Insurance | | Page 3

HHS Chides Insurer For “Excessive” Premium Increases After Affordable Care Act Rate Audit

November 21, 2011

The U.S. Department of Health and Human Services (HHS) is seeking to publicly shame Everence Insurance of Pennsylvania for charging small businesses what HHS claims are “unreasonably high” premium increases.

According to HHS, its first federal rate review under the Affordable Care Act found that Everence’s 12 percent rate increase for small businesses in Pennsylvania. After reviewing the rate, HHS says independent experts determined the choice of assumptions the company based its rate increase on reflected national data rather than reliable and available state data. These assumptions resulted in what HHS characterizes as an “unreasonably high premium in relation to the benefits provided to small businesses by Everence Insurance of Pennsylvania.

While the Affordable Care Act gave HHS the ability to conduct and publish health insurer rate reviews but does not grant HHS the authority to actually force covered health insurers to change their rates. While some state laws may give state regulators this authority, HHS’ authority remains limited to drawing public attention to carrier rate increases that HHS perceives as excessive.

In an effort to use public opinion to chastise Everence Insurance of Pennsylvania, HHS is using its media might to publicize its findings. “We have called on this insurer to immediately rescind the rate, issue refunds to consumers or publicly explain their refusal to do so,” said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services.

HHS’s announcement of its findings about Everence Insurance of Pennsylvania marks the first of many reviews that HHS will do in addition to insurance rate reviews already being done by states. HHS says it intends to review all health insurer proposals to raise rates by 10 percent or more this year.

Targeting health insurers proposing rate increases of 10 or more percent is likely to result in a significant number of reviews. A Kaiser Family Foundation Employer Health Benefits 2011 Annual Survey found average premiums increased 8% for single coverage and 9% for family coverage through May, 2011.

Companies that HHS finds have made excessive rate increases can either reduce their rate hikes or post a justification on their website within 10 days of the rate review determination. As of publication, Everence Insurance of Pennsylvania had not published a public rebuttal to the HHS announcement on its website or indicated how it plans to respond to the announcement. See here.

For More Information Or Assistance

If you need help reviewing or updating your health benefit program for compliance with ACA or other laws or with any other employment, employee benefit, compensation or internal controls matter, please contact the author of this article, attorney Cynthia Marcotte Stamer.

A 2011 inductee to the American College of Employee Benefits Council, immediate past-Chair and current Welfare Benefit Committee Co-Chair of the American Bar Association (ABA) RPPT Employee Benefits & Other Compensation Arrangements, an ABA Joint Committee on Employee Benefits Council Representative, the ABA TIPS Employee Benefit Plan Committee Vice Chair, former ABA Health Law Section Managed Care & Insurance Interest Group Chair, past Southwest Benefits Association Board Member, Employee Benefit News Editorial Advisory Board Member, and a widely published speaker and author, Ms. Stamer has more than 24 years experience advising businesses, plans, fiduciaries, insurers. plan administrators and other services providers, and governments on health care, retirement, employment, insurance, and tax program design, administration, defense and policy. Nationally and internationally known for her creative and highly pragmatic knowledge and work on health benefit and insurance programs, Ms. Stamer’s experience includes extensive involvement in advising and representing these and other clients on ACA and other health care legislation, regulation, enforcement and administration.

Widely published on health benefit and other related matters, Ms. Stamer’s insights and articles have appeared in HealthLeaders, Modern Health Care, Managed Care Executive, the Bureau of National Affairs, Aspen Publishers, Business Insurance, Employee Benefit News, the Wall Street Journal, the American Bar Association, Aspen Publishers, World At Work, Spencer Publications, SHRM, the International Foundation, Solutions Law Press and many others.

For additional information about Ms. Stamer and her experience, see www.CynthiaStamer.com.

Comments Off on HHS Chides Insurer For “Excessive” Premium Increases After Affordable Care Act Rate Audit | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: Affordable Care Act, Employee Benefits, employee benefits policy, Employer, Health Care Reform, Health Insurance, health issuer, Health Plans, health premiums, instruction, Insurance, Insurer, speech, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

EBSA Plans To Include Health Care Reform Compliance In Health Plan Audits Beginning In FY 2012; Disputes OIG Criticism Of ACA Enforcement Efforts

October 30, 2011

Insurance companies administering certain self-insurance arrangements for employers or certain other entities may qualify as exempt from the information reporting obligations imposed under Internal Revenue Code section 6050W.

Notice 2011-78 provides relief to insurance companies administering certain self-insurance arrangements on behalf of an employer or other entity from any information reporting obligations under section 6050W of the Internal Revenue Code. Insurance companies may rely on the notice until the regulations under section 6050W are amended. The IRS published Notice 2011-78 in the Internal Revenue Bulletin 2011-41 on October 11, 2011.

For More Information Or Assistance

If you need help reviewing, updating, administering or defending your health benefit or other benefit or insurance program for compliance with ACA or other federal or state employee benefit, insurance, health care or other laws or regulations, or with any other employment, employee benefit, compensation or internal controls matter, please contact the author of this article, attorney Cynthia Marcotte Stamer.

Widely published on health benefit and other related matters, Ms. Stamer’s insights and articles have been published by the HealthLeaders, Modern Health Care, Managed Care Executive, the Bureau of National Affairs, Aspen Publishers, Business Insurance, Employee Benefit News, the Wall Street Journal, the American Bar Association, Aspen Publishers, World At Work, Spencer Publications, SHRM, the International Foundation, Solutions Law Press and many others.

For additional information about Ms. Stamer and her experience, see www.CynthiaStamer.com.

Comments Off on EBSA Plans To Include Health Care Reform Compliance In Health Plan Audits Beginning In FY 2012; Disputes OIG Criticism Of ACA Enforcement Efforts | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: Affordable Care Act, benefits, Employee Benefits, employee benefits policy, Employer, Health Care, Health Care Reform, Health Insurance, health issuer, Health Plans, health policy, instruction, Insurance, Insurer, speech, Speeches, Tax, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

EBSA Plans To Include Health Care Reform Compliance In Health Plan Audits Beginning In FY 2012; Disputes OIG Criticism Of ACA Enforcement Efforts

October 7, 2011

Look for the Department of Labor Employee Benefit Security Administration (EBSA) to begin looking at compliance with the group health plan reform mandates of the Patient Protection & Affordable Care Act (PPACA) and amended by the Health Care and Education Reconciliation Act (HCERA)(collectively “ACA”) requirements as part of health plan audits in its Fiscal Year 2012.

Assistant Secretary of Labor Phyllis Borzi announced EBSA’s plan to begin examining ACA compliance as part of broader health plan compliance audits that the EBSA intends to conduct in Fiscal Year 2012 in her response to a critique of EBSA’s ACA inplementation and enforcement efforts contained in a September 30, 2011 audit report issued by the Departmentof Labor’s Office of Inspector General. According to that response, EBSA has developed a comprehensive checklist for auditing ACA compliance by health plans that it plans to use as part of health plan audits and has conducted significant staff training as part of its ACA implementation activities. In light of EBSA plans to add ACA compliance to its health plan audits in 2012, employer and union health plans, their sponsors, insurers and administrators should take appropriate steps to ensure that their programs terms and practices are up to date with these requirements.

Ms. Borzi shared the plans for audit as part of a broader rebuttle on behalf of EBSA to criticisms contained in a September 30, 2011 report by the U.S. Department of Labor Office of Inspector (OIG) critical of the effectiveness and speed of EBSA’s efforts to implement certain health care reform provisions of ACA.

Enacted on March 23, 2010, ACA makes EBSA, along with the Internal Revenue Service and the Department of Health & Human Services, a key player in the implementation and enforcement of the health benefit targeted reforms enacted as part of its sweeping health care reforms. The September 30, 2011 OIG report identified various areas of improvement that OIG indicated EBSA should make to its implementation efforts based on OIG’s review of efforts by the EBSA to carry out its responsibilities to interpret, implement and enforce these reforms.

OIG Concerns

While its September 30, 2011 report titled “Further Action By EBSA Could Help Ensure PPACA Implementation And Compliance,” (OIG Report) acknowledged the significant actions taken by EBSA toward implementing ACA, the OIG Report still found that EBSA should take additional action to help ensure the timely and effective implementation and enforcement of ACA’s reforms.

The most significant criticism expressed in the OIG report related to the adequacy of work and data reported by EBSA to HHS for HHS to use to define the benefits to be considered “essential benefits” under ACA. Under ACA, EBSA was required to provide HHS with the results of a survey of benefits typically covered by employers that is sufficiently broad to enable HHS to determine benefits provided under a typical employer plan. The OIG Report expresses several concerns about the breadth and validity of the information that EBSA provided to HHS. According to the OIG, EBSA was unable to state that the report it provided HHS was broad enough to encompass all benefits EBSA considered to be typically covered by employers. Moreover, EBSA did not address all benefits HHS requested. As a result, OIG expressed concern that HHS may not be able to ensure that State Insurance Exchanges offer the appropriate essential health benefits required by ACA.

In addition to its critique of EBSA’s essential benefits survey, the OIG also concluded:

EBSA could work with Treasury and HHS to establish a public timeline for addressing the public comments received on interim-final PPACA regulations and issuing final regulations;
EBSA should have included the ACA requirements in its health plan investigations to better leverage its enforcement resources to assist plans in complying with the new regulations; and
EBSA should develop a regulation concerning MEWAs under PPACA Section 6604, regarding the applicability of State law as a means to combat fraud and abuse.

In light of these findings, the OIG recommended that EBSA take the following actions to strengthen its ACA implementation and enforcement actions:

Work with the Departments of HHS, Treasury, and the Office of Management and Budget to establish specific timetables to respond to public comments and issue final regulations;
Incorporate the ACA requirements immediately into the enforcement program to assist plans in complying with ACA;
Provide HHS with the results of a survey of benefits typically covered by employers that is sufficiently broad to enable HHS to determine benefits provided under a typical employer plan; and
Proceed with rulemaking relative to MEWAs under ACA section 6604.

EBSA Says Will Start Checking ACA Compliance in FY 2012 But Response Disputes Certain OIG Findings

While agreeing with the first and last recommendations, Ms. Borzi defended EBSA’s decision to delay auditing of health plan compliance with ACA and the adequacy of the survey data it reported to HHS for use in establishing essential benefits under ACA.

Concerning the auditing, Ms. Borzi said that EBSA has developed a comprehensive checklist to promote consistent investigations of ACA compliance, which EBSA plans to begin using when it conducts compliance assessments as part of its Fiscal Year 2012 Health Benefits Security Project as part of a broad range of implementation activities that EBSA has performed. Ms. Borzi’s response to the OIG recommendations indicated that EBSA disagrees with OIG’s assessment that EBSA should be auditing compliance with ACA as part of its current year audits. Rather, Ms. Borzi indicated that EBSA’s assessment and experience leads it to believe it more suitable for EBSA to use a phased implementation approach under which EBSA which delayed ACA compliance audits pending the development of regulations and after plans and insurers have had the opportunity to proccss the implementing regulations and related guidance and benefit from EBSA’s extensive outreach.

Ms. Borzi also took exception to the OIG’s criticism of EBSA’s survey. In her response, she states that the report EBSA made to HHS “fully satisfies” the requirements of ACA. She pointed out that ACA “clearly requires the Secretary of HHS, rather than the Secretary of Labor, to determine the scope of benefits offered by a typical employer plan. Thc stated purpose of the Secretary of Labor’s survey is to inform this determination.” According to Ms. Borzi, the survey is based on the National Compensation Survey conducted regularly by the Department’s Bureau of Labor Statistics uses a large, nationally representative sample of employers to collect detailed information on whether particular benefits are included in employer health plans. Ms. Borzi concluded that this survey “will al1ow the Secretary of HHS to determine which are offered by a typical employer plan.

Likewise, Ms. Borzi disagreed with the OIG’s criticism that the report provided to HHS does not expressly tate which benefits are “typical” as unfounded. According to Ms. Borzi, the statute docs not require the DOL to determine a specified threshold of incidence above which (and only above which) the benefit should be considered “typical.” As a result, Ms. Borzi concluded that the EBSA report, by providing detailed data on the incidence of different benefits, fulfills the statutory purpose and requirements without taking on the function of the Secretary of HHS.

Ms. Borzi’s response also reported the EBSA’s disagreement with the OIG’s assertion that EBSA’s approach to the report could impair the public comment process. She stated that the report and associated supporting materials are easily available to the public and that commcntcrs are free to provide their views on the survey and on what benefits arc offered by a typical employer plan. Furthermore,Ms. Borzi pointed to planned opportunities for public input announced by the Secretary of HHS as offering additional opportunities for public input.

For More Information Or Assistance

For additional information about Ms. Stamer and her experience, see www.CynthiaStamer.com.

Comments Off on EBSA Plans To Include Health Care Reform Compliance In Health Plan Audits Beginning In FY 2012; Disputes OIG Criticism Of ACA Enforcement Efforts | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: benefits, Employee Benefits, employee benefits policy, Employer, Health Care Reform, Health Insurance, health issuer, Health Plans, health policy, instruction, Insurance, Insurer, speech, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

ONC Hires APP Design, Inc. To Run Patient E-Consent Trial Project

October 3, 2011

ONC’s Office of the Chief Privacy Officer recently awarded a contract to APP Design, Inc. to find an efficient, effective, and creative way to help patients better understand their choices about whether and when their health care provider can share their health information electronically, including sharing it with a health information exchange organization. The project team will design, develop, and pilot innovative ways to electronically carry out existing patient choice policies, while improving business processes for health care providers. To learn more about the E-Consent Trial project, please see the Statement of Work. ONC’s formal launch of the E-Consent Trial Project will be in October.

For Assistance or Additional Information

Nationally and internationally known for her knowledge and work on health and other employee benefit matters and engaging and informative presentations, attorney, author and policy advocate Cynthia Marcotte Stamer will help you prepare your plan and organization to cope with these and other challenges of understanding and coping with health care reform.

Chair of the American Bar Association (ABA) RPPT Employee Benefits & Other Compensation Arrangements, an ABA Joint Committee on Employee Benefits Council Representative, incoming ABA TIPS Employee Benefit Plan Committee Vice Chair, former ABA Health Law Section Managed Care & Insurance Interest Group Chair, past Southwest Benefits Association Board Member, Employee Benefit News Editorial Advisory Board Member, Board Certified in Labor and Employment Law and a widely published speaker and author, Ms. Stamer has more than 24 years experience advising businesses, plans, fiduciaries, insurers and governments on health care, retirement, employment, insurance, :and tax program design, administration, defense and policy and related employment, insurance and health care matters. Her experience includes extensive experience advising insured and self-insured ERISA group medical and other plans, Medicare and Medicaid Advantage plans, mini-med, high-deductible and other consumer driven medical, long-term care, occupational injury, ex-pat, association, fraternal benefit and other managed care and medical benefit plans and insurers, their service providers, insurers, sponsors, fiduciaries, technology providers and others. A primary drafter of the Bolivian pension law, Ms. Stamer also has more than 30 years experience working on legislative and regulatory health care, pension, workforce, education and immigration reform matters including extensive work on the Pension Protection & Affordable Care Act, HIPAA, COBRA, state managed care and other insurance and other laws. In addition to her experience advising governments and others internationally about these matters, she regularly advises and represents employers, employee benefit plans, insurers, health care and managed care providers and others about evolving laws and regulations and assists them in dealing with Congress, the Internal Revenue Service, the Department of Labor, Immigration and Customs, OCR, OIG, CMS and other HHS agenices, the FTC, the Justice Department, state insruance and health departments, and others.

A widely published author and popular speaker, Ms. also regularly publishes and speaks for a broad range of organizations including American Bar Association, Aspen Publishers, World At Work, Benefits Magazine, Employee Benefit News, Spencer Publications, SHRM, the International Foundation, Solutions Law Press and many others. She currently or previously has served on the editorial advisory board of Employee Benefits News, BNA Employee Benefits CDRolm and a wide range of other highly regarded publications. Her insights on these and other matters have appeared in Managed Care Executive, Health Leaders, Private Payers News, the Wall Street Journal, various publications of the Bureau of National Affairs, Aspen, Atlantic Information Serices, the Wall Street Journal, and many other industry and news publications. In recognition of this extensive record of employee benefit experience and involvement, Ms. Stamer recently was selected to be inducted as a Fellow in the American College of Employee Benefits Counsel.

You can learn more about Ms. Stamer and her experience, review some of her other training, speaking, publications and other resources, and register to receive future updates about developments on these and other concerns from Ms. Stamer here. For important information concerning this communication click here.

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.

Comments Off on ONC Hires APP Design, Inc. To Run Patient E-Consent Trial Project | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: benefits, Electronic Consents, Employee Benefits, employee benefits policy, Employer, Health Care Reform, Health Insurance, health issuer, Health Plans, health policy, instruction, Insurance, Insurer, ONC, Patient Empowerment, speech, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

New IRS Voluntary IRS Settlement Program Offers New Option For Resolving Payroll Tax Risks Of Misclassification But Employers Also Must Manage Other Legal Risks

September 26, 2011

Program Another Sign of Growing Audit & Enforcement Risks. Businesses Urged To Strengthen Their Worker Classification Defenses

The September 22, 2011 launch by the Internal Revenue Service of a new Voluntary Worker Classification Settlement Program (“Settlement Program”) is the latest warning to businesses using independent contractors, leased employees or other non-employee workers of the need to review critically within the scope of attorney-client privilege the defensibility of their existing classification and treatment of those workers as non-employees in light of the in light of stepped up scrutiny and enforcement emphasis by the IRS and other federal and state regulators as well as workers and others in private litigation.

Coupled with growing scrutiny and challenges to businesses efforts to avoid employment-related liability and obligations through the use or workers that the business characterizes as non-employees by other federal and state agencies and plaintiff attorneys, the Settlement Agreement announcement is another sign that businesses using workers who are not employees need to be prepared to defend their worker classification and the legality of their dealings with these workers under applicable federal and state laws.

To guard against these and other growing risks of worker classification, employers receiving services from workers who are not considered employees for purposes of income or payroll 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.

Settlement Program Establishment Should Prompt Review Defensibility of Worker Classifications

The new Settlement Program established under Announcement 2011-64 reflects the widespread emphasis by the IRS and other federal and state regulators on uncovering and redressing misclassification of workers as non-employees by businesses for purposes of tax and other laws. IRS scrutiny of worker classification practices by businesses has risen significantly over the past decade.

The IRS’ launch of the Settlement Program follows its announcement in September, 2010 of plans to conduct approximately 6,000 payroll tax audits over a three year period focusing on the appropriateness of employer worker classification and other payroll tax practices. The announcement of the new Settlement Program signals that the IRS perceives that worker misclassification by business in violation of Federal tax laws is sufficiently widespread and pervasive to merit both efforts to incentive voluntary correction through participation in the Settlement Program, as well as stiff enforcement against businesses that fail to self-correct worker classification compliance concerns.

Designed to increase tax compliance and provide what the IRS says will be “greater certainty for employers, workers and the government,” the IRS says the Settlement Program offers eligible employers concerned about potential worker misclassification exposures that might arise from a payroll tax audit the opportunity to come into compliance by making the required filing, adjusting their practices and paying the required settlement fee effectively equaling just over one percent of the wages paid to the reclassified workers for the past year. If this settlement fee is paid and the other requirements of the Settlement Program are met, the Settlement Program specifies that employers accepted into the program will not be assessed interest or penalties and not be audited on payroll taxes related to these workers for prior years.

For businesses that can meet applicable requirements for participation, participation in the Settlement Program may offer an attractive option for resolving payroll related tax risks. However, not all employers will qualify for the Settlement Program. Employers must meet the eligibility requirements for participation.

Also, employers electing to use the Settlement Program need to understand the implications of that participation on the Statute of Limitations on their payroll tax liabilities. For the first three years of participation in the program, the Settlement Program specifies that participating employers will be subject to a special six-year statute of limitations, rather than the usual three years that generally applies to payroll taxes. Businesses will need to weigh the benefits of using the Settlement Program, if available, against the risk of reclassification and the availability of other resolution options that may be available under applicable Internal Revenue Code and IRS rules and procedures. Furthermore, many businesses evaluating worker classifications also may find it difficult to determine with certainty the risk of reclassification for certain categories of workers. Whether a worker is properly classified as an employee for most purposes under the Internal Revenue Code’s income tax withholding and reporting, payroll tax and most other employment tax turns on a highly fact specific analysis of under a common law employment test. When an analysis of the evidence reflects a high degree of certainty that the classification of a worker as a non-employee was not defensible under existing tax authorities, use of the Settlement Program or other tools to resolve liability definitely merits consideration. Because of the factual nature of the analysis, however, the decision whether to use the Settlement Program where the circumstances under which the worker renders services are less clear may be more difficult. When making these assessments, businesses should avoid the temptation of being overly optimistic in their assessment of the facts and circumstances given that the Internal Revenue Code generally assigns responsibility to the business to prove the appropriateness of its classification of a worker as a non-employee. While this allocation of the burden of proof means businesses should exercise caution when engaging workers in non-employee capacities, where the facts support this characterization, classification of a worker as a non-employee can be appropriate. When deciding to continue the non-employee characterization for purposes of the Internal Revenue Code, however, businesses are urged to document the evidentiary basis and evidence supporting that determination in anticipation of a potential future audit or other challenge.

Learn more about the Settlement Program and worker classification risk management here.

Businesses Should Address Other Worker Reclassification Risks When Conducting Settlement Program Risk Analysis

As welcome as the opportunity to resolve potential payroll tax exposures through participation in the Settlement Program, businesses considering using the Settlement Program also will need to understand and prepared to address various non-tax legal concerns. Because worker misclassification tends to impact on a broad range of legal obligations and risks, businesses evaluating or planning to use the Settlement Program are act quickly, but carefully, to evaluate and determine whether and how to use the Settlement Program and to identify and take appropriate steps to address both the tax-related liabilities targeted for resolution under the Settlement Program, as well as misclassification exposures likely to arise with respect to workers to be reclassified in connection with the use of the Settlement Program.

