here, here, here and here.

Register Now For July 9 Teleconference To Catch Up On New Affordable Care Act & Other 2010 Health Plan Changes

Learn more about this and other Affordable Care Act requirements and how it will impact your group health plan by registering to participate in a special Solutions Law Press teleconference briefing on this and other emerging Affordable Care Act group health plan guidance to be conducted by Cynthia Marcotte Stamer on July 9, 2010 from Noon. to 1:30 p.m. Central Time. To register or for other details, see here.

About Ms. Stamer

As a core focus of her practice, 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. Please join us for what promises to be a most interesting discussion.

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 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. Her 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.

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.

Comments Off on Key Affordable Care Act Health Plan Coverage Mandates Guidance Issued June 28; Apply ASAP For Early Retirement Reinsurance Program | Affordable Care Act, Corporate Compliance, Employee Benefits, Employers, ERISA, Excise Tax, Health Plans, Human Resources, Income Tax, Internal Controls, Patient Protection and Affordable Care Act, Payroll Tax, Tax, Wellness | Tagged: Affordable Care Act, Early Retiree Reinsurance Program, Health Plans, preexisting conditions | Permalink
Posted by Cynthia Marcotte Stamer

Key Guidance Issued About New Affordable Care Act Health Plan Requirements; Teleconference Briefing Planned July 9

June 24, 2010

This week (June 22, 2010), the U.S. Departments of Health and Human Services, Labor and Treasury (the “Agencies”) jointly released an advanced copy of interim final rules (the “Rules”) implementing several key new health coverage mandates enacted as part of the Patient Protection and Affordable Care Act (“Affordable Care Act”).

The Rule scheduled for publication in the Federal Register on June 28, 2010 will implement and interpret the Affordable Care Act’s restrictions on the use by that group health plans and individual and group health insurance coverage (“health plans”) which generally:

Prohibit preexisting condition exclusions and limitations for children under age 19
Prohibit arbitrary insurance coverage rescissions;
Prohibit lifetime dollar limits on essential benefits;
Restrict annual dollar limits on essential benefits;
Protect certain choice of physician rights of plan members; and
Prohibit certain restrictions on emergency services.

Certain plans qualifying as “grandfathered” for purposes of the Affordable Care Act may qualify as exempt from these requirements.

The Rule is the latest in a series of recently-issued guidance implementing various health coverage requirements of the Affordable Care Act. It follows closely the June 14, 2010 publication by the Agencies of regulations on 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 Patient Protection & Affordable Care Act (Affordable Care Act).

To review an advanced copy of the Rule see here. Read the accompanying Fact Sheet here.

About Ms. Stamer

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 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. Her 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.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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.

Comments Off on Key Guidance Issued About New Affordable Care Act Health Plan Requirements; Teleconference Briefing Planned July 9 | Affordable Care Act, Employee Benefits, Employers, Health Care Reform, Health Plans, Human Resources, Insurance, Internal Controls | Tagged: Affordable Care Act, annual limits, Health Plans, lifetime limits, preexisting conditions, rescissions | Permalink
Posted by Cynthia Marcotte Stamer

Registration Open For July 9 In “Affordable Care Act & Other Federal Health Plan Guidance Update”

June 23, 2010

Solutions Law Press Invites You To Learn What You Must Do Now To Meet Key Affordable Care Act Health Plan Deadlines

Affordable Care Act & Other Federal Health Plan Guidance Update

July 9, 2010 Teleconference – Noon to 1:30 P.M. Central Time

Solutions Law Press invites you to catch up on the latest guidance on new requirements that group health plans must meet under the Affordable Care Act and other emerging federal health plan regulations by participating in the “Affordable Care Act & Other Federal Health Plan Guidance Update” teleconference to be conducted by attorney Cynthia Marcotte Stamer on Friday, July 9, 2010 from Noon to 1:30 P.M. Central Time for a registration fee of $50.00. To register for this program, see here,

Affordable Care Act Requires Prompt Action By Group Health Plans & Employers

The combined package of comprehensive health care reform legislation enacted by Congress this Spring through the Patient Protection and Affordable Care Act (Public Law 111-148) as amended by the Health Care and Education Reconciliation Act (Public Law 111-152) (collectively referred to as the “Affordable Care Act”) will require most employers, employment-based group health plans, plan sponsors, plan fiduciaries, plan administrators and other service providers and insurers take prompt action to meet compliance deadlines and preserve other options over the next several months. Employer and other group health plan sponsors, fiduciaries, insurers and administrators must act quickly to update their health plan documents, communications and 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. Quick action also may be needed to claim small employer tax credits, retiree medical subsidies or other benefits.

July 9 Briefing Provides Key Information

The July 9, 2010 “Affordable Care Act & Other Federal Health Plan Guidance Update” teleconference will include an update on the latest regulatory guidance about impending Affordable Care Act group health plan rules and other key information to help employers, group health plans, plan administrators and fiduciaries and others working with these plans to understand and respond to these new requirements.

The briefing will cover:

Key elements of Affordable Care Act reforms impacting employment-based health plans
Impending Affordable Care Act deadlines for employment-based group health plans and their sponsors during 2010 or 2011
Update on guidance on grandfathered plan status meaning, qualification and disqualification
Update on guidance on new dependent child coverage extension rules
Update on guidance on early retiree medical reinsurance program
Update on guidance on new small employer health coverage tax credit
Update on other recent and pending Affordable Care Act group health plan rule guidance
Tips to coordinate Affordable Care Act and other federal group health plan mandate compliance
Practical strategies for responding to new requirements and changing rules
Participant questions

About The Presenter

The program will be presented 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.

Other Helpful Resources & Other Information

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 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 at here. You can access other recent updates and other informative publications and resources of Ms. Stamer 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 “Remove” in the Subject here.

Comments Off on Registration Open For July 9 In “Affordable Care Act & Other Federal Health Plan Guidance Update” | Affordable Care Act, ARRA, COBRA Subsidy, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Health Plans, Human Resources, Income Tax, Insurance, Internal Controls, Patient Protection and Affordable Care Act, Payroll Tax, Stimulus Bill, Tax | Permalink
Posted by Cynthia Marcotte Stamer

HHS, DOL & IRS Rules Define “Grandfathered” Group Health Plans & Health Insurance Coverage under Affordable Care Act

June 15, 2010

Affordable Care Act Health Plan Guidance Update Teleconference Briefing Planned July 9

The U.S. Departments of Health and Human Services, Labor and Treasury on Monday (June 14, 2001) published regulations on when group health plans and insurance qualify as “grandfathered plans” for purposes of determining certain deadlines for complying with certain health care reform requirements imposed under the Patient Protection & Affordable Care Act (Affordable Care Act).

The regulations are the latest in a series of emerging guidance that federal agencies have issued regarding the Affordable Care Act since its enactment in March, 2010. Solutions Law Press author Cynthia Marcotte Stamer will host a teleconference briefing on these new regulations and other Affordable Care Act health plan guidance on July 9, 2010 from 11:30 a.m. to 1:30 p.m. Central Time. E-mail here to request an invitation and registration information.

While the Affordable Care Act generally will require that all health plans provide new mandated benefits and other rights to covered persons beginning with plan years starting after September 22, 2010, health plans that existed on March 23, 2010 that qualify as “grandfathered” are exempt from some new requirements. The regulation published yesterday specifies what health plans must do to qualify for grandfathered status for purposes of these requirements.

As part of its first wave of health insurance reforms, the Affordable Care Act dictates that all health plans – whether or not they are grandfathered plans – provide certain benefits to their covered persons for plan years starting on or after September 23, 2010 including:

New restrictions on lifetime limits on essential benefit coverage;
No rescissions of coverage when people get sick and have previously made an unintentional mistake on their application; and
Extension of parents’ coverage to young adult children under 26 years old.