When conducting this evaluation and deciding whether to use the Settlement Program, businesses also need to keep the wider implications of the analysis and their decisions regarding how to handle a potential aggressive or misclassification as a worker as a non-employee. A determination of potential aggressive or misclassification for purposes of the Internal Revenue Code’s payroll tax rules generally will necessitate the need to evaluate potential exposures that may arise from the worker misclassification under other federal and state laws.

Typically, in addition to treating a worker as a non-employee for tax purposes, a business also will treat the worker as a non-employee for immigration law eligibility to work, wage and hour, employment discrimination, employee benefits, fringe benefits, worker’s compensation, workplace safety, tort liability and insurance and other purposes. Consequently, a determination that reclassification is advisable for tax purposes generally will prompt the need to consider how to address the worker reclassification and attendant risk for purposes of other legal risks and requirements, as well as those covered by the Settlement Program. Businesses will need to consider how the voluntary reclassification of workers and settlement under the Settlement Program may impact their exposures and obligations under other laws. As the Settlement Program does not provide relief from the exposures arising from misclassification under other laws, businesses should be prepared to evaluate the advisability of reclassification of the worker for purposes of these other laws, the potential exposures attendant to misclassification of workers under those laws, and risks, challenges and opportunities for mitigating these exposures.

Businesses Cautioned To Conduct Evaluations & Discussions In Attorney-Client Privilege Due To Complexity & Significance of Potential Exposures

Conducting and discussing the Settlement Program and other related concerns within the scope of attorney-client privilege is particularly important because of the potentially significant civil and even criminal liability exposures that may arise from misclassification of workers for purposes of the various relevant laws. Because of the broad reaching and potentially significant non-tax exposure inherent in these discussions, business leaders are cautioned that the evidentiary privileges that often provides protection against disclosure of certain discussions with accountants and certain other non-attorney tax advisors for purposes of certain tax laws may be inadequate in scope to protect discussions against discovery for purposes of these other laws. Accordingly, while businesses definitely should incorporate appropriate tax advisors into the evaluation process, most businesses before commencing meaningful discussions with or engaging assessments by their accounting firm or other non-attorney tax advisor will want to engage counsel and coordinate the involvement of their accounting and other non-attorney tax advisors through qualified legal counsel to protect and maximize the ability to conduct the analysis of their risks and options within the protection of attorney-client privilege.

For Help With These Or Other Matters

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.

Ms. Stamer has more than 24 years experience advising and representing employer, employee benefit and other clients before the Internal Revenue Service, the Department of Labor, Immigrations & Customs, and other agencies, private plaintiffs and others on worker classification and related human resources, employee benefit, internal controls and risk management matters.

A board certified labor and employment attorney widely known for her extensive and creative knowledge and experience worker classification and other employment, employee benefits and workforce matters, Ms. Stamer works extensively with employers, employee benefit plan sponsors, insurers, administrators, and fiduciaries, payroll and staffing companies, technology and other service providers and others to develop and operate legally defensible programs, practices and policies that promote the client’s human resources, employee benefits or other management goals.

A featured presenter in the recent “Worker Classification & Alternative Workforce: Employee Plans & Employment Tax Challenges” teleconference sponsored by the American Bar Association Joint Committee on Employee Benefits, Ms. Stamer also is a widely published author and highly regarded speaker on these and other employee benefit and human resources matters who is active in many other employee benefits, human resources and other management focused organizations.

A Fellow in the American College of Employee Benefits Council, the immediate past Chair and current Welfare Benefit Committee Co-Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Committee, a Council Representative on the ABA Joint Committee on Employee Benefits, the Vice Chair of the ABA TIPS Employee Benefits Committee, the Gulf States Area TEGE Council Exempt Organizations Coordinator, past-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, 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 learn more about Ms. Stamer and her experience, find out about upcoming training or other events, review some of her past training, speaking, publications and other resources, and register to receive future updates about developments on these and other concerns from Ms. Stamer at www.CynthiaStamer.com.

About Solutions Law Press

For important information concerning this communication click here. 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

HHS Projects Medicare Advantage Enrollment Will Rise As Premiums Decline In 2012; Plans Face Increased Regulation & Enforcement

September 25, 2011

Medicare Advantage enrollment will rise and premiums will decline in 2012. While plans can expect increased enrollment, they also face increasing challenges in managing the demands of increased government regulation under Health Care Reform and other new regulations, as well as rising governmental scrutiny of premiums and compliance. Consequently, while more individuals than ever are expected to sign up for Medicare Advantage Plan coverage, the plans still face significant compliance and operational challenges.

According to the Department of Health & Human Services (HHS) , Medicare Advantage premiums on average will be 4% lower in 2012 than in 2011. Meanwhile HHS reports that Medicare Advantage plans project enrollment to increase by 10%. This follows an earlier HHS announcement that average prescription drug plan premiums will remain virtually unchanged in 2012.

Of people with Medicare, HHS reports 99.7% continue to enjoy access to a Medicare Advantage plan, and benefits will remain consistent with those offered in 2011. To offset declining premiums and other costs, however, many industry experts expect that plans will make greater use of technology in place of human staffing, cut back on broker compensation and utilization and implement other operational changes to help control operations costs.

While many Medicare Adtange and Medicaid Advantage Plans will benefit from increased enrollment, producing promised benefits and avoiding regulatory sanctions amid tightening budgets remains a challenge for many of these plans. Medicare and Medicaid Advantage plans are tightly regulated by federal and state law. Over the past few years, the compliance, premiums, profits and other activities of these and other health plans have been heavily scruitinzed by Congress and federal and state regulators. As part of the stepped up health care fraud and other cost containment efforts, federal regulators have stepped up audit and enforcement against these programs. Several plans have suffered administrative sanctions or other discipline under these laws. Most commentatorys anticipate this scrutiny to expand in 2012.

Learn more here.

For Assistance or Additional Information

About Solutions Law Press

Comments Off on HHS Projects Medicare Advantage Enrollment Will Rise As Premiums Decline In 2012; Plans Face Increased Regulation & Enforcement | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: benefits, Employee Benefits, employee benefits policy, Employer, Health Care Reform, Health Insurance, health issuer, Health Plans, health policy, instruction, Insurance, Insurer, speech, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

4th Circuit Rejects Two Challenges To Affordable Care Act Constitutionality

September 8, 2011

The Fourth Circuit this morning (September 8, 2011) published decisions ruled rejecting two lawsuits challenging the constitutionality of the Patient Protection and Affordable Care Act on jurisdictional grounds in Liberty University v. Geithner and Commonwealth of Virgina v. Sebelius.

Cynthia Marcotte Stamer will discuss this new development and other health care reform issues when she speaks to the Houston Chapter of WEB at 11:30 a.m on September 14, 2011 on “Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do.” The program will cover newly proposed rules that will require health plans and health plan issuers to provide a new summary of benefits and coverage beginning in 2012 and other emerging rules imposed under recently engaged health care reform laws. The program is approved for 1 hour of general continuing education credit by the Texas Department of Insurance. Get details and register online at www.webnetwork.org/houston.

As the debate over the validity and future of the sweeping health care reforms enacted under the Patient Protection and Affordable Care Act (ACA) rages in Congress and the federal courts, employer and other health plan sponsors, insurers, fiduciaries and administrators face the daunting challenge of keeping their health plans compliant, affordable and relevant in the face of the steady rollout of the deluge of new mandates imposed by the Affordable Care Act and other evolving health plan mandates and planning for changes yet to come.

A former national WEB member nationally and internationally known for her knowledge and work on health and other employee benefit matters and engaging and informative presentations, attorney, author and policy advocate Cynthia Marcotte Stamer will help you prepare your plan and organization to cope with these and other challenges of understanding and coping with health care reform.

Ms. Stamer’s presentation will focus on key health care reform information that can help employers and other plan sponsors, insurers, fiduciaries, insurers, administrators and advisors understand and cope with the effects and responsibilities of health care reform including:

Recently proposed and finalized regulations;
Updating you on the status of litigation challenging the ACA health care reforms in the courts;
Updating you on the key developments affecting health care regulatory reforms likely to impact your health plan;
Sharing an updated roadmap of the currently scheduled implementation of key future health benefit reforms enacted under ACA;
Sharing selected tips and strategies for managing compliance and other risks and deal with uncertainties arising as health care reform continues to evolve; and
Audience questions and discussion of questions and ideas.

For additional information about Ms. Stamer and her experience, see www.CynthiaStamer.com.

Comments Off on 4th Circuit Rejects Two Challenges To Affordable Care Act Constitutionality | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: benefits, Employee Benefits, employee benefits policy, Employer, Health Care Reform, Health Insurance, health issuer, Health Plans, health policy, instruction, Insurance, Insurer, speech, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

Stamer Speaks 9/14 On Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do

September 3, 2011

Cynthia Marcotte Stamer will speak to the Houston Chapter of WEB at 11:30 a.m on September 14, 2011 on “Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do.” The program will cover newly proposed rules that will require health plans and health plan issuers to provide a new summary of benefits and coverage beginning in 2012 and other emerging rules imposed under recently engaged health care reform laws. The program is approved for 1 hour of general continuing education credit by the Texas Department of Insurance. Get details and register online at www.webnetwork.org/houston.

Recently proposed and finalized regulations;
Updating you on the status of litigation challenging the ACA health care reforms in the courts;
Updating you on the key developments affecting health care regulatory reforms likely to impact your health plan;
Sharing an updated roadmap of the currently scheduled implementation of key future health benefit reforms enacted under ACA;
Sharing selected tips and strategies for managing compliance and other risks and deal with uncertainties arising as health care reform continues to evolve; and
Audience questions and discussion of questions and ideas.

For additional information about Ms. Stamer and her experience, see www.CynthiaStamer.com.

Comments Off on Stamer Speaks 9/14 On Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: benefits, Employee Benefits, employee benefits policy, Employer, Health Care Reform, Health Insurance, health issuer, Health Plans, health policy, instruction, Insurance, Insurer, speech, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

ABA TIPS Section Appoints Cynthia Marcotte Stamer Vice Chair of Employee Benefits General Committee

August 16, 2011

The American Bar Association Tort Trial & Insurance Practice Section recently appointed Solutions Law Press Managing Editor Cynthia Marcotte Stamer to serve as Vice-Chair Appointment of the Employee Benefits General Committee for the 2011-2012 fiscal year.

The TIPS Employee Benefits Committee concentrates on helping attorneys and others keep on top of and respond to developments in the constantly evolving practice area of employee benefits, with particular emphasis on litigation and regulatory compliance issues through programs, meetings, publications and other projects and activities. Additional information about involvement in the Employee Benefits Committee and its programs, publications and activities is available here.

A noted Texas-based employee benefits and employment lawyer with extensive involvement in the leadership of the ABA and other professional organizations involved in employee benefits, health care and workforce matters, is nationally and internationally known for her pioneering leadership and work as an attorney, consultant, policy advocate, speaker and author helping businesses, governments, and communities on health and other insurance and employee benefits, patient education and empowerment, wellness and disease management, and other programs, policies, and processes. For more than 24 years, Ms. Stamer’s legal practice has focused on advising and representing employers, insurers, health care providers, community leaders and governments about health care and employee benefits policy and process improvement, quality, performance management, education, compliance, communications, risk management, reimbursement and finance, and other related matters. In addition to her legal practice, Stamer also extensively consults and provides leadership to a broad range of clients, professional and civic organizations, and others on strategies for improving the health care system and the ability of health care providers, payers, employers, community organizations, government agencies to help patients and their families to access cost-effective, quality, affordable health care and other resource needs. She also has worked extensively with a broad range of business and government clients on health care, pension, social security, workforce, insurance and many other related policy matters.

In addition to her service with TIPS, Ms. Stamer also is active in the leadership of a broad range of other professional and civil organizations. For instance, Ms. Stamer presently serves as Executive Director of Project COPE, the Coalition on Patient Empowerment and the Coalition for Responsible Healthcare Policy; Vice President of the North Texas Healthcare Compliance Professionals Association; Immediate Past Chair of the American Bar Association RPTE Employee Benefits & Other Compensation Committee and its representative to the ABA Joint Committee on Employee Benefits and Vice Chair of its Welfare Benefits Committee; Past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and a current member of its Healthcare Coordinating Council; and as the Gulf Coast TEGE Council TE Committee Coordinator. She previously served as a founding Board Member and President of the Alliance for Healthcare Excellence, as a Board Member and Board Compliance Committee Chair for the National Kidney Foundation of North Texas; the Board President of the early retirement intervention agency, The Richardson Development Center for Children; Chair of the Dallas Bar Association Employee Benefits & Executive Compensation Committee; a member of the Board of Directors of the Southwest Benefits Association; on many seminar faculties and in many other professional and civic leadership and volunteer roles.

Author of the hundreds of publications and workshops these and other employment, employee benefits, health care, insurance, workforce and other management matters, Ms. Stamer’s insights on employee benefits, insurance, health care and workforce matters in Atlantic Information Services, The Bureau of National Affairs, HealthLeaders, Modern Healthcare, Business Insurance, Employee Benefits News, World At Work, Benefits Magazine, the Wall Street Journal, the Dallas Morning News, the Dallas Business Journal, the Houston Business Journal, and many other publications. She also regularly conducts training and speaks on these and other management, compliance and public policy concerns. Some recent publications and programs that may be of interest include:

Stamer Speaks 9/14 On Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do
Labor Department 2011 Stats Show Employer Health Coverage & Other Benefit Statistics
Borzi Tells House Committee Current Fiduciary Regs Flawed; Must Fix Loopholes In Investment Advisor Definition To Protect Plans
Labor Department 2011 Stats Show Employer Health Coverage & Other Benefit Statistics
Conviction Highlights Risks Of Misleading Investors
DOL Considers Easing Rules For Electronic Benefit Communications
Improving The Effectiveness Of Compliance & Risk Management By Getting Hr On The Compliance Team
IRS Establishes Safe Harbor Election For Allocating Success-Based Fees Paid On Certain Business Transactions
IRS Changing Substantiation Rules For Business Travel Expenses
9/22/11 Cutoff To Apply For Affordable Care Act Annual Limit Temporary Waiver
Spectrum Healthcare NLRB Charge Settlement Highlights Need To Defend Against Possible Unfair Labor Practices & Other Union Exposures
IRS Releases Health Savings Account, High Deductible Health Plan 2012 Indexed Amounts
IRS Guidance On Affordable Care Act Requirement That Employers Report Cost Of Health Coverage On W-2 Released
Plan Sponsors. Their Owners & Management & Others Risk Personal Liability If Others Defraud Plans Or Mismanage Employee Benefit Plan Responsibilities
Health Plans, Insurers Get Limited & Imperfect Relief From Grace Period Extension For Some New Affordable Care Act Health Claims & Appeals Rules
EEOC Finalizes Updates To Disability Regulations In Response To ADA Amendments Act: Employers Should Manage Risks
Employer Charged With Misclassifying & Underpaying Workers To Pay $754,578 FLSA Back Pay Settlement
Avoiding Liability For Another’s Health Plan Fraud
Health Plans & Employers Beware! $4.3 Million Civil Penalty Shows OCR Serious About HIPAA Enforcement
IRS Expands When HFSAS & HRAs May Allow Over-The-Counter Drug Purchases With Drug Cards
DOL Announces Changes To H-2b Prevailing Wage Calculation Rules
$1 Million + FLSA Overtime Settlement Shows Employers Should Tighten On-Call, Other Wage & Hour Practices
Affordable Care Act Grandfathered Plan Rules Loosened To Allow Insured Plans Making Some Insurance Changes To Qualify
Update Employment Practices To Manage Genetic Info Discrimination Risks Under New EEOC Final Gina Regulations
EEOC Attacks Medical Leave Denials As Prohibited Disability Discrimination
DOL Proposes To Expand Investment Related Services Giving Rise To ERISA Fiduciary Status As Investment Fiduciary

For additional information about Ms. Stamer, upcoming training, publications or other materials or events, see here or contact Ms. Stamer directly via email here or (469) 767-8872.

IIf 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, send an e-mail with the word “Remove” in the Subject to here.

Comments Off on ABA TIPS Section Appoints Cynthia Marcotte Stamer Vice Chair of Employee Benefits General Committee | Cafeteria Plans, COBRA, Corporate Compliance, Defined Benefit Plans, Defined Contribution Plans, Disability Plans, Employee Benefits, Employers, Fiduciary Responsibility, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Preemption, Prescription Drugs, Retirement Plans, Wellness, Wellness Programs | Permalink
Posted by Cynthia Marcotte Stamer

New Affordable Care Act Guidance Helps Some Health Plans Stay Grandfathered

August 2, 2011

Affordable Care Act To Require Health Plans Cover Contraception & Other Women’s Health Procedures Beginning In 2012

Contraception Mandate Might Not Apply To Certain Religious Employer Plans

Starting with plan years beginning after July 31, 2011, most employer and union sponsored group health plans and group and individual health insurers generally must cover contraceptive and certain other preventive services for women (“Women’s Preventive Services”) at no cost to comply with federal rules that these programs cover preventive care for members with no cost sharing enacted as part of the Patient Protection and Affordable Care Act (“ACA”).

On Monday, August 1, 2011, the Department of Health & Human Services (“HHS”) on Monday, August 1, 2011 announced guidelines (Women’s Preventive Services Guidelines”) that add contraception and a list of women’s health procedures to the preventive care procedures that ACA requires covered health plans and health insurance policies covered by the Affordable Care Act to cover without cost to members. ACA’s general preventive coverage rules generally have required covered health plans and policies to cover without cost a broad list of other preventive care procedures since the first plan year beginning after September 22, 2009.

Interim Final Regulations implementing ACA’s new preventive care mandate published July 14, 2010 interpreted this ACA preventive care mandate broadly to dictate that ACA covered health plans and health insurers cover as preventive services at no member cost hundreds of procedures.

Concerning the Women’s Preventive Services, however, the Interim Final Regulations delayed implementation of requirements to cover Women’s Preventive Services until August 1, 2011 to give time to HRSA time to issue its recommendations about what procedures should qualify as Women’s Preventive Services. When HRSA failed to finalize its input by August 1, 2011, HHS finalized its list of required Women’s Preventive Services now rather than to continue waiting for HRSA’s final input.

Finalization of the list of required Women’s Preventive Services now means covered health plans and policies must add coverage for these listed procedures with no co-pay beginning with all post-July 31, 2012 plan years.

While the published list of required Women’s Preventive Services generally mandates that ACA-covered health plans and policies cover contraceptive services for women at no cost beginning in 2012, some plans sponsored by religious employers and group health policies covering these groups may be exempt from the duty to coverage contraception under a new regulation that HHS, along with the Department of Labor Employee Benefit Services Administration (“EBSA) and the Department of Treasury Internal Revenue Service (“IRS”)(collectively, the “Agencies”) will jointly publish in the Federal Register on August 3, 2011. See here for more detailed information.

Plans & Insurers Should Review & Update Preventive Care & Other Wellness Benefits

Non-grandfathered health plans and policies, their sponsors, insurers, fiduciaries and administrators should carefully review and update their health plans for compliance with the existing preventive care mandates and other evolving rules about disease management and wellness benefits and coverages, as well as to consider the impending requirement to comply with additional Women’s Preventive Services coverage requirements in 2012 as part of their plan design and cost projections.

Existing health plans and health insurance should be reviewed to ensure that the programs appropriately cover all preventive services currently required by the applicable ACA mandates or other laws and re-reviewed for compliance with any updated rules before each plan year to identify any additional costs, changes to plan documents, communications, administrative procedures and vendor contracts required to administer the health plan in accordance with existing rules. For 2012, this should specifically consider the need to comply with the new Women’s Preventive Services coverage requirements that take effect next plan year also should be considered.

In addition to specifically planning for compliance with ACA’s preventive services coverage mandates, all health plans and policies, their sponsors, insurers, fiduciaries and administrators should review the other wellness and disease management components of their plans. In addition to ACA compliance, these arrangements may need redesign to minimize emerging exposures to challenge by the Equal Employment Opportunity Commission (“EEOC”) or private plaintiffs under the Americans With Disabilities Act (“ADA”). Since the Obama Administration took office, the EEOC has taken the position that many common wellness and disease management programs violate the ADA. In addition to these exposures, amendments to the nondiscrimination requirements of the Health Insurance Portability & Accountability Act (“HIPAA”), new nondiscrimination rules added by the Genetic Information & Nondiscrimination Act (“GINA”), federal mental health parity rules, evolving Affordable Care Act claims, coverage and other rules and guidance about essential benefits and other statutory, regulatory and enforcement changes often require updates to common disease management and wellness programs as well as other health plan provisions. Appropriate steps should be taken to review and update these and other plan terms, procedures, communications and practices to maintain compliance and support the ability to enforce plan terms and rely on plan cost projections.

The author of this update, attorney Cynthia Marcotte Stamer frequently conducts training and publishes on these and other matters. She is scheduled to speak about these and other changing health plan requirements in light of health care reform at the September 14, 2011 Houston WEB Chapter lunch and will be conducting briefings on preventive care, wellness and disease management and other rules for several other organizations over the next few months. You can find out about upcoming training or other events and get updates at www.CynthiaStamer.com.

For Help With These Or Other Health Plan Or Employee Benefit Matter

If you would like help reviewing or defending your organizations health plan or other insurance or employee benefit and employment practices in light of these or other laws, please contact attorney Cynthia Marcotte Stamer.

Chair of the American Bar Association (ABA) RPTE Employee Benefits & 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 recognized, internationally, nationally and locally for her more than 23 years of work, advocacy, education and publications on employee benefit and related matters.

A board certified labor and employment attorney Ms. Stamer continuously advises and assists employee benefit plans, their sponsoring employers, fiduciaries, insurers, administrators and others to monitor and respond to evolving legal and operational requirements and to design, administer, document and defend medical and other welfare benefit, qualified and non-qualified deferred compensation and retirement, severance and other employee benefit, compensation, and human resources programs and practices. She works extensively with plan sponsors, insurers, administrators, technology and other service providers and others to develop and operate legally defensible programs, practices and policies that promote the client’s human resources, employee benefits or other management goals. Ms. Stamer also is a widely published author and highly regarded speaker on these and other employee benefit and human resources matters who is active in many other employee benefits, human resources and other management focused organizations.

Ms. Stamer is scheduled to conduct training on these and other health benefit requirements for a number of organizations over the upcoming month. For information about these and other training opportunities or for other resources and information, see here or contact Ms. Stamer directly.

For Help or More Information

If you have questions or need help understanding or responding to the Regulations, with other health benefit design, administration or operations concerns, or with other employee benefits, compensation, labor or employment or other workforce management concerns, please contact the author of this update, Board Certified Labor and Employment attorney and management consultant Cynthia Marcotte Stamer here or at (469)767-8872.

Past Chair of the American Bar Association (ABA) Health Law Section Managed Care & Insurance Interest Group, Chair of the ABA RPTE Employee Benefit and Other Compensation Committee, and a council member of the ABA Joint Committee on Employee Benefits, Ms. Stamer is nationally recognized for her more than 23 years pragmatic and innovative health program work.

Board certified in labor and employment law by the Texas Board of Legal Specialization with extensive leading edge health plan experience, Ms. Stamer has worked continuously throughout her career helping health plan sponsors, fiduciaries, administrators, insurers and others design, administer and defend health and other employee benefit and insurance programs domestically and internationally. She is widely recognized for her experience helping design and implement legally compliant self-insured and insured health reimbursement, mini-med, high-deductible health plans, limited benefit plans, 24-hour and occupational medicine, ex-pat and medical tourism, deductible reimbursement and other creative health benefit programs to solve a wide range of financial and other challenges while coping with changing regulatory and market realities. Her work includes both working with clients to design, document, implement and administer these and other arrangements, as well as the development of wellness and disease management, claims administration and appeals, eligibility, and other administrative services, processes and technologies. She also works with plan fiduciaries, plan sponsors, insurers, administrators, brokers and advisors, bankruptcy trustees, creditors, debtors, service providers and their officers and directors about the prevention, investigation, mitigation and resolutions of civil and criminal liability arising from suspected or known benefit administration claims, breaches of fiduciary duty, privacy and data security breach, vendor disputes and other disputes arising in relation to employee benefit and insurance arrangements. As a continuing part of this representation, Ms. Stamer regularly represents and defends plan sponsors, fiduciaries, third party administrators and other service providers and management officials in dealings with the Department of Labor, Department of Justice, Department of Health & Human Services, Department of Defense, Securities and Exchange Commission, state insurance regulators, state attorneys general and other federal and state regulators and prosecutors and private plaintiffs in connection with investigations, prosecutions, audits and other actions arising from employee benefit, insurance and related arrangements and products.

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 regularly conducts management and other training on a wide range of labor and employment, employee benefit, human resources, internal controls and other related risk management matters. Her writings frequently are published by the American Bar Association (ABA), Aspen Publishers, Bureau of National Affairs, the American Health Lawyers Association, SHRM, World At Work, Government Institutes, Inc., Atlantic Information Services, Employee Benefit News, and many others. For a listing of some of these publications and programs, see here. Her insights on human resources risk management matters also 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, Business Insurance, the Dallas and Houston Business Journals and a host of other publications. In addition to her many ABA leadership involvements, she also serves in leadership positions in numerous human resources, corporate compliance, and other professional and civic organizations. 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, World At Work, the ICEBS, SHRM 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

Stamer Speaks 9/14 On Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do
Labor Department 2011 Stats Show Employer Health Coverage & Other Benefit Statistics
Borzi Tells House Committee Current Fiduciary Regs Flawed; Must Fix Loopholes In Investment Advisor Definition To Protect Plans
Labor Department 2011 Stats Show Employer Health Coverage & Other Benefit Statistics
Conviction Highlights Risks Of Misleading Investors
DOL Considers Easing Rules For Electronic Benefit Communications
Improving The Effectiveness Of Compliance & Risk Management By Getting Hr On The Compliance Team
IRS Establishes Safe Harbor Election For Allocating Success-Based Fees Paid On Certain Business Transactions
IRS Changing Substantiation Rules For Business Travel Expenses
9/22/11 Cutoff To Apply For Affordable Care Act Annual Limit Temporary Waiver
Spectrum Healthcare NLRB Charge Settlement Highlights Need To Defend Against Possible Unfair Labor Practices & Other Union Exposures
IRS Releases Health Savings Account, High Deductible Health Plan 2012 Indexed Amounts
IRS Guidance On Affordable Care Act Requirement That Employers Report Cost Of Health Coverage On W-2 Released
Plan Sponsors. Their Owners & Management & Others Risk Personal Liability If Others Defraud Plans Or Mismanage Employee Benefit Plan Responsibilities
Health Plans, Insurers Get Limited & Imperfect Relief From Grace Period Extension For Some New Affordable Care Act Health Claims & Appeals Rules
EEOC Finalizes Updates To Disability Regulations In Response To Ada Amendments Act: Employers Should Manage Risks
Employer Charged With Misclassifying & Underpaying Workers To Pay $754,578 FLSA Back Pay Settlement
Avoiding Liability For Another’s Health Plan Fraud
Health Plans & Employers Beware! $4.3 Million Civil Penalty Shows OCR Serious About HIPAA Enforcement
IRS Expands When HFSAS & HRAs May Allow Over-The-Counter Drug Purchases With Drug Cards
DOL Announces Changes To H-2b Prevailing Wage Calculation Rules
$1 Million + FLSA Overtime Settlement Shows Employers Should Tighten On-Call, Other Wage & Hour Practices
Affordable Care Act Grandfathered Plan Rules Loosened To Allow Insured Plans Making Some Insurance Changes To Qualify
Update Employment Practices To Manage Genetic Info Discrimination Risks Under New EEOC Final Gina Regulations
EEOC Attacks Medical Leave Denials As Prohibited Disability Discrimination
DOL Proposes To Expand Investment Related Services Giving Rise To Erisa Fiduciary Status As Investment Fiduciary

Comments Off on New Affordable Care Act Guidance Helps Some Health Plans Stay Grandfathered | 105(h), ADA, Affordable Care Act, Claims Administration, Corporate Compliance, Discrimination, Disease Management, Employee Benefits, Employers, ERISA, Fiduciary Responsibility, GINA, Health Care Reform, Health Plans, Human Resources, Insurance, Public Policy | Tagged: Affordable Care Act, Employee Benefits, grandfathered health plan, grandfathered plan, Health Care Reform, Health Insurance, Health Plans, Insurance, medical insurance | Permalink
Posted by Cynthia Marcotte Stamer

Stamer Speaks 9/14 On Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do

July 29, 2011

Cynthia Marcotte Stamer will speak to the Houston Chapter of WEB at 11:30 a.m on September 14, 2011 on “Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do.” Get details and register online at www.webnetwork.org/houston.

Updating you on the status of litigation challenging the ACA health care reforms in the courts;
Updating you on the key developments affecting health care regulatory reforms likely to impact your health plan;
Sharing an updated roadmap of the currently scheduled implementation of key future health benefit reforms enacted under ACA;
Sharing selected tips and strategies for managing compliance and other risks and deal with uncertainties arising as health care reform continues to evolve; and
Audience questions and discussion of questions and ideas.

For additional information about Ms. Stamer and her experience, see www.CynthiaStamer.com.

Comments Off on Stamer Speaks 9/14 On Coping With Health Care Reform: What’s New, What Lies Ahead & What To Do | 105(h), Affordable Care Act, CHIP, COBRA, Employee Benefits, Employers, Employment Tax, ERISA, Excise Tax, Fiduciary Responsibility, FMLA, Health Care Reform, Health Plans, HIPAA, Human Resources, Income Tax, Insurance, Malpractice, Medicare Part D, Mental Health, Mental Health Parity, Patient Empowerment, Patient Protection and Affordable Care Act, Payroll Tax, Preemption, Prescription Drugs, Protected Health Information, Reporting & Disclosure, Tax Credit, Wellness Programs | Tagged: benefits, Employee Benefits, employee benefits policy, Health Care Reform, Health Insurance, Health Plans, health policy, Insurance, Speeches, Training, WEB | Permalink
Posted by Cynthia Marcotte Stamer

Labor Department 2011 Stats Show Employer Health Coverage & Other Benefit Statistics

July 29, 2011

A new 2011 U.S. Department of Labor Bureau of Labor Statistics Study of employee benefits offered shares key insights into how many employers offer employer-provided health and other benefits The study shows that health and other benefits offered by employers, how much employers contribute and when employees enroll in offered benefits varies widely varied by whether the employer is a government or private sector employer, the industry, size and other characteristics of the employer and the income, profession, education and other characteristics of the employee. It is no surprise that government employers that can pass along costs to taxpayers provide coverage more broadly and subsidize more of the cost.

With regard to health benefits, the report reveals that practices vary significantly among employers, on average, medical care benefits were available to 69 percent of private industry workers and half of workers participated in a medical plan. For single coverage, private sector employers paid 80 percent of the medical care premiums for full-time workers and 69 percent of medical care premiums for full-time workers in private industry. Data shows employees often elect not to take offered coverage.

In addition to data on medical benefits, the study also reports that paid leave remains the most commonly provided benefit nationally and includes data on other benefits.

The DOL highlights 1st time reporting of domestic partner status for 1st time in its announcement. Data also provided on paid vacation and other leave.

Read report summary and access report at http://www.bls.gov/news.release/ebs2.nr0.htm.

For Help or More Information

About Solutions Law Press

Comments Off on Labor Department 2011 Stats Show Employer Health Coverage & Other Benefit Statistics | 105(h), Absenteeism, Affordable Care Act, COBRA, Disability, Disability, Disability Plans, Employers, ERISA, FMLA, Health Care Reform, Health Plans, Human Resources, Insurance, Public Policy | Tagged: Affordable Care Act, Employee Benefits, grandfathered health plan, grandfathered plan, Health Care Reform, Health Insurance, Health Plans, Insurance, medical insurance | Permalink
Posted by Cynthia Marcotte Stamer

Borzi Tells House Committee Current Fiduciary Regs Flawed; Must Fix Loopholes In Investment Advisor Definition To Protect Plans

July 28, 2011

Assistant Secretary of Labor, Employee Benefits Security Administration (EBSA) Phyllis C. Borzi testified Tuesday, July 26, 2011 to the House Committee on Education and the Workforce Subcommitte on Health, Employment, Labor, and Pensions that EBSA a proposed fiduciary regulation that would update EBSA regulations defining when a person is considered a “fiduciary” by reason of giving investment advice for a fee with respect to assets of an employee benefit plan or IRA will help protect employee benefit plan participants by correcting “loopholes” in a “flawed 35-year-old rule” that allow many parties providing advice about the investment of retirement plan assets to escape coverage by ERISA’s fiduciary responsibility rules. The proposed regulations and other stepped up regulations and enforcement of ERISA’s fiduciary protections by the EBSA means that plan sponsors, fiduciaries, investment advisors and other plan service providers and others involved in the sponsorship, design, and administration of an employee benefit plan need to act to manage expanding fiduciary responsibilities and exposures.

Borzi Says Loopholes & Other Flaws In Existing Regulations Hurt Plans & Their Participants

Borzi told the Committee that EBSA believes its rules about the types of advisory relationships that give rise to fiduciary status under the ERISA on the part of those providing investment advice services need to change because “technicalities” and “loopholes” in the current EBSA fiduciary regulations definition of “investment advisor” in effect since 1975 harms participants and beneficiaries by allowing many advisers to easily dodge fiduciary status.

Borzi testified that the five-part regulatory test used under the current regulations to determine when ERISA’s fiduciary requirements apply to “investment advice” and when the advisor is a “fiduciary” significantly narrowed the plain language of the ERISA statute so that much of what plainly is advice about plan investments is not treated as investment advice as fiduciary conduct under ERISA and the person paid to render that advice is not treated as an ERISA fiduciary.

Under current fiduciary regulation, an investment adviser is not treated as a fiduciary accountable for complying with ERISA’s prudence, exclusive benefit, prohibited transaction and other fiduciary responsibility safeguards if and when providing advice that meets each element of a five part test.

Under the current regulation, a person is a fiduciary under ERISA and/or the tax code with respect to their advice only if and when he or she:

Make recommendations on investing in, purchasing or selling securities or other property, or give advice as to their value;
On a regular basis;
Pursuant to a mutual understanding that the advice;
Will serve as a primary basis for investment decisions; and
Will be individualized to the particular needs of the plan.

Borzi told members of Congress this narrow definition of investment advisor exempts a wide range of parties receiving compensation for providing advice about the investment of employee benefit funds from coverage by ERISA’s fiduciary responsibility requirements. Borzi testified that the narrowness of the existing regulation opened the door to serious problems, and changes in the market since the regulation was issued in 1975 have allowed these problems to proliferate and intensify. Borzi says the narrowness of the regulation has harmed some plans, participants, and IRA holders. Research has linked adviser conflicts with underperformance. SEC reviews of certain financial sales practices may also reflect these influences. Finally, EBSA’s own enforcement experience has demonstrated specific negative effects of conflicted investment advice.

Borzi Says Proposed Regulation Would Strengthen Protections For Plans & Their Participants

Borzi said the proposed regulation published in the Federal Register on October 22, 2010 would change the rules defining a person is considered to be a “fiduciary” by reason of giving investment advice for a fee with respect to assets of an employee benefit plan or IRA by modifying the current regulation in effect since 1975 would replace the five-part test of “investment advisor” with a broader definition more in keeping with the statutory language while providing clear exceptions for conduct that should not result in fiduciary status.

According to Borzi, types of advice and recommendations that generally would trigger fiduciary status under the proposed regulations include: (1) appraisals or fairness opinions concerning the value of securities or other property; (2) recommendations as to the advisability of investing in, purchasing, holding or selling securities or other property; or (3) recommendations as to the management of securities or other property.

To be a fiduciary for performing these or other activities treated as fiduciary investment advice, Borzi explained that a person engaging in one of these activities must receive a fee and also meet at least one of the following four conditions:

Represent to a plan, participant or beneficiary that the individual is acting as an ERISA fiduciary;
Already be an ERISA fiduciary to the plan by virtue of having any control over the management or disposition of plan assets, or by having discretionary authority over the administration of the plan;
Be an investment adviser under the Investment Advisers Act of 1940; or
Provide the advice pursuant to an agreement or understanding that the advice may be considered in connection with investment or management decisions with respect to plan assets and will be individualized to the needs of the plan.

At the same time, Borzi testified that the proposed regulation recognizes that activities by certain persons should not result in fiduciary status. Specifically, these are:

Persons who do not represent themselves to be ERISA fiduciaries, and who make it clear to the plan that they are acting for a purchaser/seller on the opposite side of the transaction from the plan rather than providing impartial advice;
Persons who provide general financial/investment information, such as recommendations on asset allocation to 401(k) participants under existing Departmental guidance on investment education;
Persons who market investment option platforms to 401(k) plan fiduciaries on a non-individualized basis and disclose in writing that they are not providing impartial advice; and
Appraisers who provide investment values to plans to use only for reporting their assets to the DOL and IRS.
EBSA Still Working To Address Expressed Concerns

The proposed regulation has prompted a large volume of comments and a vigorous debate. Borzi testified that the EBSA is working hard to hear and consider every stakeholder concern and shared some examples of how EBSA is considering addressing certain of these concerns. Borzi said EBSA is taking multiple steps in its effort to respond to these and other concerns in its efforts to finalize the regulation including:

Borzi told the Committee EBSA is working to better understand how specific compensation arrangements would be affected by the proposed rule and whether clarifications of existing prohibited transactions exemptions would be appropriate. Borzi said EBSA has already begun to issue subregulatory guidance describing some of these clarifications and will continue to do so as necessary as it completes its analysis.

Borzi also said that as EBSA further develops its thinking in this rulemaking, EBSA is paying special attention to the two primary exceptions to fiduciary status under the proposed rule: (1) clarifying the difference between investment education that does not give rise to fiduciary status and fiduciary investment advice; and (2) clarifying the scope of the so-called “sellers’ exception” under which sales activity is not fiduciary advice. In both cases, Borzi said EBSA intends to analyze and address the comments and concerns that were raised during our extensive public comment period.

Finally, Borzi said EBSA is exploring a range of appropriate regulatory options for moving forward, taking into consideration public comments submitted for the record, EBSA’s economic analysis, and relevant academic research. In so doing, Borzi told the Committee EBSA is aiming to address conflicted investment advice while not unnecessarily disrupting existing compensation practices or business models.

Plan Sponsors, Fiduciaries, Service Providers Should Prepare For Tighter Rules While Continuing To Provide Input To EBSA

The proposed changes to the definition of investment advisor is one of many steps that EBSA is taking to tighten the regulations implementing ERISA’s fiduciary requirements and to enforce the protections of ERISA. The proposal to expand the conditions that providing investment advice regarding retirement plan assets will trigger the fiduciary protections of ERISA is designed to expand the reach of those regulations. Service providers involved in providing these or other related services generally will want to review and update their processes, documentation and training to manage new exposures likely to arise from these proposed regulations, while continuing to share feedback to EBSA and other rulemakers.

Service providers are not the only parties that need to update practices and provide input about these rules. Plan sponsors, fiduciaries, service providers, participants and beneficiaries also are impacted. Employers and other plan sponsors, fiduciaries and others need to anticipate and respond effectively to the inevitable efforts by providers of investment advice and other services to avoid or shift liability. Parties securing or relying on advice or services about investments or other responsibilities should:

Carefully, prudently conduct a documented investigation and critical analysis of existing and proposed advisors and other service providers credentials, analysis, performance, contract, recommendations and other conduct;
Carefully review contracts and other materials and secure appropriate constractual and other safeguards;
Require indemnification, insurance and other protections;
Ensure that appropriate action is taken to appoint parties intended to perform fiduciary advisory or other services to manage risks
Secure and maintain appropriate fiduciary and other liability insurance coverage;
Carefully conduct an appropriate, well-documented prudent review of performance, credentials and other relevant factors on a regular basis to preserve ongoing evidence of prudence; and
Other appropriate safeguards to manage risks and liabilities.

To help guard and position themselves to defend against fiduciary exposures plan sponsors, fiduciaries, service providers and others involved in the administration of health or other employee benefit plans should seek the advice of legal counsel with appropriate experience with employee benefit and other related matters to develop an understanding of ERISA and other laws and the duties and liabilities that these rules may create for their organizations and themselves personally. For additional tips and information about managing these risks, see here.

For Help With These Or Other Risk Management Matters

If you need assistance in auditing or assessing, updating or defending your wage and hour or with other labor and employment, employee benefit, compensation or internal controls 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. Her experience includes extensive work helping employers implement, audit, manage and defend wage and hour and other workforce and internal controls policies, procedures and actions. 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, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works, publishes and speaks extensively on wage and hour, worker classification and other human resources and workforce, employee benefits, compensation, internal controls and 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.

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Posted by Cynthia Marcotte Stamer

9/22/11 Cutoff To Apply For Affordable Care Act Annual Limit Temporary Waiver

June 20, 2011

6/17 Guidance Says Temporary Relief Offered Through 2014 Unavailable For Plans Not Applying By 9/22/11

Health plans and insurers wishing to qualify for a temporary waiver of annual limit restrictions enacted under the Affordable Care Act after September 22, 2011 must act quickly and should expect to face tougher qualification requirements. Plans and insurers not applying by a newly set September 22, 2011 deadline will be permanently disqualified from eligibility to request the relief for post-September 22, 2011 plan years according to guidance issued Friday, July 17, 2011.

Plans Must Apply Before 9/22/11 & Meet Tightened Requirements To Preserve Possibility Of Temporary Relief Qualification For Post 9/22/11 Plan Years

On Friday, June 17, 2011, the Centers for Medicare and Medicaid Services (CMS) announced that CMS will not accept or consider any new applications or requests for extensions of temporary waivers of the Affordable Care Act annual limitation requirements.

Additionally, CMS also updated the requirements that plans and insurers applying for a new or extension of an existing annual limit waiver before September 22, 2011 through 2013. Under the new guidance, any plans receiving these waivers also will have to meet tighter requirements to qualify for the requested annual limit waiver for post-September 22, 2011 plan years.

The Affordable Care Act will ban annual limits for non-grandfathered health plans beginning in 2014. Until then, the Affordable Care Act provides for the phased out of annual limits. The phase out of the annual limits is intended to preserve access to needed benefits and the affordability of coverage until the reforms scheduled to take effect in 2014 are in place.

Currently, most plans cannot impose an annual limit that is lower than $750,000. Beginning in September, 2011, the allowable annual limit under the Affordable Care Act will increase to $1.25 million and to $2 million for plan years beginning in September 2012.

Temporary Waiver Program Provides Relief For Some Qualifying Plans

In response to concerns that compliance with the phased in annual limit restrictions would result in significant cost increases or coverage terminations for many plans, CMS last year issued guidance that granted temporary waivers from the phased in annual limits for qualifying limited benefit,, “mini-med” or certain other qualifying plans that submitted timely applications demonstrating that compliance with the phaseout limits would result in a significant decrease in access to benefits or a significant increase in premiums and met other qualification requirements. (For a list of applications previously approved or denied by city and state, see cciio.cms.gov/resources/files/approved_applications_for_waiver.html.)

CMS Most Likely To Approve Waiver Requests For Plans With Lower Annual Limits But Other Plans Also Can Apply

Like the waiver program guidance for 2010, the June 17, 2011 guidance technically gives all plans and issuers with restricted annual limits below $2 million the opportunity to apply for a temporary waiver before September 22, 2011. However, not all plans will necessarily qualify for the requested relief.

Under the temporary waiver program, CMS authority to decide whether to approve or deny an annual limit waiver request made by a plan that otherwise meets all requirements. CMS has indicated that it is most likely to approve waivers for plans with low annual limits (e.g., $10,000), as CMS sees these plans as most likely to need waivers to prevent a significant increase in premiums or decrease in access to coverage to comply with the current limit of $750,000. In contrast, CMS views plans with higher annual limits as less needful of a temporarywaiver because complying with the new rules is unlikely to lead to a significant increase in premiums or decrease in access to care. CMS says that its actuarial analysis indicates that most plans that currently have annual limits above $750,000 and below $2 million can meet the increased 2011 annual limit of $1.25 million with minimal premium increases (less than one percent). Similarly, CMS predicts that increasing annual limits from $1.25 million to $2 million in 2012 will have a “small impact” on premiums. Consequently, CMS is less likely to approve waiver requests for plans that already have higher limits in effect.