For post September 22, 2010 plan years, non-grandfathered plans also generally must meet certain other conditions including:

No coverage exclusions for children with pre-existing conditions;
No “restricted” annual limits set by regulations to be issued in the future;
Coverage of recommended prevention services with no cost sharing;
Patient protections such as access to OB-GYNs and pediatricians without a referral by a separate primary care provider;
Greater freedom for patients to obtain certain emergency treatment without certain plan restrictions; and
Other requirements.

Under the Affordable Care Act, grandfathered plans are exempt from certain of these mandates and may enjoy delayed compliance deadlines for certain other requirements.

The grandfather rule published June 14 provides certain “routine changes” will not cause a health plan that existed on March 23, 2010 to give up grandfathered status. Allowable changes include cost adjustments to keep pace with medical inflation, adding new benefits, making modest adjustments to existing benefits, voluntarily adopting new consumer protections under the new law, or making changes to follow State or other Federal laws. For this purpose, the regulation states that premium changes are not taken into account when determining whether or not a plan is grandfathered.

On the other hand, the regulation provides that a health plan that existed on March 23, 2010 will lose its eligibility for grandfathered status if the plan is amended to make significant changes that cut benefits or increase costs to covered persons.

Furthermore the regulation also addresses the effect of mergers and acquisitions and various other events and amendments on the eligibility of health plans for grandfathered status.

You can view the regulation here. Details about what routine changes insurers and employers can make without losing their grandfathered status, and the projected impact on large and small employer plans and the individual plan market can be found here. A fact sheet about the regulation can be found here. You can read the Questions and Answers on the Regulation here.

If you need help reviewing or responding to this or other health benefit regulations or other related matters please contact Cynthia Marcotte Stamer here or (469)767-8872.

About Ms. Stamer

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 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. Her 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.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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.

Comments Off on HHS, DOL & IRS Rules Define “Grandfathered” Group Health Plans & Health Insurance Coverage under Affordable Care Act | Employee Benefits, Employers, ERISA, Fiduciary Responsibility, Health Plans, Human Resources, Insurance, Internal Controls, Patient Protection and Affordable Care Act, Wellness Programs | Tagged: Affordable Care Act, ERISA, Grandfathered Plans, Health Care Reform, Health Plans, Insurance | Permalink
Posted by Cynthia Marcotte Stamer

Stamer Speaks On “Designing Legally Defensible Wellness Programs That Work Amid Changing Federal Regulations” On June 10 in Dallas

May 25, 2010

The D/FW International Society of Certified Employee Benefits Specialists invites members and other interested persons learn about “Designing Legally Defensible Wellness Programs That Work Amid Changing Federal Regulations” from Cynthia Marcotte Stamer schedule on June 10, 2010 at Haggar Clothing Co., 11511 Luna Road, Dallas TX 75234.

Changing federal regulations create new challenges, risks and opportunities for employers and health plans in designing legally defensible wellness programs that work. Attorney and consultant Cynthia Marcotte Stamer will share:

An update on evolving employment-based wellness program requirements under the Affordable Care Act, GINA, ADA, HIPAA, and other core federal laws and regulations
What employers and health plans can and can’t do when implementing wellness programs
Legal “gray areas” and other risk traps for employers and health plans to watch and
Pointers for designing and administering these programs.

Advanced registration required. For registration fees and arrangements or other information, contact David W. West, CLU, CEBS, DFW ISCEBS Chapter Administration at (972) 744-2328 (direct), (972) 808-3174 (fax) or davidw@gpatpa.com (E-mail).

About the Speaker

The creator of the PlayForLife™ Wellness Program, the Patient Empowerment Toolkit™ and a wide range of other practical health and benefit management tools and programs, Ms. Stamer is a highly regarded legal advisor and consultant, author and speaker, nationally and internationally recognized for her cutting edge work and leadership with employers, health plans, health care organizations, schools, civic organizations and governments on the design, implementation, administration and defend legally defensible employee and community health, injury prevention and disease management; employee and patient health education and empowerment; managed care and other health and wellness; employee benefit and human resources, insurance, education, and other programs, practices, products and policies.