CMS Also Tightening Other Requirements For Waiver Relief Qualification

In addition to applying for a waiver before September 22, 2011 and showing the requisite impact on plan costs or coverage, the July 17 guidance also will require that plans seeking a temporary waiver of the annual limit after September 22, 2011 meet other more stringent conditions. Among other things, plans with waivers will be required:

To tell consumers that their health care coverage is subject to an annual dollar limit lower than what is allowed under the law;
Include the dollar amount of the annual limit along with a description of the plan benefits to which the limit applies;
Show how the annual limit would affect a consumer who was hospitalized to help people understand how far their coverage will reach if they become seriously ill; and
Must attest annually to their compliance with the consumer disclosure requirement.

Plans & Sponsors Should Act Quickly To Keep Option of Qualification For Temporary Relief Option

Plans and insurers that wish to preserve the possibility of qualifying for temporary relief from the otherwise applicable Affordable Care Act limitations on annual waivers for post-September 22, 2011 plan years should act quickly to prepare and submit their application for relief.

For Help or More Information

Ms. Stamer is scheduled to conduct training on these and other health benefit requirements for a number of organizations is upcoming months. For information about these and other training opportunities or for other resources and information, see here or contact Ms. Stamer directly.

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Posted by Cynthia Marcotte Stamer

Spectrum Healthcare NLRB Charge Settlement Highlights Need To Defend Against Possible Unfair Labor Practices & Other Union Exposures

May 20, 2011

The National Labor Regulations Board (NLRB)’s announcement of a settlement against a Connecticut nursing home operator this week in conjunction with a series of other enforcement actions highlight the need for businesses to tighten defenses and exercise other caution to minimize their organization’s exposure to potential NLRB charges or investigation. As reflected by many of these enforcement acts, the exposures arise both from active efforts by businesses to suppress union organizing or contracting activities, as well as the failure to identify and manage hidden labor law exposures in the design and administration of more ordinary human resources, compliance, business operations and other policies and practices.

On May 17, 2011, the NLRB announced here that Connecticut nursing home operator Spectrum Healthcare has agreed to settle a NLRB case involving multiple allegations of unlawful suspensions, discharges and unilateral changes in violation of the National Labor Relations Act and other federal labor laws by offering reinstatement and back pay to all discharged and striking workers and signing a new three-year collective bargaining agreement with its employees’ union, New England Health Care Employees Union District 1199, SEIU.

Along with the contract and reinstatement of all employees, the company agreed to pay $545,000 in back pay and pension benefits to employees who were harmed by the unfair labor practices, and to expunge any disciplinary records related to the case. As a result, all NLRB charges against the company have been withdrawn. Spectrum admits to no wrongdoing in the settlement.

The settlement, reached midway through a hearing before an NLRB administrative law judge in Connecticut and approved by the judge yesterday, ends a long-running dispute which grew into a strike by almost 400 employees at four nursing homes in Connecticut operated by Spectrum Healthcare, LLC. Complaints issued by the NLRB Regional Office in Hartford alleged that, beginning in the fall of 2009, several months after the prior collective bargaining agreement expired, Spectrum discharged seven employees and suspended three others to retaliate against their union activities and to discourage other employees from supporting the union. In addition, one employee was discharged and seven others were suspended after the employer unilaterally changed its tardiness discipline policy without first bargaining with the union.

The complaints further alleged that in April 2010, employees at the four nursing homes — in Derby, Ansonia, Winsted, and Hartford — went on strike to protest the unfair labor practices. When the strikers offered unconditionally to return to work in late August, the employer refused to take them back. Under federal labor law, if a strike is called because of an unfair labor practice, employees are entitled to reinstatement after an unconditional offer to return to work.

The reinstated employees are due to return to the facilities this week.

The Spectrum Healthcare settlement is reflective of the growing number of NLRB enforcement orders against employers generally and health care providers specifically under the Obama Administration. The Obama Administration has close ties and has expressed its strong and open support for union and union organizing activities. The adoption of a series of union friendly labor law reforms was one of the key campaign promises of President Obama during his election campaign. While other legislative priorities and the change in the leadership of the House of Representatives appears to have slowed efforts to push through this agenda, it has not slowed the Administration’s efforts to support unions with strong enforcement activities. Empowered by a difficult economic and job situation and an awareness of the Obama Administration’s strong support for union organizing and other activities, unions are stepping up organizing efforts and more aggressively challenging employers actions.

Over the past few months, public awareness of the Obama Administration’s aggressive enforcement agenda on behalf of unions has drawn new attention as a result of the widespread media coverage of NLRB actions challenging Boeings planned relocation of certain manufacturing jobs intervention in a planned relocation of certain manufacturing operations. See, e.g., Acting General Counsel Lafe Solomon releases statement on Boeing complaint; National Labor Relations Board issues complaint against Boeing Company for unlawfully transferring work to a non-union facility. However, the Boeing and Spectrum Healthcare actions represent only the tip of the iceberg of the rising number of NLRB enforcement activities, most of which take place with little media or public attention.

Along side the Spectrum Healthcare and Boeing actions, in recent weeks, the NLRB also has been busy with several other enforcement activities. For instance:

On May 9 2011, the NLRB issued a complaint against Hispanics United of Buffalo (HUB), a nonprofit that provides social services to low-income clients, that alleges that HUB unlawfully discharged five employees after they took to Facebook to criticize working conditions, including work load and staffing issues. The case involves an employee who, in advance of a meeting with management about working conditions, posted to her Facebook ; and
On May 17, the NLRB secured a temporary injunction from a U.S. District Court in San Jose California against San Jose area waste hauling company OS Transport LLC, charged with engaging in unfair labor practices including the termination of a lead organizer and another Union supporter, retaliation against Union efforts in the form of unfavorable assignments, threats to Union supporters, and promises of improved treatment of employees who disavow the Union for the alleged purpose of defeating a union. o offer reinstatement to two drivers and restore full assignments to other drivers who had expressed support for a union during an organizing campaign. More Details here.,

In addition, in recent weeks, the NLRB also has:

Sued the state of Arizona on amendment limiting method for choosing union representation on May 5, 2011;
Secured an order requiring a Milwaukee job training center to pay back pay and reinstate workers fired for complaining about bounced paychecks on May 3, 2011;
Ordered a concrete supplier to rehire employees in Indianapolis on May 2, 2011;
Found a New York egg processing plant of unlawful interference and ordered a third election ohm April 27, 2011; and
Secured a settlement from Build.com of unlawful dischrage charges for firing employee based on Facebook comments on April 20

Amid this difficult enforcement environment, business leaders should exercise special care to prepare to defend their actions against both potential organizing efforts, to understand the types of actions and activities that may help fuel charges, and take steps to manage these and other union organization and other labor risks.

For Help With Labor & Employment, Employee Benefits Or Other Risk Management and Defense

If you need assistance in auditing or assessing, updating or defending your labor and employment, employee benefits, compliance, risk manage or other internal controls practices or actions, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

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Posted by Cynthia Marcotte Stamer

IRS Releases Health Savings Account, High Deductible Health Plan 2012 Indexed Amounts

May 18, 2011

The Department of Treasury released the inflation adjusted amounts for Health Savings Accounts (HSAs) applicable for purposes of § 223 of the Internal Revenue Code for 2012.

Under Revenue Procedure 2011-32, for 2012 the following inflation adjusted amounts will apply for purposes of applying the HSA limits during 2012:

Annual Contribution Limitation

For calendar year 2012, the annual limitation on deductions under § 223(b)(2)(A) is:

For an individual with self-only coverage under a high deductible health plan is $3,100.
For an individual with family coverage under a high deductible health plan is $6,250.

High Deductible Health Plan

For calendar year 2012, Revenue Procedure 2011-32 leaves the minimum deductible allowable for an arrangement to qualify as a “high deductible health plan” unchanged from the amounts implemented for 2011. This means that in 2012 a “high deductible health plan” will continue to be defined under § 223(c)(2)(A) as a health plan with an annual deductible that is not less than:

$1,200 for self-only coverage or
$2,400 for family coverage, and the annual out-of pocket expenses (deductibles, co-payments, and other amounts, but not premiums) do not exceed $6,050 for self-only coverage or $12,100 for family coverage.

HSA sponsors and administrators will want to ensure that their HSA plan documents, communications are timely and properly updated to reflect the adjusted numbers well in advance to the 2012 enrollment period. At the same time, high deductible health plan and HSA plan sponsors and administrators also should verify that their programs, as well as any health care flexible spending arrangements are updated for changes such as new rules conditioning reimbursement of over-the-counter medical expenses by HSAs and health care flexible spending accounts on the fulfillment of prescription requirements enacted as part of health care reform as well as other updates.

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Posted by Cynthia Marcotte Stamer

New Affordable Care Act Guidance Helps Some Health Plans Stay Grandfathered

April 20, 2011

Guidance published by the Departments of Health and Human Services (HHS), Labor and the Treasury (the Agencies) on April 1, 2011 provides welcome clarifications about the workings of the “grandfathered health plan rules” that play a key role in determining what health plans and insurance policies must comply with certain key health insurance coverage reforms enacted as part of the Patient Protection and Affordable Care Act (PPACA), as amended by the Health Care and Education Reconciliation Act of 2010 (the Reconciliation Act) (collectively, the Affordable Care Act).

Health plans, health insurers and sponsors, fiduciaries and service providers of these arrangements should monitor and consider carefully this and other emerging guidance when making decisions about the design and administration of health benefit programs in response to the Affordable Care Act.

Grandfathered Health Plan Status A Key Determinant of What Health Care Reform Rules Apply

While the Affordable Care Act generally requires that health plans and health insurance policies comply with a series of new mandates established by the Affordable Care Act beginning with the first plan year that begins after September 22, 2010, the Affordable Care Act, Interim Final Regulations originally jointly published June 17, 2010 as subsequently amended on November 17, 2011 (the Regulations).provide that certain plans or coverage existing on March 23, 2010 that qualify as “grandfathered health plans” are subject to only certain provisions of the Affordable Care Act. The Affordable Care Act and Regulations refer to these plans or health insurance coverage as “grandfathered health plans.”

Qualifying As Grandfathered Health Plan

For plans and insurers wishing to preserve the grandfathered health plan status of their programs, understanding when changes or other events affect the health plan’s ability to qualify as a grandfathered health plan is critical to understanding the consequences and potential costs of proposed plan design changes or certain other actions.

For purposes of determining when an arrangement that existed on March 22, 2010 qualifies as a “grandfathered health plan” for purposes of ACA, the Regulations require that the plan meet certain notification, documentation and other requirements set forth in the Regulations. The Regulation also provides 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. In order to avoid a loss of grandfathered health plan status, the Regulations require that except for certain “routine changes” identified in the Regulation, the health plan not have been modified or impacted by certain other changes after March 22, 2011. See HHS, DOL & IRS Rules Define “Grandfathered” Group Health Plans & Health Insurance Coverage under the Patient Protection and Affordable Care Act. Consequently, sponsors, insurers and administrators of health plans or health insurance policies that intend to rely upon grandfathered health plan status to limit the mandates applicable to their programs under the Affordable Care Act need a clear understanding of what changes and events will disqualify their plan or program for grandfathered health plans status.

April 1 Guidance

The FAQIV guidance jointly published April 1 by the Agencies helps to clarify certain aspects of the workings of the grandfathered health plan rules as construed and implemented under these Regulations. FAQIV, among other things:

Clarifies the date that a loss of grandfathered status becomes effective as a result of a plan amendment or other change is the date that the plan amendment or other change that will result in the loss of grandfathered status takes effect under the terms of the plan;
Shares a non-exhaustive list of reasons for transferring employees from a grandfathered health plan to another health plan that the Agencies recognize as “bona fide employment-based reasons” that permit the transfer of employees from one grandfathered health plan to another plan without a loss of grandfathered health plan status;
States that forfeiture of grandfathered health plan status does not result solely as a result of an increase in the participant co-payment or other cost-sharing under a health plan that results because a drug originally classified as having no generic alternative changes because a generic alternative becomes available and is added to the formulary, with a resulting increase in the cost-sharing level for the brand-name drug;
States that for purposes of determining if a health plan has experienced a change in the employer contribution rate that would result in a loss of grandfathered health plan status in a health plan where the employer contribution is determined based on a formula, an increase in the amount of the required employee contribution resulting as plan costs increase will not trigger a loss of grandfathered status if the employer contribution formula (or its underlying elements used to calculate the contribution) does not change;
Provides added guidance about when a health plan can add or expand value based design features to a health plan without forfeiting its grandfathered health plan status; and
Invites public input about how the Agencies should treat value based plan design or wellness program related additions or changes to health plans for purposes of the grandfathered health plan rules.

FAQIV is only one of a continuous stream of new guidance about the Affordable Care Act and other federal and state health benefit program mandates which plan sponsors, insurers, administrators and fiduciaries need to understand and respond to effectively as they deal with their health benefit programs and arrangements. Ms. Stamer is scheduled to conduct training on these and other health benefit requirements for a number of organizations over the upcoming month. For information about these and other training opportunities or for other resources and information, see here or contact Ms. Stamer directly.

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Posted by Cynthia Marcotte Stamer

Health Plans & Sponsors Should Monitor, Begin Preparing To Meet New Health Care Reform Low-Income Member Voucher Requirements

April 14, 2011

The Affordable Care Act will require employer sponsored plans to honor vouchers to help pay the cost of coverage for certain lower income individuals and children.

Employers and their health plans will face new responsibilities to figure relevant family income, to provide information about their plans and costs of coverage, and to follow voucher handling requirements for employees and others whose coverage will be paid for in whole or in part with these low-income vouchers. While the rules are still evolving, employers and health plans nevertheless need to start preparing to meet these new responsibilities. Employers and heatlh plans need to keep an eye on the development of these rules at the Federal and state level and begin planning for how they will administer these responsibilities.

A Kaiser Family Foundation Issue Brief discusses some of the ways and implications of income determinations to be made for this purpose.

For Help With Investigations, Policy Updates Or Other Needs

If you have questions or need help responding to the RFI or have any questions or need help understanding or dealing with these or any other workforce management, employee benefits, compensation or other internal control concerns, please contact the author of this update, Board Certified Labor and Employment attorney and management consultant Cynthia Marcotte Stamer here or at (469)767-8872.

Ms. Stamer has advised, represented, trained, and defend a broad range of employer, employee benefit plan, insurance and other clients in relation to electronic and other communications and other employee benefit concerns and frequently publishes and is interviewed about electronic and other employee benefit plan communications and other employee benefit plan matters. Chair of the ABA RPTE Employee Benefit and Other Compensation Committee, a council member of the ABA Joint Committee on Employee Benefits, and the Legislative Chair of the Dallas Human Resources Management Association Government Affairs Committee, Ms. Stamer helps businesses, employee benefit plans and other organizations 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. Board certified in labor and employment law by the Texas Board of Legal Specialization, with more than 23 years management-focused human resource and employee benefits experience, Ms. Stamer helps businesses manage their people-related risks and the performance of their internal and external workforce though appropriate human resources, employee benefit, worker’s compensation, insurance, outsourcing and risk management strategies domestically and internationally. Throughout her career, Ms. Stamer has continuously has advised and represented a broad range of fiduciaries, plan sponsors, bankruptcy trustees, creditors, debtors, service providers and their officers and directors about the prevention, investigation, mitigation and resolutions of civil and criminal liability arising from suspected or know breaches of fiduciary duty, fraud or other misconduct involving health, pension or other employee benefit and insurance arrangements. As a continuing part of this representation, Ms. Stamer regularly represents and defends plan sponsors, fiduciaries, third party administrators and other service providers and management officials in dealings with the Department of Labor, Department of Justice, Department of Health & Human Services, Department of Defense, Securities and Exchange Commission, state insurance regulators, state attorneys general and other federal and state regulators and prosecutors and private plaintiffs in connection with investigations, prosecutions, audits and other actions arising from employee benefit, insurance and related arrangements and products.

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Posted by Cynthia Marcotte Stamer

IRS Guidance On Affordable Care Act Requirement That Employers Report Cost of Health Coverage On W-2 Released

April 9, 2011

The Internal Revenue Service has released an advance copy of interim guidance implementing requirements that employers report to employees of the cost of their employer-sponsored group health plan coverage required under Internal Revenue Code (Code) § 6051(a)(14) of the Code, as enacted as part of the Affordable Care Act.

The interim guidance contained in Notice 2011-28 generally applies beginning with 2012 Forms W-2 (that is, the forms required for the calendar year 2012 that employers generally are required to furnish to employees in January 2013 and then file with the Social Security Administration (SSA)).

The Affordable Care Act will require that employers report to employees information about the cost of employer provided health care coverage beginning in January 2013. According to Notice 2010-69, employers are permitted, but not required to report the cost of health coverage on any forms required to be furnished to employees prior to January 2013. However, any employers that choose to report earlier (on the 2011 Forms W-2 generally furnished to employees in January 2012) may look to this notice for guidance regarding that voluntary earlier reporting.

Reporting to employees pursuant to Code § 6051(a)(14) is for their information only. The report of the information is intended by Congress to inform employees of the cost of their health care coverage. It does not cause otherwise excludable employer-provided health care coverage to become taxable. This notice provides interim guidance that

Notice 2011-28 will be published in Internal Revenue Bulletin 2011-16 on April 18, 2011.

For Help With Affordable Care Act or Other Employee Benefits or HR Needs

The new W-2 reporting requirement is one of a multitude of changes impacting the responsibilities of employment based health care coverage enacted under the Affordable Care Act.

If you have any questions or need help responding to the Affordable Care Act or other any other health plan or insurance employee benefit, compensation, workforce or internal control concerns, please contact the author of this update, Cynthia Marcotte Stamer here or at (469)767-8872.

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Posted by Cynthia Marcotte Stamer

Plan Sponsors. Their Owners & Management & Others Risk Personal Liability If Others Defraud Plans or Mismanage Employee Benefit Plan Responsibilities

April 4, 2011

Mitigate Risk With Appropriate Prevention, Monitoring & Response

Executives, board members, and other business leaders of companies providing health, 401(k) or other employee benefits under plans regulated by the Employee Retirement Income Security Act of 1974, as amended (ERISA) should heed a series of recent fiduciary liability settlement orders and lawsuits of the U.S. Department of Labor (Labor Department) as important reminders of the potential personal liability exposures executives can may face if their company’s benefit programs are not appropriately maintained and administered.

Recent Enforcement Actions, Changing Regulations Highlight Fiduciary Risks

On March 29, 2011, the Labor Department sued the owner of Eyeglass Factory, Inc. (EGF), Stephen Schaffer, for breach of fiduciary duties under ERISA by failing to ensure that EGF timely forwarded health plan contributions collected from employees to pay health plan contributions to the plan and failing to ensure that he and other plan fiduciaries and service providers were bonded in accordance with ERISA’s fidelity bond requirements.[i] The Labor Department suit charges that from July 1, 2000 to October 1, 2000, Schaffer and EGF withheld and failed to forward to the health plan contributions deducted from employee pay for health insurance coverage and contributions made to the flexible benefit plan sponsored by EGF from January 1, 2000 to December 4, 2000. The employees’ paycheck withholdings were commingled with the company’s general assets and used for its general operating expenses. The Labor Department is asking the court to order that Schaffer and other defendants make restitution to the plan for the misapplied contributions, including lost opportunity costs, to correct prohibited transactions and to appoint an independent fiduciary to oversee the plans once Schaffer is removed as the plan fiduciary.

The Schaffer suit follows the Labor Department’s successful prosecution of a breach of fiduciary duty action against Larry Lauterback, the president and former owner of a Minnesota Cement Company, for his role in allowing his construction company to commingle with company assets and divert to company use employee health and 401(k) contributions withheld from employee’s pay. In Solis v. Larry Lauterback, [ii] the District Court ordered Lauterback to restore $17,273.18 in unremitted employee contributions and lost opportunity costs to the company’s health and dental plan, and $747.20 in unremitted employee contributions to the company’s 401(k) plan and enjoins Lauterback from serving or acting as a fiduciary or service provider to any employee benefit plan for three years.. The order followed the entry of a consent judgment against Lauterback and the plan sponsor, Slate Cement, Inc., for failure to remit employee contributions, failure to forward employee contributions to medical and dental providers, co-mingling employee contributions of the general assets and using those assets for company operations.

The Schaffer and Lauterback actions taken in March, 2011 are only the most recent in a series of enforcement actions taken against business executives, board members, plan vendors and others for their role in committing or failing to take prudent steps to prevent or redress alleged misconduct relating to the maintenance, administration and funding of various employee benefit programs regulated by ERISA. In recent months and years, the Labor Department has filed several lawsuits against business executives and businesses for alleged breaches of fiduciary duties. While misuse of employee contributions by plan sponsors is a common focus of many of these actions, plan sponsors, plan service providers and members of their management with discretionary authority or responsibility over plan assets or administration or the election of those appointed to administer those responsibilities often arise out of the failure or these individuals to take prudent steps to prevent, monitor or address misconduct by other plan fiduciaries or service providers.[iii]

Plan sponsors, fiduciaries, service providers and their management should anticipate these risks and their attendant responsibilities will continue to rise as the Labor Department moves forward to adopt and implement revisions and enhancements to its fiduciary regulations such as those provided for in the new “Interim Final Regulation Relating to Improved Fee Disclosure for Pension Plans” scheduled to take effect in July, 2011 and the Proposed Regulation on the “Definition of the Term Fiduciary” published by the Labor Department in July and October, 2010 respectively.

Meanwhile, the Labor Department enforcement activities highlight the longstanding and ongoing policy of aggressive investigation and enforcement of alleged misconduct by companies, company officials, and service providers in connection with the maintenance, administration and funding of ERISA-regulated employee benefit plans. In its Fiscal Year 2010, the Labor Department closed 3,112 civil investigations, of which 2,301 (73.94%) resulted in monetary recoveries or other corrective action. The Labor Department referred 264 cases for civil litigation and filed 128 civil lawsuits. Meanwhile on the criminal side, the Labor Department closed 281 criminal investigations and obtained indictments against 96 people.