Chair of the American Bar Association (ABA) RPTE Employee Benefits and Other Compensation Group, a member of the leadership council of the ABA Joint Committee on Employee Benefits (JCEB), Past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, and Board Certified In Labor and Employment Law, Ms. Stamer has 23 plus years legal and operational experience assisting these and other clients design, implement and operate health and wellness, disease management, disability and absence management, and other related workforce, benefit and insurance, and health care programs, practices, products and technologies.

Founder and Executive Director of the Coalition for Patient Empowerment (COPE) and the Coalition for Responsible Health Policy, former member of the National Kidney Foundation of North Texas Board of Directors, past-President of the Board of the Richardson Development Center for Children, and a founding Board Member of the Alliance for Excellence, Ms. Stamer also has extensive experience designing and managing the implementation of a wide range of wellness, health promotion and other related programs in a diverse range of contexts including electronic, on site and offsite health and wellness clinics, health screening programs, occupational health, health education, disease management and other programs.

The publisher and editor of Solutions Law Press, Ms. Stamer also is a popular speaker and widely published author who regularly conducts management and other training on wellness, health benefit and a wide range of other employee benefit, human resources, health care, insurance and other topics. Her hundreds of highly regarded writings are published by the American Bar Association, Aspen Publishers, the Bureau of National Affairs (BNA), the American Health Lawyers Association, SHRM, World At Work, Government Institutes, Inc. and many others. Her insights on health and human resources concerns have been quoted in The Wall Street Journal, various publications of The Bureau of National Affairs and Aspen Publishing, the Dallas Morning News, Spencer Publications, Health Leaders, Modern Health Care, Caring for The Elderly, Business Insurance, the Dallas and Houston Business Journals and a host of other publications. She also serves in leadership positions in numerous human resources, corporate compliance, and other professional and civic organizations.

For more information about Ms. Stamer’s credentials, publications, workshops and other training, and work, contact Ms. Stamer via telephone at 469.767.8872 or via e-mail at cstamer@solutionslawyer.net or see CynthiaStamer.com.

About The Sponsor

The Dallas/Ft. Worth Chapter of ISCEBS is a non-profit organization dedicated to enhancing one’s career in employee benefits. Chapter membership is open to ISCEBS members (CEBS graduates and GBA and RPA designees), and students of the CEBS program. Attendance at educational programs is open to everyone. More information about the local chapter and directions to the meeting are available at http://www.dfwiscebs.org.

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Posted by Cynthia Marcotte Stamer

New Rule Requires Federal Government Contractors To Post New “Employee Rights Under The National Labor” Poster

May 20, 2010

Federal government contractors and subcontractors generally must post a new federally-mandated ‘‘Employee Rights Under The National Labor” poster informing employees of federal unionization rights and protections under the National Labor Relations Act under a new rule U.S. Department of Labor Office of Labor-Management Standards (DOL) today (May 20, 2010).

The new regulation available here implements the Executive Order 13496 (‘‘Executive Order 13496’’) signed by January 30, 2009, which requires nonexempt Federal departments and agencies to include within their Government contracts specific provisions requiring contractors and subcontractors with whom they do business to post notices informing their employees of their rights as employees under Federal labor laws protecting union organizing rights.

This final rule establishes the content of the notice required by the Executive Order’s contract clause, and implements other provisions of the Executive Order, including provisions regarding sanctions, penalties, and remedies that may be imposed if the contractor or subcontractor fails to comply with its obligations under the Order and the implementing regulations. Among other things the regulation:

Defines terms;
Prescribes the size, form and content of the employee notice;
Establishes exceptions to the requirements for exceptions for certain types of contracts and contracting departments and agencies; and
Standards and procedures related to complaint procedures, compliance evaluations, and enforcement of the rule; and
Other standards and procedures related to certain ancillary matters.

To fulfill the new requirements, covered government contractors must post a new Labor Department poster containing the required notice in accordance with the Rule. Covered employers may obtain the required poster from either:

The applicable Federal contracting agency;
The Division of Interpretations and Standards, Office of Labor-Management Standards, U.S. Department of Labor, 200 Constitution Avenue, NW., Room N–5609, Washington, DC 20210;
Any Labor Department Office of Labor-Management Standards or Office of Federal Contract Compliance
Programs;
By download from the Office of Labor-Management; or
Standards Web site Office of Labor-Management Standards Website.

If the contractor or subcontractor customarily posts notices to employees electronically, it also must electronically prominently on any Web site maintained by the contractor or subcontractor customarily used for notices to employees about terms and conditions of employment, a link to the Department of Labor’s Web site that contains the full text of the poster in the manner required by the regulation.

Backed by the Obama Administration and the Democrat Majority in Congress, union organizing, public policy and other activities are creating significant new challenges for employers. The new Rule reflects this support. In the face of this expanding activities and proposed legislation and regulations that designed to further strengthen unions, employers need to clearly understand their obligations and rights and obligations under the NLRA and other federal labor laws and consider and carefully administer strategies to manage employment and operational risks that heightened union activities can create. If you need additional information about the new Rule, help understanding or responding to union matters, or assistance with other employment, employee benefit or compensation matters a contact the author of this update, attorney and consultant Cynthia Marcotte Stamer, for assistance at (469) 767-8872 or here.

About Ms. Stamer

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 businesses manage labor and employment, employee benefits, performance management and discipline, compliance and internal controls, risk management, and public policy matters including specific labor-management relations experience. The Editor and Publisher of Solutions Law Press, 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 American Bar Association, American Health Lawyers Association (AHLA), Health Care Compliance Association, Institute of Internal Auditors, Society of Human Resources Management, 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. Her 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.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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.

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Posted by Cynthia Marcotte Stamer

Stamer Speaks June 9 On “Health Care Reform’s Implications For Employers, Health Plans & Employee Benefits Practitioners” In Houston

May 19, 2010

Cynthia Marcotte Stamer will discuss “Health Care Reform’s Implications for Employers, Health Plans and Employee Benefits Practitioners” at the June 9, 2010 meeting of Houston WEB. The program is scheduled for Wednesday, June 9, 2010 at the DoubleTree Guest Suites, 5353 Westheimer, Houston, Texas from 11:30 a.m. to 1:30 pm.

Narrowly passed by Congress in March after a year of contentious debate, the comprehensive health care reform legislation imposes a complex array of reforms impacting employment based health plans, employers, and the insurers and other vendors and administrators of these programs. Ms. Stamer will explore key elements of these reforms impacting employers and employment based health coverage and their implications for employers, employment based health plans, and employee benefits and other attorneys providing advice about these arrangements.

To register or for more information about this event, see here. If you need assistance reviewing or responding to these or other employee benefit, compensation or labor and employment concerns, contact the author of this update, Cynthia Marcotte Stamer, for assistance at (469) 767-8872 or here.

About Ms. Stamer

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 businesses manage labor and employment, employee benefits, performance management and discipline, compliance and internal controls, risk management, and public policy matters including significant, cutting edge experience advising employer and other health plan sponsors, fiduciaries, insurers, administrators and others design, administer, and defend defensible, cost-effective health and other employee benefit programs.

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 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. Her 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.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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.

Comments Off on Stamer Speaks June 9 On “Health Care Reform’s Implications For Employers, Health Plans & Employee Benefits Practitioners” In Houston | Affordable Care Act, CHIP, COBRA, COBRA Subsidy, Corporate Compliance, Employee Benefits, Employers, Employment Tax, ERISA, Fiduciary Responsibility, FMLA, HIPAA, Human Resources, Insurance, Internal Controls, Medicare Part D, Mental Health, Mental Health Parity, Payroll Tax, Prescription Drugs, Privacy, Protected Health Information, Public Policy, Risk Management, Tax, Uncategorized, Wellness, Wellness Programs | Tagged: Affordable Care Act, Employee Benefits, Employers, ERISA, Fiduciary, Health Care Reform, Health Insurance, Health Plan, Health Plans, Insurer | Permalink
Posted by Cynthia Marcotte Stamer

CBO Raises Estimated Cost of Health Care Reforms As Employers, Health Plans Brace Costs Of Newly Effective & Impending Mandates