In addition to prosecutions brought by the Labor Department, companies and individuals that exercise discretion and control of the administration or funding of employee benefit plans regulated by ERISA also may be sued personally by participants and beneficiaries for breach of fiduciary under ERISA. A review of the Labor Department’s enforcement record and existing precedent makes clear that where the Labor Department perceives that a plan sponsor or its management fails to take appropriate steps to protect plan participants, the Labor Department will aggressively pursue enforcement regardless of the size of the plan sponsor or its plan, or the business hardships that the plan sponsor may be facing.

Plan Sponsors, Fiduciaries, Service Providers & Their Management Should Act To Manage Exposures

Given these exposures, businesses providing employee benefits to employees or dependents, as well as members of management participating in, or having responsibility to oversee or influence decisions concerning the establishment, maintenance, funding, and administration of their organization’s employee benefit programs need a clear understanding of their responsibilities with respect to such programs, the steps that they should take to demonstrate their fulfillment of these responsibilities, and their other options for preventing or mitigating their otherwise applicable fiduciary risks.

To help guard and position themselves to defend against these and other exposures, plan sponsors, fiduciaries, service providers and others involved in the administration of health or other employee benefit plans should seek the advice of legal counsel with appropriate experience with employee benefit and other related matters to develop an understanding of ERISA and other laws and the duties and liabilities that these rules may create for their organizations and themselves personally. For additional tips and information about managing these risks, see here.

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[i] Chao v. Stephen Schaffer, the Eyeglass Factory, Inc., No O2-CV-60197, as announced in EBSA Release No. 11-341-CHI (March 29, 2011).

[ii] Solis v. Larry Lauterback, as announced in EBSA Release No 11-322-CHI (March 14, 2011).

[iii] See, e.g. Chao v. Associated Plan Administrators, as announced in EBSA Release No. 07-1265-BOS/BOS 2007-298 (October 16, 2007); Chao v. Starkey, as announced in EBSA Release No. 05-747-ATL (May 2, 2005); Chao v. Perry., as announced in EBSA Release BOS 2002-054 (March 21, 2002); Chao v. Mabry, as announced in EBSA Release No. 160 (March 20, 2002). See also, e.g., Baker v. Kingsley, 2006 WL 2027606 (N.D.Ill.2007); In Re Enron Corp Securities Derivative & “ERISA” Litigation, 284 F.Supp. 511 (S.D.Tex. 2003); Varity Corp. v. Howe, 516 U.S. 489 (1996); Brink v. DeLesio, 496 F. Supp. 1350 (D.Md. 1980).

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Posted by Cynthia Marcotte Stamer

Health Plans, Insurers Get Limited & Imperfect Relief From Grace Period Extension For Some New Affordable Care Act Health Claims & Appeals Rules

March 24, 2011

The Departments of Labor, Health & Human Services and Internal Revenue Service are extending a previously announced enforcement grace period under which the agencies will not take enforcement against health plans or health insurers that attempt to operate in good faith compliance with, but fail to meet certain new requirements for handing medical claims and appeals enacted as part of the Patient Protection and Affordable Care Act (Affordable Care Act). While health plans and insurers working in good faith to comply with the new requirements may find the enforcement relief helpful for dealing with some areas of uncertainty about the interpretation of certain requirements, it is important to keep in mind that the enforcement grace period provides only limited and somewhat imperfect relief. As a result, health plans, health insurers and those responsible for their design and administration are encouraged to continue to move forward on efforts to comply with the new requirement in thoughtful and well-documented manners despite the announced grace period extension.

New Claims & Appeals Requirements & Enforcement Grace Period

As signed into law on March 23, 2010, the Affordable Care Act generally requires that health plans and health insurance policies that are not “grandfathered” to begin complying with a series of new requirements by the first day of the first plan year that begins after September 22, 2010. These new requirements include a number of new requirements about the way that nongrandfathered health plans and health insurance policies handle medical claims and appeals. For instance, the Affordable Care Act as construed by the agencies in interim final regulations published by the agencies on July 23, 201 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 that among other things mandate independent external review of medical judgment based decisions in accordance with the regulations for reviews of appeals of medical judgment based denials;
Provide a broad range of new information in notices regarding claims and do so in a culturally and linguistically appropriate manner;
Provide continued coverage pending the outcome of an internal appeal; and
Comply with a laundry list of 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.

After the agencies jointly published interim final regulations defining and implementing these requirements on July 23, 2010, last September the agencies announced that they would not enforce certain elements (but not all) of the new requirements set forth in the interim final regulations against covered health plans or health insurers seeking to comply in good faith with the new requirements through July 1, 2011. In the March 18, 2011 announcement, the Department of Labor said that the agencies now have agreed to extend this reprieve from agency enforcement of the requirements listed in the guidance against plans seeking to comply in good faith with the new requirements until plan years beginning on or after January 1, 2012.

While offering welcome relief, covered health plans and insurers, their sponsors and issuers should not over-estimate the reach and protection provided by this new guidance. For instance:

First, in order to qualify for the enforcement grace period, efforts must be made to administer the health plan or health insurance policy in good faith compliance with the new requirements during the enforcement grace period.
Second, the enforcement grace period provides only limited relief. The extension to 2012 only four of a series of new requirements set forth in the interim final regulations. Nongrandfathered plans and their administrators and insurers remain accountable for prudently administering claims and appeals in accordance with all other requirements of the Affordable Care Act as well as pre-existing claims and appeals regulations set forth in 2000 claims regulations issued by the Department of Labor pursuant to the Employee Retirement Income Security Act.

Third, the enforcement grace period guidance only means that the agencies will not exercise their power to take action against a non-compliant plan. It does not prevent plan members, health care providers with benefit assignments or other plan beneficiaries from bringing lawsuits against health plans, health insurers or their administrators for failing to comply with the new requirements during post- September 22, 2010 plan years even if the enforcement grace period otherwise protects the plan or insurer from agency enforcement action. This means that health insurers and health plans may still run the risk that plan members or beneficiaries will ask courts to reverse claims or appeals denials or impose other penalties and sanctions against plans or their fiduciaries for failing to meet the new requirements for post-September 22, 2010 plan years.

Finally, and perhaps most significantly, the grace period guidance requires nongrandfathered plans and insurers to make “good faith” efforts to comply with the requirements covered by the relief during the grace period in order to be eligible to claim the relief offered by the enforcement grace period guidance.

Consequently, despite the relief announced March 18, nongrandfathered health plans still have significant work to do to comply with the new Affordable Care Act claims and appeals requirements even during the announced enforcement grace period.

For Help With Affordable Care Act or Other Employee Benefits or HR Needs

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Posted by Cynthia Marcotte Stamer

EEOC Finalizes Updates To Disability Regulations In Response to ADA Amendments Act

March 24, 2011

Employers Urged To Tighten Disability Related Discrimination Risk Management

Employers should review and update their existing employment and employee benefit practices in response to updated regulations (Final Regulations) governing the disability discrimination rules of the Americans With Disabilities Act as amended by the ADA Amendments Act (ADAAA) that the Equal Employment Opportunity Commission (EEOC) will publish in the Friday, March 25, 2011 Federal Register.

On Thursday, March 24, 2011, the EEOC released an advance copy of the Final Regulations along with two Question-and-Answer documents about the Final Regulations to aid the public and employers – including small business – in understanding the law and new regulations. The Final Regulations, accompanying Question and Answer documents and a fact sheet are available on the EEOC website here .

The changes contained in the updated Final Regulations update the EEOC’s disability regulations in response to amendments made to the ADA by Congress as part of the ADAAA. Like the ADAAA they implement, the Final regulations are designed to simplify the determination of who has a “disability” and make it easier for people to establish that they are protected by the Americans with Disabilities Act (ADA).

The Final Regulations and the ADAAA amendments they implement make it likely that businesses generally will face more disability claims from a broader range of employees and will possess fewer legal shields to defend themselves against these claims. Since these changes make it easier for certain employees to qualify as disabled under the ADA, businesses should act strategically to mitigate their ADA exposures in response to the Final Regulations. Learn more about the Final Regulations and get suggestions for risk management of expanding disabilities discrimination exposures here.

For Help With Disability Discrimination Risk Management or Other Needs

If you need assistance in auditing or assessing, updating or defending your disability management or with other labor and employment, employee benefit, compensation or internal controls practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

CMS Publishes Proposed Consumer Disclosure Notices Detailing Required Health Insurer Rate Increase Justification Disclosures

March 7, 2011

The Centers for Medicare & Medicaid Services (CMS) on March 7, 2011 published proposed consumer disclosure notices that it proposes to require insurers proposing rate increases over 10 percent to electronically file in furtherance of CMS’ implementation of the Affordable Care Act premium rate review regulation published by HHS in December of 2010. The proposed consumer disclosure notices can be found here listed under “CMS-10379.”

Like the premium rate review regulation, the proposed notification requirements would apply to non-grandfathered group or individual insurance plans in the individual and small group markets.

Under the premium rate review regulation, rate increases by insurers for non-grandfathered group or individual health insurance plans that exceed a specified threshold amount are subject to review by either State insurance officials or HHS if the State does not have an effective process for reviewing rates. The proposed threshold for the first year is 10%. After 2011, a state-specific threshold will be set for disclosure of rate increases, using data and trends that better reflect cost trends particular to that state. According to CMS’, the review of rates under the rate review regulation could begin as early as July 2011.

CMS contemplates that the proposed consumer disclosure notices published March 7, 2011 will ‘help consumers know what their insurance companies are proposing while the rate increase requests are being reviewed. The notices would provide some basic information about health insurance rate increases and their review, as well as detailed information about the specific increase that an insurer has proposed. Consumers would also be able to see what the insurance company believes is driving the increase in premiums and how much of the increase would go to profits and administrative expenses. CMS intends to make the information provided by insurers in the notices available to consumers on CMS’ website. According to CMS, once rates begin being reviewed, HHS will work to post information on proposed rates as quickly as possible.

For Help Responding To Affordable Care Act or Other Health Plan Rules

The proposed premium rate review and associated consumer disclosure notice requirements are part of the rapidly evolving federal and state rules, court decisions, enforcement actions and other developments that require quick action by health plans, health insurers and their sponsors and administrators. If you need assistance in auditing or assessing, updating or defending your health plan or policies, documents, practices or conduct, or other labor and employment, employee benefit, compensation, privacy and data security, or other related practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

Nationally and internationally known for her leading edge work on health benefit and insurance matters, Ms. Stamer has counseled, represented and trained employers and other employee benefit plan sponsors, plan administrators and fiduciaries, insurers and financial services providers, third party administrators, human resources and employee benefit information technology vendors and others privacy and data security, fiduciary responsibility, plan design and administration and other compliance, risk management and operations matters for more than 23 years. She also is recognized for her publications, industry leadership, workshops and presentations on health benefit reform and other related health and pension, human resources, insurance, privacy and health care concerns. She also regularly conducts training on these and other related matters for a broad range of organizations including the Association of State and Territorial Healthcare Organizations (ASTHO), the Los Angeles County Health Department, a multitude of health plans and their sponsors, health care providers, the American Bar Association, SHRM, the Society for Professional Benefits Administrators and many others 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

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Posted by Cynthia Marcotte Stamer

Avoiding Liability For Another’s Health Plan Fraud

February 25, 2011

TPA’s Embezzlement Guilty Plea Reminds Plan Sponsors, Fiduciaries & Service Providers To Ensure Fiduciaries, Administrators & Staff Prudently Selected, Monitored & Bonded

The guilty plea of an Ohio-based third-party administrator to embezzlement of $1 million in plan assets reminds employers and other employee benefit plan sponsors and members of their management participating in plan related activities, plan administrators and other plan fiduciaries and plan service providers (“plan decision-makers”) of the importance of ensuring appropriate, well-documented credentialing and selection, oversight, auditing and bonding the individuals and companies acting as fiduciaries and others participating in administration of plans or their assets (“plan workforce members”) to minimize their potential exposure to potential personal liability as a result of the fraud under the Employee Retirement Income Security Act (ERISA).

Cox Prosecution Reflective DOL Readiness To Prosecute Parties For Misuse of Plan Monies & Other Plan Fraud

According to a February 23, 2011 U.S. Department of Labor (DOL) announcement, Rhonda Sue Irvin Cox, owner of Irvin Administrative Solutions LLC (IAS), pleaded guilty to the embezzlement of $1 million of retirement plan assets from client plans administered by IAS. The DOL reports that between January 2003 and April 2007, Cox plead guilty to using used her position with ISC to embezzle the funds from 12 of 59 plans for which IAS served as a third party administrator. Cox also pleaded guilty to one count of making false statements in documents required under ERISA to be kept and certified by the plans’ administrator. Scheduled to be sentenced on June 1, 2011, Cox faces a maximum of five years in prison on each criminal count, a $250,000 fine and a special assessment. Cox is scheduled to be sentenced on June 1, 2011.

The DOL and Justice Department have a long-standing record of aggressive investigation and prosecution of embezzlement or other fraud impacting health and other employee benefit plans. Their criminal and civil enforcement and prosecution record makes clear this commitment remains strong.

Plan Sponsors, Fiduciaries & Service Providers May Face Civil Liability From When Others Defraud Their Plans

While plan decision-makers generally are aware that individuals defrauding health or other employee benefit plans risk criminal and civil prosecution, many fail to recognize their own potential civil liability exposures that may arise out of the fraudulent acts or other misconduct of another plan workforce member.

Embezzlement of plan assets is one of many acts of misconduct that can create potential fiduciary liability exposure for plan decision-makers under ERISA. Until confronted with potential fraud, misconduct or other misfeasance by a plan fiduciary, service provider or other plan workforce member, many plan decision-makers lack an adequate appreciation of the personal liability they may incur if they cannot demonstrate appropriate steps were taken to protect their health plan from this misconduct.

Under ERISA’s fiduciary responsibility rules, embezzlement or other misuse of employee contributions or other plan assets as well as certain other misconduct or misfeasance by a plan fiduciary, service provider or other plan workforce member can create personal liability exposures for plan decision-makers with responsibility or discretionary authority over the selection, retention, or management of plan workforce members if the plan decision-maker cannot demonstrate appropriate steps were taken to select, monitor and bond the plan workforce and other prudent action was taken to prevent and redress the fraud. Accordingly, health plans, their sponsors, fiduciaries, service providers, their management, and others serving as, or selecting, managing or retaining companies or individuals that participate in the handling of health plan assets or administration should act to strengthen their health plans and themselves against these exposures.

Risk Management Strategies & Tips

When embezzlement or other concern affecting their health plan arises, plan decision-makers concerned about protecting their health plans and themselves must act promptly in a carefully documented, prudent manner to investigate and respond to the concern. They should be prepared to present well-documented evidence of the scope and limits of their responsibility, authority, awareness, and potential for the selection, monitoring and oversight of the plan workforce member or others responsible for the performance of those actions, the adequacy of the bonding arrangements for the plan, and other efforts to prudently protect the plan before, during and after the discovery of the concern. While these and other steps can help strengthen the ability of a plan decision-maker to liability exposures that can result from the other plan workforce member’s embezzlement of plan assets or other misconduct, plan sponsors and plan decision-makers also should acquire suitable fiduciary and other liability insurance coverage and make other arrangements to help provide for the potential financial costs and other demands that are likely to arise in the event that it becomes necessary to investigate or redress fraud or other misconduct. Learn more here.

For Help With Investigations, Policy Review & Updates Or Other Needs

If you need help investigating or responding to fraud or other misconduct affection a health or other employee benefit plan, dealing with an employee benefit plan investigation or enforcement action by the Labor Department, private plaintiffs or another public or private party, reviewing current or proposed health plan processes or procedures, or responding to other employee benefit, labor and employment or other related controls and practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

For more than 23 years, Ms. Stamer has counseled, represented and trained employers and other employee benefit plan sponsors, plan administrators and fiduciaries, insurers and financial services providers, third party administrators, human resources and employee benefit information technology vendors and others privacy and data security, fiduciary responsibility, plan design and administration and other compliance, risk management and operations matters. In connection with this work, Ms. Stamer regularly counsels and helps clients to defend a broad range of clients about employee benefit plan fraud and other fiduciary responsibility concerns. Throughout her career, she has represented and served as special counsel to health and other employee benefit plans, plan sponsors, plan service providers, officers, directors and other management officials, bankruptcy trustees, debtors and creditors, and others in connection with health and other employee benefit plan fraud and other fiduciary responsibility and related investigations, prosecutions and other actions involving the Labor Department, IRS, HHS, Justice Department, state insurance and attorneys general, bankruptcy actions, and participant, beneficiary and vendor disputes. She also is recognized for her publications, industry leadership, workshops and presentations on these and other employee benefits, insurance and 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

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on health care, human resources, employee benefits, data security and privacy, 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 including:

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Posted by Cynthia Marcotte Stamer

Health Plans & Employers Beware! $4.3 Million Civil Penalty Shows OCR Serious About HIPAA Enforcement

February 23, 2011

A $4.3 million civil monetary penalty (CMP) imposed by the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) against Cignet Health of Prince George’s County, Md., (Cignet) signals the growing need for health plans and their sponsors, health care providers, health care clearinghouses and their business associates covered by the Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule to get serious about HIPAA compliance.

The first CMP ever assessed by OCR under the HIPAA Privacy Rule, the Cignet CMP assessment announced February 22, 2011, the $4.3 million CMP against Cignet announced February 22, 2011 applies the expanded HIPAA violation categories and increased HIPAA civil monetary penalty amounts authorized as part of the expansion of HIPAA obligations and penalties enacted as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009.

The Cignet penalty announcement is the latest in a series of developments documenting the rising risks that health care providers, health plans, health care clearinghouses and their business associates (“covered entities”) face for violations of HIPAA.

Even before the announcement of the Cignet CMP, the HIPAA Privacy exposures of covered entities for failing to comply with HIPAA already had risen significantly. While OCR had not assessed any civil monetary penalties against any covered entity for violation of HIPAA before Cignet, OCR’s collection of $1 Million from Rite Aid in a 2010 Resolution Agreement, $2.25 million from CVS Pharmacy, Inc. under a 2009 Resolution Agreement and $100,000 from Providence Health & Services under a 2008 Resolution Agreement demonstrated that covered entities could face significant civil liability for willful violations of the Privacy Rules. In addition, the Department of Justice has secured several criminal convictions or pleas under HIPAA’s criminal provisions. OCR data confirms that the covered entities involved in these actions included health care providers, health plans, and others.

Health plans and other covered entities as well as their business associates should tighten privacy policies, breach and other monitoring, training and other practices to mitigate against exposures in light of recently tightened requirements and new enforcement risks. To minimize the potential that the health plan’s sharing of information with the employer will create or spread HIPAA or other privacy risks to the employer or members of its workforce, employers and other plan sponsors and members of their workforce also should take steps to ensure not only that their health plan documents, policies and procedures, as well as those policies and practices applicable to employer, its human resources, and benefits advisors when accessing or handling health plan or other medical information on behalf of the employer, rather than the plan, are appropriately designed and administered.

Read more details and get tips here.

For Help With Investigations, Policy Review & Updates Or Other Needs

If you need assistance in auditing or assessing, updating or defending your HIPAA or other health plan, or other labor and employment, employee benefit, compensation, privacy and data security, or other internal controls and practices, please contact the author of this update, attorney Cynthia Marcotte Stamer here or at (469)767-8872.

Ms. Stamer, a noted Texas-based employee benefits and employment lawyer Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, will discuss HIPAA and other privacy risks and risk management strategies for employers, health and employee benefit plan sponsors and their administrators at the Southwest Benefits Association/IRS Plan Administrator Skills Workshops to be held February 25 in Dallas and March 4 in Houston.

For more than 23 years, Ms. Stamer has counseled, represented and trained employers and other employee benefit plan sponsors, plan administrators and fiduciaries, insurers and financial services providers, third party administrators, human resources and employee benefit information technology vendors and others privacy and data security, fiduciary responsibility, plan design and administration and other compliance, risk management and operations matters. She also is recognized for her publications, industry leadership, workshops and presentations on privacy and data security and other human resources, employee benefits and health care concerns. Her many highly regarded publications on privacy and data security concerns include “Privacy Invasions of Medical Care-An Emerging Perspective.” ERISA Litigation Manual. BNA, 2003-2009; “Privacy & Securities Standards-A Brief Nutshell.” BNA Tax Management and Compliance Journal. February 4, 2005; “Cybercrime and Identity Theft: Health Information Security beyond HIPAA.” ABA Health eSource. May, 2005 and many others. She also regularly conducts training on HIPAA and other privacy and data security compliance and other risk management matters for a broad range of organizations including the Association of State and Territorial Healthcare Organizations (ASTHO), the Los Angeles County Health Department, a multitude of health plans and their sponsors, health care providers, the American Bar Association, SHRM, the Society for Professional Benefits Administrators and many others.t 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.

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Posted by Cynthia Marcotte Stamer

IRS Expands When HFSAs & HRAS May Allow Over-The-Counter Drug Purchases With Drug Cards

January 24, 2011

Recent Internal Revenue Service (IRS) guidance loosens the conditions under which health flexible spending account (HFSA) and health reimbursement accounts may permit participants to use debit cards to purchase over-the-counter medicines or drugs after January 15, 2011. Under Internal Revenue Code rules amended by the Affordable Care Act, drug card and other over-the-counter prescription drug purchases must meet new requirements to qualify for reimbursement by a HFSA or HRA. HFSA and HRA sponsors and administrators wishing to allow participants to use debt cards to purchase over-the-counter drugs must ensure that their arrangements comply with this updated guidance. Sponsors and administrators that are unable or unwilling to meet the conditions established under the updated rules for allowing debt card reimbursement of over-the-counter drugs should act quickly to confirm that all relevant plan documents, procedures and communications clearly forbid reimbursement of over-the-counter medicines and drugs to the extent required by the updated rules.

IRS Notice 2011-5 modifies IRS guidance providing that HFSA and HRA debit cards generally could not be used after January 15, 2011 to purchase over-the-counter medicines or drugs after January 15, 2011, except with respect to “90 percent pharmacies.” previously announced in Notice 2010-59

Under the new rules announced in Notice 2011-5, after January 15, 2011, the IRS has expanded the circumstances under which HFSA and HRA debit cards may continue to be used to purchase over-the-counter medicines or drugs depends on where and how they are purchased. Different conditions must be met if the over-the-counter drug is purchased with a drug card from a vendor that under IRS rules:

Is a “90-percent pharmacy;”
Has a “health care related Merchant Code;
Is a non-health care merchant that has a pharmacy, or that sells prescription drugs via mail order or the web.

Where the applicable requirements established for each of these types of vendors is met, Notice 2011-5 permits HFSAs and HRAs to continue to allow participants to purchase over-the-counter drugs using debit cards after January 15, 2011. In contrast, if the vendor is not one of these types of vendors or is a listed vendor but the applicable requirements for allowing a debit card purchase of an over-the-counter medicine for that type of vendor are not met, HFSA and HRA debit cards may not be used to purchase over-the-counter medicines or drugs after January 15, 2011.

For More Information Or Assistance

If you need assistance evaluating or updating your HSFA, HRA or other health and cafeteria plans in response to these new rules or auditing or assessing, updating or defending 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, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works, publishes and speaks extensively on wage and hour, worker classification and other human resources and workforce, employee benefits, compensation, internal controls and 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, Inc.™

Solutions Law Press, Inc.™ 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 in exploring other Solutions Law Press, Inc. ™ tools, products, training and other resources here and reading some of our other Solutions Law Press, Inc.™ human resources or other updates here.

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Posted by Cynthia Marcotte Stamer

IRS, HHS & DOL To Delay Enforcement of New Insured Group Health Plan Non-Discrimination Rules Pending Guidance; Seek Public Input on Rules

January 24, 2011

Implications of Announced Reprieve on Possible Participant Suits Unclear

The Internal Revenue Service (IRS), Department of Labor (DOL) and Department of Health & Human Services (HHS) recently announced that the agencies do not plan to enforce new rules that prohibit non-grandfathered insured group health plans from discriminating in favor of highly compensated employees until guidance is published on the workings of certain key elements of these requirements. The IRS announced the relief from enforcement of the new insured group health plan nondiscrimination requirements enacted as part of the Patient Protection and Affordable Care Act (Affordable Care Act) in Notice 2011-1, which was published in the Internal Revenue Bulletin on January 7, 2011. According to Notice 2011-1, the Agencies determined that questions about the construction of certain aspects of the non-discrimination rules made it inappropriate to require insured group health plans to comply or to impose sanctions for their failure to comply with the new non-discrimination rules until the agencies publish certain regulations or other administrative guidance. According to Notice 2011-1, pending the publication of further guidance, the agencies do not intend to enforce sanctions for non-compliance with the new non-discrimination rules and will not require insured group health plan sponsors to file IRS Form 8928 with respect to excise taxes resulting from the incorporation of Public Health Services Act (PHS Act) § 2716 into Internal Revenue Code (Code) § 9815. Its unclear how this guidance will impact possible participant or beneficiary suits to enforce the new rules under Section 512 of the Employee Retirement Income Security Act (ERISA).

New Insured Plan Non-Discrimination Rules

As part of the Affordable Care Act health care reforms, Congress amended the PHS, Code and ERISA to require insured non-grandfathered group health plans to satisfy non-discrimination rules like those applicable to self-insured group health plans under Code § 105(h). Unlike the taxation of highly compensated participants that generally results from a discriminatory self-insured group health plan, however, the Affordable Care Act provides for potentially draconian sanctions against an insured group health plan or its sponsor when an insured group health plan violates these non-discrimination requirements.

The Affordable Care Act generally provides that if a non-grandfathered insured employer-sponsored group health plan that discriminates in favor of highly compensated employees in a manner that would violate the non-discrimination requirements of Code § 105(h)(2) in any post-September 22, 2010 plan year, the plan or plan sponsor may face significant excise taxes, civil money penalties, and lawsuits to compel it to provide nondiscriminatory benefits to non-highly compensated participants equivalent to the discriminatory benefits provided to highly compensated participants.

According to Notice 2011-1, the agencies determined from initial public comments that without regulations or other administrative guidance under PSA § 2716, plan sponsors are uncertain how to apply the nondiscrimination provisions. Accordingly, Notice 2011-1 indicates that the agencies decided that their enforcement of the new insured group health plan nondiscrimination rules should be delayed until the publication of that guidance. Notice 2011-1 invites concerned plan sponsors and others to submit comments on a broad range of concerns relating to this guidance. According to Notice 2011-1, the deadline for submission of this input is March 11, 2011.

Implications of Relief For Insured Group Health Plans

While Notice 2011-1 indicates that HHS and DOL also plan to hold off enforcement of the new non-discrimination rules, it is unclear what effect, if any, the relief announced in the Notice will have on the ability of participants and beneficiaries to enforce the requirements by filing civil lawsuits under ERISA. Under ERISA § 512, participants and beneficiaries generally have the ability to sue plans and their fiduciaries for equitable relief to enforce violations of ERISA. As amended by the Affordable Care Act, the new non-discrimination requirements for insured group health plans of ERISA § 715(a)(1) are effective for all post-September 22, 2010 plan years. Accordingly, while insured group health plans and their sponsors still potentially risk participant or beneficiary law suits if their program is discriminatory.

While awaiting further guidance from the agencies, insured and self-insured group health plans, their sponsors and fiduciaries should document their attempt to prudently evaluate and determine their responsibilities under the non-discrimination rules, and other federal laws. In addition, plans, their fiduciaries, sponsors and service providers should begin implementing and administering the data collection and other processes that they are likely to need to test their programs for discrimination and perform other requirements. To encourage the agencies to adopt regulations that are sensitive to the challenges of plan sponsors and plans in meeting these requirements, plan sponsors, fiduciaries, insurers and service providers also should provide input to the agencies and Congressional health care policy leaders about these concerns.

For More Information Or Assistance

If you need assistance submitting comments to the agencies, evaluating or updating your plans in response to these new rules or auditing or assessing, updating or defending 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, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works, publishes and speaks extensively on wage and hour, worker classification and other human resources and workforce, employee benefits, compensation, internal controls and 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, Inc.™

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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 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. To unsubscribe, send an e-mail with “Unsubscribe” in the subject here. For important information concerning this communication click here.

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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

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.

About Solutions Law Press

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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.

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 Affordable Care Act’s Health Plan External & Internal Review Safe Harbor & Other Regulations Require Health Plan Updates | Affordable Care Act, Claims Administration, Employee Benefits, Employers, Employment Tax, ERISA, Fiduciary Responsibility, Health Plans, Human Resources, Insurance, Internal Controls, Internal Investigations, Patient Empowerment, Patient Protection and Affordable Care Act, Preemption, Public Policy, Risk Management | Tagged: Affordable Care Act, Appeals, appeals procedures, Claims, Claims Procedures, ERISA, external review, Health Insurance, Health Plans, Insurance, internal review, self-insured | Permalink
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.

Comments Off on Health Care Reform: What You Need To Know To Build Your Family’s Healthcare Survival Plan | Disability Plans, Employers, ERISA, family leave, Health Plans, Human Resources, Insurance, Leave, medical leave, Patient Empowerment, Patient Protection and Affordable Care Act | Tagged: Disability Planning, Employers, Estate Planning, Health Care, Health Care Reform, Health Plans, Patient Centric, Patient Empowerment, Patients | Permalink
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.

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

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

To register or get additional information, see here.

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

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

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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

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

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

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.

Comments Off on New Affordable Care Act Health Plan Appeals Regulations Require Health Plan Updates | Affordable Care Act, COBRA, COBRA Subsidy, Employee Benefits, Employers, ERISA, family leave, Fiduciary Responsibility, FMLA, H.R. 4872, Health Care Reform, Health Plans, Human Resources, Insurance, Leave, medical leave, Mental Health, Mental Health Parity, Patient Protection and Affordable Care Act, Protected Health Information, Tax, Wellness, Wellness Programs | Tagged: Affordable Care Act, Appeals, Claims, Claims Procedures, ERISA, Health Care Reform. Health Plans, Health Insurance, Health Plans | Permalink
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.

Comments Off on CMS & ONC To Co-Host 7/22 ONC Certification & Medicare/Medicaid EHR Incentive Program Audio Training | Affordable Care Act, Data Security, Employee Benefits, Employers, ERISA, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Medicare Part D, Patient Protection and Affordable Care Act, Protected Health Information, Public Policy | Tagged: ARRA, EHR, electronic health records, Electronic Medical Records, EMR, Health IT, Health Plans, HIPAA, HITECH Act | Permalink
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

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 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.

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

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.

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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.

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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.

Comments Off on Stamer Speaks On “Designing Legally Defensible Wellness Programs That Work Amid Changing Federal Regulations” On June 10 in Dallas | Employee Benefits, Employers, Employment Tax, ERISA, Health Plans, Human Resources, Insurance, Tax, Uncategorized, Wellness | Permalink
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

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

Agencies Invite Public To Share Input About Insurer Obligation To Report About Health Premium Use Under Health Care Reform Law

April 14, 2010

April 15, 2010

By Cynthia Marcotte Stamer

The Departments of Treasury (IRS), Labor (DOL) and Health & Human Services (HHS) are inviting public comments in advance of future rulemaking on impending new federal requirements that will obligate health insurance issuers offering individual or group medical coverage to send annual reports to HHS on the percentages of premiums that the coverage spends on reimbursement for clinical services and activities that improve health care quality, and to provide rebates to enrollees if this spending does not meet minimum standards for a given plan year added as Section 2718 of the Public Health Service Act (PHS Act) by the Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, enacted on March 23, 2010.

Among other things, the new requirements in Section 2718 of the PHS Act, Section 715 of the Employee Retirement Income Security Act of 1974 (ERISA) and Section 9815 of the Internal Revenue Code of 1986 (the Code) will require health insurance issuers offering group or individual coverage to report to HHS annually:

The ratio of the incurred loss (or incurred claims) plus the loss adjustment expense (or change in contract reserves) to earned premiums (also known as the medical loss ratio (MLR)); and
The percentage of total premium revenue–after accounting for collections or receipts for risk adjustment and risk corridors and payments of reinsurance–that the coverage spends: (1) on reimbursement for clinical services provided to enrollees; (2) for activities that improve health care quality; and (3) on all other non-claims costs, including an explanation of the nature of these costs, and excluding Federal and State taxes and licensing or regulatory fees.

PPACA also requires that HHS make these reports available to the public on the Internet Web site of HHS. To review the request for comments and its instructions for commenting on the new requirements, see here.

For Added Information or Assistance

If your organization need advice or help with these or other health benefit, labor and employment, employee benefits, compensation or related matters, consider contacting 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, Chair of the American Bar Association (ABA) Real Property, Probate & Trust Section Employee Benefits & Other Compensation Arrangements Group, a Council Member of the ABA Joint Committee On Employee Benefits Council, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, Vice President of the North Texas Health Care Compliance Professionals Association, and Exempt Organization Vice-Coordinator of the Southern States IRS TEGE Council, , Ms. Stamer has extensive experience advising and representing management about labor and employment, employee benefits, compensation and other related management matters. A nationally recognized author and lecturer, Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

Other Information & Resources

We hope that this information is useful to you. 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 future editions of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates that may be of interest include:

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 here.

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Posted by Cynthia Marcotte Stamer

Stamer To Discuss “Health Care Reform’s Implications For Employers, Health Plans & Employee Benefits Practitioners” At May 5 Dallas Bar Association Meeting

March 22, 2010

Cynthia Marcotte Stamer will discuss “Health Care Reform: Implications for Employers, Health Plans and Employee Benefits Practitioners” at the May 5, 2010 meeting of Dallas Bar Association Employee Benefits/Executive Compensation Section to be held from 12:00 noon – 1:00 p.m. in the Haynes & Boone Ballroom of Dallas Bar Association Belo Mansion located at 2101 Ross Avenue in Dallas, Texas.

Chair of the American Bar Association RPTE Employee Benefits & Compensation Committee, an ABA Joint Committee on Employee Benefits Council member, Chair of the Curran Tomko Tarski Labor, Employment & Employee Benefits Practice and former Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and the Dallas Bar Association Employee Benefits & Executive Compensation Section, Ms. Stamer is nationally recognized for more than 22 years of work 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. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

If you need assistance with evaluating or responding to this new legislation or other employee benefits, employment, compensation 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 cstamer@cttlegal.com, 214.270.2402; or your other preferred Curran Tomko Tarski LLP attorney.

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

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of Ms. Stamer here and learn more about other Curran Tomko Tarski LLP attorneys 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 or e-mailing this information to Cstamer@CTTLegal.com or registering to participate in the distribution of these and other updates on our Solutions Law Press distributions here. For important information concerning this communication click here.

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Posted by Cynthia Marcotte Stamer

House Could Vote On Obama Health Care Reform Sunday

March 18, 2010

By Cynthia Marcotte Stamer

Time is running out for Americans to make their health care reform views known to key Congressional decision-makers. The stage now appears to be set for the House of Representatives to vote as early as Sunday on the Reconciliation Act of 2010 (H.R. 4872), the latest version of health care reform backed by President Obama, Speaker Nancy Pelosi and other key Congressional Democrats. The impending deadline means that Americans concerned about the potential outcome of the impending vote need to act quickly if they wish to attempt to influence the decision. For tips about sharing your input with Congress effectively, see Getting Your Health Care Reform Message Heard By Key Congressional Leaders.

Developments Today Start Clock Running For Vote

On Thursday, March 18, 2010, two key developments set the stage for a vote on H.R. 4871 as early as Sunday:

The House Rules Committee posted the text of H.R. 4872 on its website; and
The Congressional Budget Office (CBO) delivered its scoring of H.R 4872 to House Speaker Nancy Pelosi.

The delivery of CBO scoring started the clock running on the 72 hour mandatory period between the release of the CBO scoring and any final vote on the bill. This means the House could vote on H.R. 4872 as early as Sunday, March 21.

If passed by the House, H.R. 4872 would make sweeping changes to the U.S. health care system impacting virtually every American patient, health care provider, employer and taxpayer. To learn the facts about these proposed changes, read the full text of H.R. 4872 here.

According to the CBO, H.R. 4872 will cost $940 billion over 10 years to extend coverage to 32 million uninsured people. To learn more specifics about these CBO cost and other determinations, review the CBO scoring here.

This Is Only The Beginning: Stay Involved

The outcome of this latest health care reform push is only a small part of a continuing process. Whether or not the President’s proposal or some other version of health care reform passes this week, Congress already has and will continue to consider other legislation impacting health care reform. This reality is demonstrated by Congressional actions recently taken on the COBRA premium subsidy extension, Medical reimbursement for physicians, continuing federal efforts to develop and implement federal health care quality and technology standards, and other legislative, regulatory and enforcement actions taken while public attention has been focused largely only on the broader health care reform debate.

Upcoming mid-term elections will significantly impact the nature and scope of these upcoming efforts. Perhaps even more significantly, the enactment of legislation is only a beginning point. The real meaning of these or other health care reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye. Monitoring and staying active in these ongoing processes provides a critical opportunity to continue to monitor your issues and provide input to shape how they are addressed.

To help stay informed about health industry and other developments and join the discussion about these and other health care reform proposals, concerned Americans are invited to join the Coalition for Responsible Health Care Reform Group on Linkedin and registering to receive these updates here.

If you need assistance evaluating or formulating comments on the proposed reforms contained in the House Bill or on other health industry matters please contact Cynthia Marcotte Stamer at cstamer@cttlegal.com or 214.270.2402.

Ms. Stamer has extensive experience advising and assisting employers, health industry, and health insurance clients and others about a diverse range of health care, employee benefit, and employment policy, regulatory, compliance, risk management and operational concerns. You can get more information about her health industry experience here.

Former Chair of the American Bar Association Health Law Section Managed Care & Insurance Interest Group and currently Chair of the American Bar Association RPTE Employee Benefits & Compensation Committee, a Council Representative to the ABA Joint Committee on Employee Benefits and Vice President of the North Texas Health Care Compliance Association, Ms. Stamer is nationally recognized for more than 22 years work with health care providers, managed care and other payers, employers, governments and other clients on health care, employee benefit, and other concerns. From her extensive involvement with federal and state legislative and regulatory health, pension and other reforms in the U.S. to her involvement as a lead advisor to the Government of Bolivia on its pension privatization legislation, Ms. Stamer’s experience includes significant experience working with clients domestically on key health care and other public policy matters. The publisher of Solutions Law Press, Ms. Stamer also publishes, conducts training and speaks extensively on these and related concerns. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

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

You can review other publications and resources and additional information about the experience of Ms. Stamer here and learn more about other Curran Tomko Tarski LLP attorneys 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 or e-mailing this information to Cstamer@CTTLegal.com or registering to participate in the distribution of these and other updates on our Solutions Law Press distributions 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.

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Posted by Cynthia Marcotte Stamer

Stamer To Speak About TPA & Other Plan Services Agreement Contracting Strategies For Managing Risks & Improving Effectiveness At 2010 Great Lakes Benefits Conference

March 13, 2010

Curran Tomko Tarski LLP Labor & Employment Practice Chair and Solutions Law Press Publisher Cynthia Marcotte Stamer will discuss “TPA & Other Plan Services Agreements- Managing Risks & Improving Effectiveness” At 2010 Great Lakes Benefits Conference to be held at the Wyndham Chicago Hotel on June 16-17, 2010.

Growing regulatory, fiduciary and other compliance risks magnify the importance of the careful negotiation and documentation of third party administration and other plan-related service agreements for plans, plan sponsors, plan fiduciaries and service providers. Careful credentialing, negotiation and documentation of administrative and other services relationships plays an increasingly key role in the ability of plan sponsors, plans, fiduciaries and service providers to allocate and efficiently manage plan operations, meet compliance obligations, and allocate and manage fiduciary and other legal risks.

Ms. Stamer’s workshop will examine key concerns like how administrative services contract terms, plan terms, the parties of actions and other factors help determine which parties are exposed to fiduciary and other liabilities; who is responsible for fiduciary, administrative, reporting and disclosure, bonding, indemnification and other responsibilities; and terms and processes that may help parties manage their relationships and legal risks by exploring some of the common issues and concerns that need to be considered when entering into these contractual arrangements.

Co-hosted by the Internal Revenue Service and ASPPA, this two day Conference features presentations on regulatory, legislative, administrative and actuarial and other employee benefit issues lead by local, regional and national government representatives from the Internal Revenue Service and the Department of Labor and nationally recognized employee benefit leaders from private industry. To register for the Conference or for additional information, see here.

Chair of the American Bar Association RPTE Employee Benefits & Compensation Committee, an ABA Joint Committee on Employee Benefits Council member, Chair of the Curran Tomko Tarski Labor, Employment & Employee Benefits Practice and former Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer is nationally recognized for more than 22 years domestic work with employer and other plan sponsors, fiduciaries, administrative and other service providers, insurers, and other clients on employee 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 additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

If you need assistance with vendor or other outsourcing contracts, or other employee benefits, employment, compensation 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, CTT Labor & Employment Practice Chair at cstamer@cttlegal.com, 214.270.2402; or your other preferred Curran Tomko Tarski LLP attorney.

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

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Posted by Cynthia Marcotte Stamer

Extension of Unemployment Benefits Signed Into Law & Immediately Effective As Filibuster Ends

March 3, 2010

By Cynthia Marcotte Stamer

Effective yesterday, the Temporary Extension Act of 2010, H.R. 4691,extended unemployment benefits to April 5, 2010. It also extended and expanded the COBRA premium subsidy requirements originally established under the American Recovery and Reinvestment Act (ARRA) and plan sponsor penalties for noncompliance.

In recent days, H.R. 4691 drew great media attention when its enactment was delayed by a filibuster by Kentucky Senator Jim Bunning. As media coverage of the Bunning filibuster focused almost exclusively on its unemployment benefit extension provisions, many U.S. employers and others are unaware of its provisions extending and expanding the COBRA premium subsidy mandates and authorizing higher pay for Medicare doctors and funding for federal highway programs. President Obama signed H.R. 4691 into law on March 2, 2010 just hours after Senator Bunning ended his highly publicized filibuster.

Unemployment Benefit Extensions

H.R. 4691’s unemployment insurance benefit provisions became immediately effective when signed by the President. These provisions:

Extend the period during which individuals may file applications for Federal Emergency Unemployment Compensation (EUC) from the current end date of February 28, 2010 to April 5, 2010 and extend the period during which individuals may claim and be paid EUC from July 31, 2010 to September 4, 2010.
Extend from the current end date of February 28, 2010 to April 5, 2010 the period during which individuals may qualify for the Federal Additional Compensation (FAC), the extra $25 weekly benefit amount on state and federal unemployment compensation, while also providing for weekly payment during the phase out period for weeks ending October 5, 2010 instead of August 31, 2010.
Extend the period during which 100% federal reimbursement for weeks of regular federal extended benefit payments to April 5, 2010, with the state option to continue the extended period from July 31, 2010 to September 4, 2010.

COBRA Premium Subsidy Extended & New Penalties Added

In addition to extending unemployment benefits, H.R. 4691 also extends and expands the availability of the temporary COBRA subsidy rules originally added to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) medical coverage continuation requirements by the American Recovery and Reinvestment Act of 2009 (“AARA”) last February. For details about these COBRA premium subsidy amendments, see here. To minimize their COBRA rights under the amended COBRA premium subsidy rules, group health plans, their employer or union sponsors, administrators, insurers and service providers will need to act quickly to prepare and provider required updated notifications to assistance eligible individuals of these extended eligibility periods and their resulting rights, and otherwise update their plan documents, procedures, and COBRA notifications in light of these new rules.

For Added Information or Assistance

If your organization need advice or assistance with these or other labor and employment, employee benefits, compensation or related matters, consider contacting Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer.

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Ms. Stamer has extensive experience advising and representing management about labor and employment, employee benefits, compensation and other related management matters. A nationally recognized author and lecturer, Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates that may be of interest include:

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.

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Posted by Cynthia Marcotte Stamer

COBRA Premium Subsidy Requirements Expanded & Extended Under Newly Signed Unemployment Extension Legislation

March 3, 2010

By Cynthia Marcotte Stamer

Employers, insurers and administrators again must move quickly to deal with newly enacted changes to the premium subsidy requirements temporarily applicable to the medical coverage continuation requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”).