May 15, 2010

By Cynthia Marcotte Stamer

New analysis released Tuesday, May 11 by the non-partisan Congressional Budget Office shows H.R. 3590, the Patient Protection and Affordable Care Act, Public Law 111-148 (Health Care Reform Law) passed in March will cost $115 Billion more than originally estimated in the CBO’s March 15, 2010 discretionary spending analysis. News of the cost estimate increase comes as U.S. employer and other health plan sponsors, insurers and others are bracing for the first wave of new federal health plan mandates enacted as part of the Health Care Reform Law to take effect in September and a host of other federal mandates previously enacted that take effect in the 2009 and 2010 plan years.

Projected Cost of Health Care Reform Increased

According to CBO, additional information about the potential effects of the Health Care Reform Law on spending funded through the annual appropriation process (discretionary spending). By their nature all such potential effects on discretionary spending are subject to future appropriation actions, which could result in greater or smaller costs than the sums authorized by the legislation. While still limited in certain respects, the updated CBO analysis provides information on the major components of such costs in three general categories:

The costs that will be incurred by federal agencies to implement the new policies established by the Health Care Reform Law, such as administrative expenses for the Department of Health and Human Services and the Internal Revenue Service for carrying out key requirements of the legislation.
Explicit authorizations for future appropriations for a variety of grant and other program spending for which the act identifies the specific funding levels it envisions for one or more years. (Such cases include provisions where a specified funding level is authorized for an initial year along with the authorization of such sums as may be necessary for continued funding in subsequent years.)
Explicit authorizations for future appropriations for a variety of grant and other program spending for which no specific funding levels are identified in the legislation. That type of provision generally includes legislative language that authorizes the appropriation of “such sums as may be necessary,” often for a particular period of time.

According to the updated analysis, CBO estimates that total authorized costs in the first two categories probably exceed $115 billion over the 2010-2019 period. CBO still does not have an estimate of the potential costs of authorizations in the third category.

CBO previously issued an estimate of the Health Care Reform Law’s direct spending and revenue effects in combination with the Reconciliation Act of 2010 (Public Law 111-152), which amended it. (Direct spending effects are those that do not require subsequent appropriation action.) CBO estimated that those two laws, in combination, would produce a net reduction in federal deficits of $143 billion over the 2010-2019 period as a result of changes in direct spending and revenues.

Impending Federal Health Plan Mandate Changes Bring New Costs, Risks Now

CBO’s adjustment to its cost projections comes as U.S. employers and insurers already are bracing to cope with a host of new federally imposed health plan mandates and accompanying costs that already have or will in the next 12-months impact their existing health benefit programs. Examples of these new mandates include:

COBRA Stimulus Bill Premium Subsidy and Other Mandates
New FMLA and USERRA Coverage Continuation Mandates
Dependent Care Coverage Extension Mandates For Students Requiring Medical Leave Effective
Genetic and Other Disability Discrimination Mandates under GINA, ADA Amendments Act of 2008, HIPAA Portability and Other Federal Mandates
Expanded Mental Health Parity Mandates
HIPAA Data Breach and Other Protected Health Information Privacy and Data Security Mandates
New IRS Excise Tax Self-Assessment & Reporting Mandates For Plans Violating COBRA, Mental Health Parity and Wide Range of Other Federal Mandates
Changes To Retiree Medical Subsidy Rules
Early Retiree Medical Reinsurance Program For Employers Providing Qualifying Retiree Coverage
New Small Employer Tax Credit Rules
Mandated extension of dependent coverage to age 26
Prohibition of Pre-Existing Condition Limits on Dependent Coverage
New restrictions on annual and lifetime benefit limitations
Mandate to cover 100% of preventative care
Prohibition against coverage rescissions
Primary Care Physician choice mandates
Restrictions on coverage limitations for emergency and obstetrical care
Extension of Internal Revenue Code Section 105(h) nondiscrimination mandates to certain insured health plans
Many others

Employer and other health plan sponsors, their insurers, administrators and others responsible for updating and administering group and other health plans must move immediately to meet these evolving mandates while bracing for anticipated increased costs and other obligations expected to result as the Health Care Reform Law takes effect over the next few years. Employers, administrators and insurers needing additional information about these changes can review the resources and training materials available here and/or contact the author of this update, attorney and consultant Cynthia Marcotte Stamer, for assistance at (469) 767-8872 or here

Responsible & Prompt Action Needed

Employer and other health plan sponsors, administrators, fiduciaries and insurers both should act quickly to update their programs, plan documents, communications and practices to comply with federal mandates that have and are scheduled to take effect and stay involved with regulators and Congress as the regulatory rules and processes to implement the Health Care Reform Law are developing. Ultimately, the cost and other implications of the Health Care Reform Law will depend largely upon how its provisions are construed and implemented by federal and state regulators, along with any subsequent adjustments, if any that Congress may elect to enact. With federal officials hard at work preparing implementing regulations and other guidance and procedures, health industry leaders and other concerned Americans should stay informed and continue to share their input on these critical issues as these decisions are shaped. Join the discussion by participating in the Coalition For Responsible Health Care Policy linked in group and/or its subgroup, Project COPE: Coalition for Patient Empowerment and/or register to receive updates Coalition for Responsible Heath Care Policy by RSS Feed.Coalition for Responsible Health Care Policy Coalition for Responsible Health Care Policy Coalition for Responsible Health Care Policy

The author of this update, Cynthia Marcotte Stamer, recently has conducted briefings on the implications of the Affordable Care Act and other regulatory changes impacting health plans and their employer and other sponsors, insurers, administrators and others for the Society of Professional Benefits Administrators, the Dallas Bar Association and others. Several other presentations and update are scheduled in the upcoming months. For information about these programs or to register to receive information about these programs, see here.

About Ms. Stamer

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 22 years of work helping businesses manage labor and employment, employee benefits, performance management and discipline, compliance and internal controls, risk management, and public policy matters including significant, cutting edge experience advising employer and other health plan sponsors, fiduciaries, insurers, administrators and others design, administer, and defend defensible, cost-effective health and other employee benefit programs.

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, Vice President of the North Texas Health Care Compliance Professionals 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 health industry and human resources concerns. She regularly speaks and conducts training for the ABA, American Health Lawyers Association (AHLA), Health Care Compliance Association, Institute of Internal Auditors, Harris County Medical Society, the Medical Group Management Association, Society for Professional Benefits Administrators, Southwest Benefits Association, Harris County Medical Society, Medical Group Management Association, Society of Human Resources Management, 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. Her 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.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer 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.

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Posted by Cynthia Marcotte Stamer

Join Project COPE: Help Develop Real Tools To Meaningfully Empower Patients & Improve Health Care Access, Affordability & Quality

May 15, 2010

With all the recent debate about health care policy reforms, it is important to keep the focus on the practical needs of patients and their families in dealing with an illness or disability, and simple steps that health care providers, employers, insurers and other payers, churches and other community organizations, and regular people can do to meaningfully help patients and their families effectively access and pay for care and meet other related challenges attendant to illness and disabilities.

No easy, one-size fits all cure exists to help patients and their families deal with illness or disability. Paying for care is only a small part of the health care challenge for any patient and his or her family. The good news is that health treatment and disease management advances increasingly are converting once deadly illnesses and disabilities into chronic conditions. The challenge is that patients living with these conditions often survive with ongoing (often expensive) medical treatments, work-life adjustments and other continuous partial but imperfect fixes that come at great financial, productivity and personal costs to themselves, their families and society. The government and its public policies can’t change this anymore than the patients, families, employers, friends and communities that live and deal with these patients. Indeed, the process of reform and the confusion it will foster is likely to create new complications in the upcoming years.

Consequently, to make any real and meaningful difference in the empowerment of patients and the mitigation of the financial and other challenges that patients and their families, health care providers, employer and other business and community leaders, health plans, insurers and others experience in dealing with ill or disabled person starts with recognition of basic realities of illness and disabilities and pursuing the many small practical opportunities to mitigate these challenges, including the following:

No One Easy Fix; Just Many Small Ones

Being old or being sick (or having a loved one who is) stinks. Not everyone was born with a BMW for a body and even some BMW’s are lemons. Even for a car, there isn’t always a clear “evidence based” answer to the unavoidable “why me/us” questions every patient and their family must face. However, the answers to these and other tough questions often are must less clear and more intractable for patients and their families:

What’s wrong with this body?
Can it be fixed and if so, how do I fix it?
If it can’t be fixed, what do I do?
How do I pay for the fix? How do I find the money and other resources?
How do we keep working and keep pursuing the cure at the same time?
I am scared, lonely, confused, tired, hurting, alone, uneducated, unemployed, etc.

Money only can do so much to fix or mitigate the experience of being ill, old or disabled and there isn’t enough money to pay for all the fixes that exist for those people with broken or aging body parts. While dollars play a critical role in a patient’s ability to access certain resources, it can only partially answer these questions. All patients and their families still struggle to deal with these intractable questions.

Communication & Understanding Key Tools

The best way to get Americans to make better choices about the health care they choose is to provide better communications and other tools to empower them with improved understanding needed to make better choices and better cope. Misunderstanding and miscommunications in the system fuel much pain and inefficiency.

When families and patients get good information that indicates that the $20,000 spent for a procedure will only cause a lot of suffering and expense to extend a life already suffering for another 48 hours, they usually chose quality of life over length of life.
Studies show that physicians and the RNs working with them agree in less than 70 percent of the times about the care ordered and how to administer it. Communication elsewhere among health care providers further erodes cost effectiveness and quality.
Government regulation and the tension that results from regulation and practices that break up health care teams makes this worse contributes to this problem.

Better communication and understanding between health care providers and the patients and their families and friends that help the patients will improve quality and efficiency of care.

All Americans need to be taught basic communication and coping skills to be better and more responsible health care patients, and effective health care buddies for their family and friends.
Providers need to communicate effectively with patients, family members, payers and each other. Patients and families need to learn to take responsibility to insist on answers to the questions they have that are necessary to meet their care needs.
Health plans, insurers and other payers need to communicate effectively with patients and their families, as well as health care providers about what coverage is being purchased, what is and is not covered, what must be done to qualify for coverage, care choices affecting coverage, and the availability of other alternatives when coverage is limited or not available.

Demographic Realities Ensure Inadequacy Of Funding

The aging population means that the gap between patients that need money for care and the available dollars to pay for care will continue to grow unless care is rationed in some way that limits or denies certain care to some ill, disabled or aging people. Decisions about rationing by necessity require individual specific, personal decision-making. Just because the most health care dollars are spent in the last months of life doesn’t mean that these dollars are necessarily wasted. The question should be what quality of life was realized for the dollars spent. This is a qualitative decision that is of necessity highly personal for each patient and his or her family. It cannot be fully accounted for or decided based on actuarial and accounting curves. Many old and sick people are extraordinary functional, valuable and important to someone.

Personal Responsibility For Self & Neighbor Best Investment

The most overlooked opportunities for quality and cost improvements rest with the people in health care:

The patients, their families and friends
Health care providers
Employers, churches, social organizations and other community organizations and resources that deal with patients and their families;
Health plans, insurers, and others that administer care; and
Others that encounter patients and their families.

Caring for ourselves, our families, our friends and others in our community is our right, our privilege and our job. The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans. The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch. Americans can best improve health care for ourselves, our loved ones, our friends and Americans generally by stop waiting for someone else to do it. Noone is better qualified to care about your loved ones than you. Do what you can and celebrate what you can do. Speak up, step up and help bridge the gap when you or your organization can do so by extending yourself a little bit. Speak up to help communicate and facilitate when you can. Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process. Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist. The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye. Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families. While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources.

Other Helpful Resources & Other Information

We hope that this information is useful to you. You can access information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,” using the “PlayForLife” resources to organize low cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here If you found these updates of interest, you also be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here. 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. You can access other recent updates and other informative publications and resources

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 “Remove” in the Subject to here.

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Posted by Cynthia Marcotte Stamer

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