The extension and other changes to the COBRA premium subsidy requirements became immediately effective yesterday (March 2, 2010) when President Obama signed the Temporary Extension Act of 2010 (H.R. 4691). H.R. 4691 both extends unemployment benefits through April 5, 2010 and extends and expands the availability of the COBRA subsidy program originally established under the American Recovery and Reinvestment Act (ARRA).

Over the past several days, H.R. 4691 has drawn great media attention when its enactment was delayed by a filibuster by Kentucky Senator Jim Bunning. As media coverage of the Bunning filibuster focused almost exclusively on its unemployment benefit extension provisions, many U.S. employers and others are unaware of its provisions extending and expanding the COBRA premium subsidy mandates and authorizing higher pay for Medicare doctors and funding for federal highway programs. President Obama signed H.R. 4691 into law just hours after Senator Bunning ended his filibuster.

COBRA Premium Subsidy Extended & New Penalties Added

Group health plans and their sponsoring employers face added responsibilities under the COBRA subsidy amendments adopted under H.R. 4691.

The COBRA subsidy rules originally were added to COBRA’s medical coverage continuation requirements by the American Recovery and Reinvestment Act of 2009 (“AARA”) last February. Originally, an employee or dependent was required, among other things, to have experienced a loss of coverage as a result of an involuntary termination occurring between September 1, 2008 and December 31, 2009 to qualify for coverage under the COBRA premium subsidy rules as “assistance eligible individual for up to 9 months. In subsequently enacted legislation, however, Congress extended the involuntary termination period through February 28, 2010 and lengthened the maximum premium COBRA subsidy period to 15 months. For more details, see here. H.R. 4691 now further extends and expands these COBRA premium subsidy rules.

H.R. 4691’s COBRA provisions both extend the period that an involuntary termination can qualify an employee or dependent for the COBRA premium subsidy, the employment losses that can qualify as an eligible involuntary termination, and the potential liability that can result from noncompliance. Specifically, H.R. 4691 among other things:

Extends through March 31, 2010 the period within which an involuntary employment loss resulting in a loss of health coverage can qualify an employee or his dependent for the 15-month 65 percent COBRA premium subsidy. Before H.R. 4691, the involuntary termination period was scheduled to end February 28, 2010. Now, the involuntary termination period runs from September 1, 2009 through March 31, 2010;
Amends the COBRA subsidy program to clarify that an employee that first experiences a loss of group health plan coverage due to a reduction in hours before subsequently being terminated qualifies as an employee involuntarily terminated for purposes of determining his eligibility for the COBRA premium subsidy;
Details rules and procedures that group health plans and employers or others charged with administration of the COBRA premium subsidy rules must follow to notify affected individuals about and administer the new or expanded COBRA premium subsidy rights added by H.R. 4691;

In addition to these extensions to the COBRA premium subsidy requirements, H.R. 4691 also expands the exposures that plan sponsors and health insurers violating these requirements can face. H.R. 4691 provides that in addition to civil actions that already authorized for violations of COBRA:

“[T]he appropriate Secretary” or an affected individual can bring a civil suit for declaratory or other appropriate relief; and
The appropriate Secretary” can assess a penalty against a plan sponsor or health insurance issuer of up to $110 per day for each failure to comply with a determination of the Secretary within 10 days after receipt of the determination.

To minimize their COBRA rights under the amended COBRA premium subsidy rules, group health plans, their employer or union sponsors, administrators, insurers and service providers will need to act quickly to prepare and provider required updated notifications to assistance eligible individuals of these extended eligibility periods and their resulting rights, and otherwise update their plan documents, procedures, and COBRA notifications in light of these new rules.

Other Health Plan Updates Also Required

The COBRA premium subsidy changes in H.R. 4691 are only part of the ever-growing list of federal mandates that group health plan sponsors, fiduciaries, insurers, administrators and service providers need to be concerned about. Health plans, their sponsors, administrators, fiduciaries, insurers, business associates and other service providers face a host of other new federal health plan and privacy mandates that have taken effect over the past year, will become subject to additional mandates in upcoming months and face expanded penalty and other liability exposures. Consequently, beyond the COBRA premium subsidy updates required by yesterday’s amendments, health plans, their employer or other sponsors, insurers, fiduciaries, administrators and service providers also should not overlook the need to review and update their health plans in response to a host of other changes in federal health plan mandates.

In addition to otherwise applicable civil damage awards and civil penalty exposures that can result from violations of these requirements, new Internal Revenue Service regulations that took effect January 1, 2010 also require that employers, health plans or others self-report violations of certain of these requirements and self assess and pay resulting excise taxes arising under the Internal Revenue Code. See, e.g., COBRA, HIPAA, GINA, Mental Health Parity or Other Group Health Plan Rule Violations Trigger New Excise Tax Self-Assessment & Reporting Obligations.

The highly volatile health plan regulatory environment makes it likely that many health plans are not appropriately updated to comply with these and other federal requirements. In recent months, health plans, their employer or other sponsors, administrators and others also have become obligated to comply with a host of other expanded federal health plan rules and requirements. See e.g., New Mental Health Parity Regulations Require Health Plan Review & Updates; New Labor Department Rule Allows Employers 7 Days To Deliver Employee Contributions To Employee Benefit Plans; Newly Extended COBRA Subsidy Rules Require Employers, Administrators Send Required Notices & Update Health Plan Documents & Procedures Quickly; Employer & Other Health Plans & Other HIPAA-Covered Entities & Their Business Associates Must Comply With New HHS Health Information Data Breach Rules By September 23.

These and other developments make it imperative that health plans, their sponsors, administrators, insurers, fiduciaries and service providers get serious about complying with these and other federal health plan mandates, to tighten their credentialing, selection, oversight and contracts with administrators and vendors, and take other prudent steps to manage health plan related risks.

Unemployment Insurance Extensions

In addition to amending and extending ARRA’s COBRA premium subsidy rules, H.R. 4691’s unemployment insurance benefit provisions:

Extend the period during which individuals may file applications for Federal Emergency Unemployment Compensation (EUC) from the current end date of February 28, 2010 to April 5, 2010 and extend the period during which individuals may claim and be paid EUC from July 31, 2010 to September 4, 2010;
Extend from the current end date of February 28, 2010 to April 5, 2010 the period during which individuals may qualify for the Federal Additional Compensation (FAC), the extra $25 weekly benefit amount on state and federal unemployment compensation, while also providing for weekly payment during the phase out period for weeks ending October 5, 2010 instead of August 31, 2010; and.
Extend the period during which 100% federal reimbursement for weeks of regular federal extended benefit payments to April 5, 2010, with the state option to continue the extended period from July 31, 2010 to September 4, 2010.

For Added Information or Assistance

If your organization need advice or assistance about COBRA, unemploymenent benefits or other labor and employment, employee benefits, compensation or related matters, consider contacting Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer.

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Ms. Stamer has extensive experience advising and representing management about these and other labor and employment, employee benefits, compensation and other related management matters. The current Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group, a council member of the ABA Joint Committee on Employee Benefits and the former Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer works extensively with employer and other health plan sponsors and fiduciaries, insurers, third party administrators and others to design, document, administer and defend group and other health plan designs in light of COBRA and other federal and state regulations. A nationally recognized author and lecturer, Ms. Stamer is the author of the “Health Plan Eligibility Toolkit” and many other highly regarded publications and workshops on COBRA and other health plan mandates. She speaks and writes extensively on these and other related matters.

To seek the assistance of Ms. Stamer with these or other matters or to make arrangements for her to present a workshop or other training, contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here. To explore other publications by Ms. Stamer, see here or contact Ms. Stamer directly.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates that may be of interest include:

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.

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Posted by Cynthia Marcotte Stamer

Privacy Rule Changes & Posting of Breach Notices On OCR Website Signal New Enforcement Risks For Health Plans, Their Sponsors & Business Associates

February 23, 2010

By Cynthia Marcotte Stamer

The Department of Health and Human Services Office of Civil Rights (OCR) has begun disclosing on its website the employer and other health plans, health care providers, health care clearinghouses and their business associates (Covered Entities) that report breaches of unsecured protected health information (UPIC) affecting more than 500 individuals as required by new rules enacted as part of the Health Information Technology for Economic and Clinical Health Act (HITECH Act). This posting of Covered Entities reporting breaches comes just days after these and other Covered Entities became subject on February 17, 2010 to a host of other tighter federal requirements for the use, access, protection and disclosure of protected health information under Privacy & Security Standards of the Health Insurance Portability & Accountability Act (HIPAA) also enacted as part of the HITECH Act. As failing to comply with the amended rules effective February 17, 2010 can trigger obligations under the Breach Regulations and other exposures, prompt action to manage risk under both the Breach Regulations and the revised HIPAA rules is critical to minimize Covered Entity and business associate exposures under both these rules. With criminal, administrative and civil prosecutions of such violations increasing and likely to expand, timely action to manage compliance and other risks is warranted. Health plans and their business associates also should prepare for increased awareness and oversight of the adequacy of their medical information safeguards as these disclosures and other enforcement actions heighten interest and awareness of employees and others in these rules.

Covered Entity Breach Notification Requirements

OCR posted the initial list of Covered Entities disclosing these breaches on its website for the first time yesterday (February 22, 2010) to comply with breach notification requirements imposed by Section 164.408 of the interim “Breach Notification For Unsecured Protected Health Information” regulation (Breach Regulation) published here.

The Breach Regulation requires Covered Entities subject to the Health Insurance Portability & Accountability Act (HIPAA) to notify affected individuals, OCR and certain other parties following a “breach” of “unsecured” protected health information occurring on or after September 23, 2009. The Breach Regulation implements new breach notification requirements added to HIPAA by Section 13402(e)(3) of the Health Information Technology for Economic and Clinical Health Act (HITECH Act). It and the posting of Covered Entities reporting breaches of protected health information are part of the ongoing implementation and enforcement of new and stricter personal health information privacy and data security requirements for Covered Entities added to HIPAA under provisions of the HITECH Act and expanded remedies for violations signed into law on February 17, 2009 as part of American Recovery and Reinvestment Act of 2009 (ARRA).

You can review the list of Covered Entities that have reported breaches on the OCR website here. Learn more about the Breach Regulation requirements here.

Broader & Stricter Medical Privacy Mandates Effective 2/17/210

Just last Wednesday (February 17, 2010) Covered Entities and their business associates also became subject to tighter federal requirements for the use, access, protection and disclosure of protected health information under amendments to HIPAA’s Privacy & Security Standards enacted by the HITECH Act. The changes that became effective on February 17, 2010 generally require that Covered Entities and their business associates make specific changes to update their written policies, operational procedures, privacy notices, business associate agreements, training, and other management procedures in several respects. For more details, see here.

While the HITECH Act gave Covered Entities and business associates a year to complete the necessary arrangements to comply with these HITECH Act changes, many Covered Entities and business associates have remain unnecessarily exposed under these new requirements by not completing or otherwise failing to adequately implement the necessary arrangements despite expanding liability exposures that can result from noncompliance. To mitigate these exposures, Covered Entities and their business associates should act quickly to review and update their policies, procedures, training, business associate and other services agreements, and other practices and procedures, as well as to implement the training, oversight, and other management necessary to comply with the HITECH Act changes and to mitigate other HIPAA risks.

Exposures Significant & Growing

Covered Entities and business associates failing to devote adequate attention and resources to managing HIPAA compliance and associated risks risk increasing peril. Aside from the potential implications that disclosures of violations may have on patients and others impacting their business, the legal risks of noncompliance for Covered Entities, business associates and others mishandling protected health information are real and growing.

Timely action to comply with the amended HIPAA requirements and Breach Regulations is important both to preserve critical trust in the business, to avoid triggering breach notifications that can undermine this trust and fuel legal complaints, and to avoid exposure to an expanding range of sanctions that can result when a violation occurs.

Amendments made under the HITECH Act have expanded the size and availability of remedies that can be imposed for HIPAA violations as well as the parties empowered to pursue these remedies. Wrongful use, access or disclosure of protected health information in violation of HIPAA subjects participating health plans, health care providers, health care clearinghouses, their business associates and other workforce members and others to civil penalties, criminal prosecution and, since February 17, 2009, civil lawsuits brought by state attorneys general on behalf of citizens of their states whose HIPAA rights were violated. Since September 23, 2009, health plans and other HIPAA Covered Entities as well as their business associates also became obligated to provide breach notification under new mandates imposed by the HITECH Act. Coupled with increased enforcement emphasis by regulators, these expansions to HIPAA’s remedy provisions increase the risk that Covered Entities or business associates violating HIPAA face investigation and sanction. Furthermore, the wrongful use, access or disclosure of protected health information or other confidential information also increasingly is the basis of civil or criminal actions brought under a variety of other federal and state laws.

Expanded HIPAA & Other Federal Prosecutions & Remedies

The expanded requirements imposed under the Breach Regulation and the other HITECH Act changes that took effect on February 17, 2010 follow the implementation changes to HIPAA’s civil and criminal sanctions that took effect on February 17, 2009, when President Obama signed the HITECH Act into law. The HITECH Act amendments to HIPAA’s remedies significantly increase the risk that health plans and other Covered Entities and their business associates will face civil lawsuits, civil or criminal penalties or other consequences for violating HIPAA. Noncompliance with these and other HIPAA requirements subjects Covered Entities and business associates to civil penalties, criminal prosecution, civil damage awards under lawsuits brought by state attorneys general, and other legal remedies. In addition, timely update written policies, procedures, business associate agreements, training and documentation is imperative in order for Covered Entities and their business associates to fulfill their breach notification obligations under new rules enacted as part of the HITECH Act.

HITECH Amendments Expand Liability Exposures

The expanded risks stem in part from the HITECH Act’s amendments to HIPAA’s remedy provisions. Among other things, the HITECH Act amended HIPAA to:

Allow a State Attorney General to sue health plans or other Covered Entities, business associates or both that harm state citizens by committing HIPAA violations after February 16, 2009;
Expand the mandate by OCR to investigate violations and audit compliance with HIPAA;
Require Office of Civil Rights to impose civil sanctions against Covered Entities and business associates involved in violations of HIPAA in accordance with tightened standards added to HIPAA by the HITECH Act;
Revise the criminal sanctions that the Department of Justice can seek against Covered Entities, their business associates and others for violations of HIPAA; and
Amend HIPAA to make clear that HIPAA’s criminal sanctions also can imposed on business associates, workforce members and other persons that improperly use, access and disclose protected health information in violation of HIPAA.

State Attorney General Lawsuit Exposures

Covered Entities and their business associates now also need to be concerned about the potential that a state Attorney General may bring civil suit to remedy damages caused to state citizens by a breach of HIPAA.

The HITECH Act empowers a state attorney general to sue Covered Entities or business associates engaging in HIPAA violations that harms citizens of the state for statutory damages equal to the sum of the number of violations multiplied by 100 up to a maximum of $25,000 per calendar year plus attorneys fees and costs

A HIPAA civil lawsuit filed on January 13, 2010 demonstrates the willingness of at least some states to exercise the new authority created by the HITECH Act on February 17, 2009 to sue Covered Entities and business associates that violate HIPAA for civil damages.

On January 13, 2010 Connecticut Attorney General Richard Blumenthal sued Health Net of Connecticut, Inc. (Health Net) for failing to secure private patient medical records and financial information involving 446,000 Connecticut enrollees and promptly notify consumers endangered by the security breach. The suit also names UnitedHealth Group Inc. and Oxford Health Plans LLC, who have acquired Health Net. The first attorney general enforcement action brought based on amendments made to HIPAA under the HITECH Act, Connecticut charges that Health Net violated HIPAA by failing to safeguard protected medical records and financial information on almost a half million Health Net enrollees in Connecticut then allowing this information to remain exposed for at least six months before notifying authorities and consumers.

Stepped Up Federal Enforcement

Even before the HITECH Act amendments, however, OCR and Department of Justice already were stepping up HIPAA investigation and enforcement. The Department of Justice has obtained a variety of criminal convictions against violators of HIPAA. See, e.g., 2 New HIPAA Criminal Actions Highlight Risks From Wrongful Use/Access of Health Information. Meanwhile, OCR also is emphasizing HIPAA enforcement. In February, 2009, for instance, OCR announced that CVS Pharmacies, Inc. would pay $2.25 million to resolve HIPAA charges. This announcement followed OCR’s announcement in July, 2008 that Providence Health Care would pay $100,000 to resolve HIPAA violation charges. OCR also has taken HIPAA enforcement actions against a broad range of other Covered Entities to redress HIPAA violations or other compliance concerns. To review examples of these other actions, see here. While not resulting in the significant payments involved in CVS or Providence, all Covered Entities involved in these and other enforcement actions or investigations have incurred significant legal and other defense costs, loss of community trust, or both.

In addition to these HIPAA-specific exposures, wrongful use, access or disclosure of medical information also can give rise to liability for health plans and other Covered Entities, business associates, employees and other members of their workforce and others improperly using, accessing or disclosing protected health information. Federal and state prosecutions may and increasingly do criminally prosecute individuals for improperly accessing or using medical or other personal information under a variety of other federal or state laws . See e.g., Cybercrime & Identity Theft: Health Information Security Beyond HIPAA; NY AG Cuomo Announcement of 1st Settlement For Violation of NY Security Breach Notification Law; Woman Who Revealed AIDs Info Gets A Year. Additionally, State courts also increasingly are permitting individuals harmed by HIPAA violations to use HIPAA as the foundation of state law duties used to maintain state negligence, invasion of privacy, retaliation or other claims for damages. Read more here.

State Civil Lawsuits

Meanwhile, disgruntled employees or other business partners also increasingly raise alleged HIPAA misconduct as a basis of their legal complaints. For instance, private plaintiffs employed by Covered Entities also are increasingly pointing to HIPAA as the basis for their retaliation or wrongful discharge claims. See, e.g., Retaliation For Filing HIPAA Complaint Recognized As Basis For State Retaliatory Discharge Claim. Coupled with the HITECH Act changes, these and other enforcement actions signal growing potential hazards for Covered Entities and their business associates that fail to properly manage their HIPAA compliance obligations and risks.

Given these and other developments, Covered Entities and their business associates generally should resist the temptation to underestimate their potential HIPAA exposure for a variety of reasons. In fact, a number of factors demonstrate that the risks are significant and growing for Covered Entities, business associates and others that breach HIPAA’s mandates or otherwise inappropriately access protected health information.

Covered Entities & Business Associates Urged To Act Promptly To Manage Expanded HIPAA Risks & Obligations

As a consequence of these collective HITECH Act changes and growing HIPAA-related and other exposures, Covered Entities, their business associates and business associates generally will find it necessary or advisable among other things to:

Conduct well-documented due diligence within the scope of attorney-client privilege on their own practices and procedures;
Review the adequacy of the practices, policies and procedures of the Covered Entities, business associates, and others that may come into contact with protected health information;;
Renegotiate their service provider agreements to detail the specific compliance obligations of each party relating to for auditing compliance, investigating potential breaches; providing required breach notifications; specify leadership and required cooperation in the event of a breach, charge, or other concern; indemnification and other liability allocations; and other related matters;
Update policies, privacy and other notices, practices, procedures, training and other practices as needed to promote compliance and defensibility;
Conduct well-documented training as necessary to ensure that business associates and other members of the Covered Entity’s workforce understand and are prepared to comply with the expanded requirements of HIPAA, can detect potential breaches or other compliance concerns, and understand and are prepared to follow appropriate procedures for reported suspected violations; and
Pursue appropriate liability and other protection as appropriate to improve their ability to demonstrate both their commitment to compliance and their realistic efforts to ensure that these commitments are both appropriately documented on paper and operationalized in performance.

As part of these compliance and risk management efforts, most Covered Entities and their business associates will find it advisable to devote significant attention to the business associate relationship and its associated business associate agreements. Proper management of the expanded compliance obligations and liability exposures created by the HITECH Act generally will necessitate that Covered Entities and their business associates focus significant attention on the reworking of their operating and contractual relationships including the definition of detailed procedures for monitoring, reporting, investigating, and resolving potential breaches or other compliance concerns.

Even before the impending HIPAA changes scheduled to take effect on February 17, 2010, a strong need for more detailed contracting and planning of these relationships already existed. Since the enactment of HIPAA, the practice of many Covered Entities and their business associates of appending generic “business associate” representations onto existing services contracts without specific tailoring and planning has created undesirable ambiguities in these agreements. Further updating and tailoring of these and other provisions of services agreements has become even more important over the past year in light of the new breach notification mandates that took effect under the HITECH Act in September, 2009, changes to HIPAA’s civil and criminal sanctions that took effect on February 17, 2009, and the impending extension by the HITECH Act to business associates of direct liability for compliance with HIPAA scheduled to occur on February 17, 2010.

These and other stepped up oversight and enforcement activities make it critical that all Covered Entities and their business associates update their policies and practices, conduct training, tighten their compliance and data breach monitoring processes, strengthen their internal controls and documentation, and take other steps to prepare to defend their actions under the newly strengthened Privacy Rules. Covered Entities and their business associates more than ever must ensure their ability to demonstrate to federal regulators the effectiveness of their HIPAA compliance efforts by both adopting the written policies and procedures required by HIPAA and continuously monitoring and administering these safeguards. Covered Entities should consider reviewing the adequacy of their current HIPAA Privacy and Security compliance practices taking into consideration the Corrective Action Plan, published OCR noncompliance and enforcement statistics, their own and reports of other security and privacy breaches and near misses, and other developments to determine if additional steps are necessary or advisable.

For Assistance With Compliance Or Other Concerns

If your organization need advice or assistance in reviewing, updating, administering or defending its HIPAA or other privacy policies, practices, business associate or other agreements, notices or other related activities, consider contacting the author of this article, Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail here.

Ms. Stamer is nationally known for her work, training and presentations, and publications on privacy and security of health and other sensitive information in health and managed care, employment, employee benefits, financial services, education and other contexts.

Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 22 years experience advising clients about health and other privacy and security matters. A popular lecturer and widely published author on privacy and data security and other related health care and health plan matters, Ms. Stamer is the Editor in Chief of the forthcoming 2010 edition of the Information Security Guide to be published by the American Bar Association Information Security Committee in 2010, as well as the author of “Protecting & Using Patient Data In Disease Management: Opportunities, Liabilities And Prescriptions,” “Privacy Invasions of Medical Care-An Emerging Perspective,” “Cybercrime and Identity Theft: Health Information Security Beyond HIPAA,” and a host of other highly regarded publications. She has continuously advises employers, health care providers, health insurers and administrators, health plan sponsors, employee benefit plan fiduciaries, schools, financial services providers, governments and others about privacy and data security, health care, insurance, human resources, technology, and other legal and operational concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry privacy, data security and other technology, regulatory and operational risk management matters. Her insights on health care, health insurance, human resources and related matters appear in the Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments

If you found this information of interest, you also may be interested in information about upcoming programs to be presented by Ms. Stamer, acquiring a copy of a recording or materials from previous programs she has presented, or arranging training for your organization. For more information about these opportunities, contact Ms. Stamer directly.

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

Curran Tomko Tarski LLP Can Help

If your organization need advice or assistance in reviewing, updating, administering or defending its HIPAA or other privacy policies, practices, business associate or other agreements, notices or other related activities, consider contacting Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer.

A widely published author and speaker on HIPAA and other employee benefit and human resources related matters, Ms. Stamer has extensive experience advising health plans, their employer and other sponsors, health insurers, TPAs and other business associates and others about HIPAA and other health plan and privacy matters. Currently serving as both Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group and as an ABA Joint Committee on Employee Benefits Council representative and Former Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer has more than 23 years experience assisting employers, insurers, plan administrators and fiduciaries and others to design, implement, draft and administer health and other employee benefit plans and to defend audits, litigation or other disputes by private parties, the IRS, Department of Labor, Office of Civil Rights, Medicare, state insurance regulators and other federal and state regulators. A nationally recognized author and lecturer, Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates that may be of interest include:

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 Privacy Rule Changes & Posting of Breach Notices On OCR Website Signal New Enforcement Risks For Health Plans, Their Sponsors & Business Associates | Corporate Compliance, Data Security, Employee Benefits, Employers, ERISA, Fiduciary Responsibility, GINA, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Privacy, Risk Management, Wellness Programs | Tagged: Corporate Compliance, Employee Benefits, Employer, ERISA, GINA, Health Care Reform, Health Insurance, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Medical Coverage, Privacy, Risk Management | Permalink
Posted by Cynthia Marcotte Stamer

Health Plan Liability Heats Up As Plans & Businesses Face New Obligations, Costs & Exposures under New HIPAA Privacy Rules Effective 2/17 & Other Expanding Federal Health Plan Mandates

February 17, 2010

Today (February 17, 2010), employer and other health plans and health insurers (“covered entities”) and service providers performing functions on behalf of these entities (“business associates”) must begin complying with tighter federal requirements for the use, access, protection and disclosure of protected health information under Privacy & Security Standards of the Health Insurance Portability & Accountability Act (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH Act). Coming as U.S. employers continue to struggle to provide health benefits in the face of skyrocketing health benefit costs, these and other new federal regulations impacting employment-based health plans and their sponsoring businesses, fiduciaries and administrators are forcing U.S. business leaders to make appropriate health plan cost and compliance management a key management priority.

2/17/10 & Other HIPAA Privacy Rule Changes Require Prompt Attention

The HIPAA Privacy Rule changes scheduled to take effect February 17, 2010 are likely to require that health plans and their business associates update their written policies, operational procedures, privacy notices and business associate agreements in several respects.

While the HITECH Act gave covered entities and business associates a year to complete the necessary arrangements to comply with these impending HITECH Act changes, many health plans and business associates have not completed the necessary arrangements despite expanding liability exposures that can result from noncompliance. To mitigate these exposures, covered entities and their business associates should act quickly both to update their services agreements, plans and policies, practices, and procedures, and to implement the training, oversight, and other management procedures necessary to comply with the HITECH Act changes and to mitigate other HIPAA risks.

The risks of noncompliance for health plans, business associates and others mishandling protected health information are real and growing. Wrongful use, access or disclosure of protected health information in violation of HIPAA subjects participating health plans, health care providers, health care clearinghouses, their business associates and other workforce members and others to civil penalties, criminal prosecution and, since February 17, 2009, civil lawsuits brought by state attorneys general on behalf of citizens of their states whose HIPAA rights were violated. Since September 23, 2009, health plans and other HIPAA covered entities as well as their business associates also became obligated to provide breach notification under new mandates imposed by the HITECH Act.

In addition to these HIPAA-specific exposures, wrongful use, access or disclosure of medical information also can give rise to liability for health plans and other covered entities, business associates, employees and other members of their workforce and others improperly using, accessing or disclosing protected health information. Federal and state prosecutions may and increasingly do criminally prosecute individuals for improperly accessing or using medical or other personal information under a variety of other federal or state laws . See e.g., Cybercrime & Identity Theft:Health Information Security Beyond HIPAA; NY AG Cuomo Annoucment of 1st Settlement For Violation of NY Security Breach Notification Law; Woman Who Revealed AIDs Info Gets A Year. Additionally, State courts also increasingly are permitting individuals harmed by HIPAA violations to use HIPAA as the foundation of state law duties used to maintain state negligence, invasion of privacy, retaliation or other claims for damages. Read more here.

To manage these and other HIPAA-related risks, sponsoring employers, fiduciaries, administrators, insurers and their vendors should begin with carefully and timely reviewing and updating existing plan documents, vendor agreements, privacy notices and other communications and associated practices and policies. The focus of these efforts definitely should seek both to adopt the specific technical changes necessary to make the health plans and their contracts technically comply on paper with these and other HIPAA mandates, and to tailor these documents, communications and practices promote operational compliance and minimize exposure to associated risks. In relation to these efforts, sponsoring employers, insurers, fiduciaries and administrators also should ensure that required certifications from employers and other plan sponsors, representations from business associates, training and other compliance conditions are properly in place. In this respect, employers sponsoring health plans should not overlook the potential need to adopt appropriate policies and implement needed training and safeguards to enable the health plan and the employer demonstrate, if necessary that HIPAA’s requirements for sharing protected health information with members of the employer’s workforce for plan administration, underwriting or certain other purposes have been satisfied.

Other Health Plan Updates Also Required

The HIPAA Privacy Rule changes effective today are only part of the ever-growing list of federal mandates that group health plan sponsors, fiduciaries, insurers, administrators and service providers need to be concerned about. In addition to the new HIPAA Privacy Rule requirements taking effect today, health plans, their sponsors, administrators, fiduciaries, insurers, business associates and other service providers face a host of other new federal health plan and privacy mandates that have taken effect over the past year, and will become subject to additional mandates in upcoming months. Consequently, while focusing on HIPAA compliance, health plans, their employer or other sponsors, insurers, fiduciaries, administrators and service providers also should not overlook the need to review and update their health plans in response to a host of other changes in federal health plan mandates.

The highly volatile health plan regulatory environment makes it likely that many health plans are not appropriately updated to comply with these and other federal requirements. In recent months, health plans, their employer or other sponsors, administrators and others also have become obligated to comply with a host of other expanded federal health plan rules and requirements. See e.g., New Mental Health Parity Regulations Require Health Plan Review & Updates; New Labor Department Rule Allows Employers 7 Days To Deliver Employee Contributions To Employee Benefit Plans; Newly Extended COBRA Subsidy Rules Require Employers, Administrators Send Required Notices & Update Health Plan Documents & Procedures Quickly; Employer & Other Health Plans & Other HIPAA-Covered Entities & Their Business Associates Must Comply With New HHS Health Information Data Breach Rules By September 23.

These and other developments make it imperative that health plans, their employer or other sponsors, administrators, insurers, fiduciaries and service providers get serious about complying with these and other federal health plan mandates and managing health plan related liabilities and costs. Sponsors, insurers, fiduciaries and administrators should ensure that health plan documents, insurance and other vendor contracts, policies, procedures and communications are timely updated to comply with these and other emerging mandates. When implementing these updates, parties concerned about costs or liabilities also should exercise care to ensure that plan documents, communications, contracts, administrative forms and procedures are optimally designed and drafted not only to be technically compliant, but also to support the enforceability of plan design and cost expectations, minimize administrative and other avoidable costs, and minimize liability exposures. In furtherance of these efforts, employer and other plan sponsors also should consider tightening their practices and requirements for credentialing, selection, oversight and contracting with administrators and vendors, and take other prudent steps to manage health plan related risks.

Curran Tomko Tarski LLP Can Help

If your organization need advice or assistance in reviewing, updating, administering or defending its HIPAA or other privacy policies, practices, business associate or other agreements, notices or other related activities, consider contacting Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates that may be of interest include:

For important information concerning this communication click here.

Comments Off on Health Plan Liability Heats Up As Plans & Businesses Face New Obligations, Costs & Exposures under New HIPAA Privacy Rules Effective 2/17 & Other Expanding Federal Health Plan Mandates | COBRA, Corporate Compliance, Data Security, ERISA, Fiduciary Responsibility, FMLA, GINA, Health Care Reform, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Prescription Drugs, Privacy, Wellness Programs | Tagged: Corporate Compliance, Employer, Health Plans, HIPAA, internal control, Mental Heatlh Parity, Privacy, Privacy Standards, Risk Management | Permalink
Posted by Cynthia Marcotte Stamer

Health Plans & Business Associates Face 2/17 Deadline To Update Policies, Contracts & Procedures For HIPAA Privacy Rule Changes

February 15, 2010

Connecticut AG Lawsuit Highlights Expanding Civil Damage Exposure Risks Of Noncompliance

By Cynthia Marcotte Stamer

By Wednesday, February 17, 2010, employer and other health plans and health insurers (“covered entities”) and service providers performing functions on behalf of these entities (“business associates”) must begin complying with tighter federal requirements for the use, access, protection and disclosure of protected health information under Privacy & Security Standards of the Health Insurance Portability & Accountability Act (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH Act). The changes scheduled to take effect February 17, 2010 are likely to require that health plans and their business associates update their written policies, operational procedures, privacy notices and business associate agreements in several respects.

2/17/10 Deadline To Comply With HITECH Act HIPAA Amendments

On February 17, 2010, health plans and other covered entities and their business associates will become subject to the latest to take effect in a series of amendments to the HIPAA enacted under the HITEC Act. The new rules are part of a broader series of changes to HIPAA made by the HITECH Act that collectively both significantly expand the obligations of covered entities and their business associates to regarding the use, protection and disclosure of protected health information and the liability exposures that can result when covered entities or business associates violate these requirements.

The changes scheduled to take effect February 17, 2010 are likely to require that health plans and their business associates update their written policies, operational procedures, privacy notices and business associate agreements in several respects. For instance, effective February 17, 2010, the HITECH Act generally requires that covered entities and their business associates revise their written privacy policies, privacy notices and operating procedures:

To meet expanded requirements to honor individual’s requests for special restrictions on uses and disclosures of protected health information to health plans for payment purposes
To restrict protected health information disclosures to the minimum necessary required to accomplish otherwise allowable purpose;
To comply with new rules that require that the covered entity and its business associates treat any use, access or disclosure of any protected health information made for purposes of making communications about products or services as made for marketing, rather than operational, purposes which are prohibited by HIPAA except where HIPAA’s requirements are met;
To comply with new restrictions on certain fundraising communications made for operational purposes including expanded obligations to allow recipients to opt out of further fundraising communications;
To prohibit covered entities or business associates from selling protected health information without meeting the amended requirements of HIPAA that a valid HIPAA authorization from the subject of the information and specific reassurances from the purchaser concerning its subsequent use of the protected health information except as otherwise permitted by HIPAA;
To take into account these tightened restrictions on the use, access or disclosure of protected health information for purposes of complying with new HITECH Act breach notification requirements that took effect in September, 2009, which apply when a covered entity or its business associate knows or should know a breach of “unsecured protected health information” has occurred and for purposes of making the necessary changes in written policies and business associate agreements, training and operational procedures necessary to comply with these rules;
To directly require business associates comply with HIPAA’s requirements in the same manner as other covered entities and make it necessary or advisable that that service provider agreements between health plans and business associates be updated to reflect these and other changes to HIPAA; and
To implement the necessary written policy changes, notification updates, business associate agreement amendments, training, management oversight and other procedural changes necessary to demonstrate fulfillment with these requirements.

Noncompliance with these and other HIPAA requirements subjects covered entities and business associates to civil penalties, criminal prosecution, civil damage awards under lawsuits brought by state attorneys general, and other legal remedies. In addition, timely update written policies, procedures, business associate agreements, training and documentation is imperative in order for covered entities and their business associates to fulfill their breach notification obligations under new rules enacted as part of the HITECH Act.

Under the HITECH Act, health plans and other covered entities and their business associates have been obligated since September 23, 2009 to notify individuals who are the subject of protected health information, the Department of Health & Human Services and in some cases the media if and when a breach of “unsecured protected health information occurs. Failing to timely update written policies, procedures and training increases the likelihood that health plans, other covered entities or business associates will be obligated to provide breach notifications under these new rules, in addition to their otherwise applicable exposures under HIPAA.

HIPAA Enforcement & Liability Exposures Real and Rising

Health plans and other covered entities, their business associates and others involved in health plan design and operations generally should resist the temptation to underestimate their potential HIPAA exposure based on the limited enforcement of HIPAA by the Office of Civil Rights between 2003 and 2009 for a variety of reasons.

First, the changes taking effect on February 17, 2010 follow the implementation changes to HIPAA’s civil and criminal sanctions that took effect on February 17, 2009, when President Obama signed the HITECH Act into law and the new breach notification requirements added by the HITECH Act that took effect on September 23, 2009. The HITECH Act amendments to HIPAA’s remedies significantly increase the risk that health plans and other covered entities and their business associates will face civil lawsuits, civil or criminal penalties or other consequences for violating HIPAA.

The expanded risks stem in part from the HITECH Act’s amendments to HIPAA’s remedy provisions. Among other things, the HITECH Act amended HIPAA to:

Allow a State Attorney General to sue health plans or other covered entities, business associates or both that harm state citizens by committing HIPAA violations after February 16, 2009;
Expand the mandate by the Office of Civil Rights to investigate violations and audit compliance with HIPAA;
Require Office of Civil Rights to impose civil sanctions against health plans and other covered entities and their business associates involved in violations of HIPAA in accordance with tightened standards added to HIPAA by the HITECH Act;
Revise the criminal sanctions that the Department of Justice can seek against health plans and other covered entities, their business associates and others for violations of HIPAA;
Amend HIPAA to make clear that HIPAA’s criminal sanctions also can imposed on business associates, workforce members and other persons that improperly use, access and disclose protected health information in violation of HIPAA.

A HIPAA civil lawsuit filed on January 13, 2010 demonstrates the willingness of at least some states to exercise the new authority created by the HITECH Act on February 17, 2009 to sue covered entities and business associates that violate HIPAA for civil damages.

The HITECH Act empowers a state attorney general to sue covered entities or business associates engaging in HIPAA violations that harms citizens of the state for statutory damages equal to the sum of the number of violations multiplied by 100 up to a maximum of $25,000 per calendar year plus attorneys fees and costs

Even before the HITECH Act amendments, however, the Office of Civil Rights and Department of Justice already were stepping up HIPAA investigation and enforcement. The Department of Justice has obtained a variety of criminal convictions against violators of HIPAA. See, e.g., 2 New HIPAA Criminal Actions Highlight Risks From Wrongful Use/Access of Health Information. Meanwhile, the Office of Civil Rights in February, 2009 announced that CVS Pharmacies, Inc. would pay $2.25 million to resolve HIPAA charges. This announcement followed the Office of Civil Rights announcement in July, 2008 that Providence Health Care would pay $100,000 to resolve HIPAA violation charges. While not resulting in the significant payments involved in CVS or Providence, the Office of Civil Rights also taken HIPAA enforcement actions against a broad range of other covered entities to redress HIPAA violations or other compliance concerns. To review examples of these other actions, see here.

Along side these governmental actions, state courts also increasingly are willing to allow individual plaintiffs to rely on violations of HIPAA as the basis for bringing state privacy, retaliation or other actions. While prior to the recent HITECH Act amendments, federal courts had ruled that private plaintiffs could not sue under HIPAA for damages they incurred from a covered entity’s violation of HIPAA, state courts have allowed private plaintiff’s to use the obligations imposed by HIPAA as the basis of a covered entity’s duty for purposes of certain state law lawsuits. In Sorensen v. Barbuto, 143 P.3d 295 (Utah Ct. App. 2006), for example, a Utah appeals court ruled a private plaintiff could use HIPAA standards to establish that a physician owed a duty of confidentiality to his patients for purposes of maintaining a state law damages claim. Similarly, the Court in Acosta v. Byrum, 638 S.E. 2d 246 (N.C. Ct. App. 2006) ruled that a plaintiff could use HIPAA to establish the “standard of care” in a negligence lawsuit. Meanwhile, private plaintiffs employed by covered entities also are increasingly pointing to HIPAA as the basis for their retaliation claims. See, e.g., Retaliation For Filing HIPAA Complaint Recognized As Basis For State Retaliatory Discharge Claim. Coupled with the HITECH Act changes, these and other enforcement actions signal growing potential hazards for covered entities and their business associates that fail to properly manage their HIPAA compliance obligations and risks.

Health Plans & Business Associates Should Take Timely Action To Comply & Manage Risks

As a consequence of these collective HITECH Act changes and growing HIPAA-related exposures, both health plans and business associates generally will find it necessary or advisable among other things to:

Conduct well-documented due diligence on each other’s practices and procedures to improve their ability to demonstrate both their commitment to compliance and their realistic efforts to ensure that these commitments are operationalized in performance;
Renegotiate their service provider agreements to detail the specific compliance obligations of each party relating to for auditing compliance, investigating potential breaches; providing required breach notifications; specify leadership and required cooperation in the event of a breach, charge, or other concern; indemnification and other liability allocations; and other related matters; and
Pursue appropriate liability and other protection as appropriate.

As part of these compliance and risk management efforts, most covered entities and their business associates will find it advisable to devote significant attention to the business associate relationship and its associated business associate agreements.

Proper management of the expanded compliance obligations and liability exposures created by the HITECH Act generally will necessitate that health plans and other covered entities and their business associates focus significant attention on the reworking of their operating and contractual relationships.

Further updating and tailoring of these and other provisions of services agreements has become even more important over the past year in light of the new breach notification mandates that took effect under the HITECH Act in September, 2009, changes to HIPAA’s civil and criminal sanctions that took effect on February 17, 2009, and the impending extension by the HITECH Act to business associates of direct liability for compliance with HIPAA scheduled to occur on February 17, 2010.

Given these changes and the associated obligations and risks, both health plans and other covered entities and their business associates generally should act quickly to manage their own compliance and to minimize exposures that may result from the other’s compliance deficiencies. As part of these efforts, both covered entities and their business associates generally should review and tighten business associate and other service agreement provisions to provide for more specific and comprehensive HIPAA-related contractual assurances, as well as improved cooperation, coordination, management and oversight.

Curran Tomko Tarski LLP Can Help

If your organization need advice or assistance in reviewing, updating, administering or defending its HIPAA or other privacy policies, practices, business associate or other agreements, notices or other related activities, consider contacting Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer.

A widely published author and speaker on HIPAA and other related matter, Ms. Stamer has extensive experience advising health plans, their employer and other sponsors, health insurers, TPAs and other business associates and others about HIPAA and other health plan and privacy matters. Currently serving as both Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group and as an ABA Joint Committee on Employee Benefits Council representative and Former Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer has more than 23 years experience assisting employers, insurers, plan administrators and fiduciaries and others to design, implement, draft and administer health and other employee benefit plans and to defend audits, litigation or other disputes by private parties, the IRS, Department of Labor, Office of Civil Rights, Medicare, state insurance regulators and other federal and state regulators. As part of this work, she regularly assists clients to review and update policies, practices, contracts, notices and procedures to comply with HIPAA and other requirements. A nationally recognized author and lecturer, Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates that may be of interest include:

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Posted by Cynthia Marcotte Stamer

Inapplicability of HIPAA Privacy To Disability Insurer Not License To Impose Unreasonable Claims Requirements

February 8, 2010

By Cynthia Marcotte Stamer

While finding the Privacy Standards imposed by the Health Insurance Portability & Accountability Act (HIPAA) inapplicable to disability insurers, a recent Louisiana Court of Appeals nevertheless ruled that the insurer was not entitled to dismissal of the lawsuit challenging the denial of disability benefits brought by a state employee for failure to meet proof of loss requirements based on his failure to sign insurer required medical authorization. Disability insurers and plan fiduciaries should heed the decision as a reminder that exemption from HIPAA does not amount to a license to impose unreasonable proof of loss or requirements inconsistent with a reasonable reading of the terms of the applicable plan or policy, or other applicable regulations.

Harris v. Metropolitan Life Ins. Co., — So.3d —-, 2010 WL 415262, 2009-0034 (La.App. 1 Cir. 2/5/10), involved a lawsuit challenging the continuing refusal of Metropolitan Life Insurance to and its designates to approve the disability benefit claim of Louisiana Supreme Court employee Jack Harris. Metropolitan repeatedly asked insisted that Mr. Harris submit to a physical examination and sign various medical and other authorizations including an “Attending Physician’s Statement” and an “Employee Authorization,” and sign certain other documents. While Mr. Harris sent the “Attending Physician’s Statement” to his treating physician, he declined to sign the Employee Authorization and certain other subsequently requested consents on the grounds of HIPAA. While he provided to a HIPAA-compliant authorizations to his medical providers to release all medical records, medical opinions, and medical reports relating to Mr. Harris’ past and current treatment for purposes of the claim, he declined and instead filed suit contending that the information and releases already provided met the proof of loss requirements of the policy.

Upon motion of Metropolitan, the trial court found that Mr. Harris’ failure to sign the authorizations and submit to the medical examination required by Metropolitan rendered his claim “premature.” Upon appeal, however, the Court of Appeals overruled this determination. While the Court of Appeals agreed with the trial court that the special authorization rules imposed by HIPAA did not apply to a disability insurer such as Metropolitan, it also ruled that its right to require a claimant to sign authorizations, submit to medical examinations or meet other proof of loss conditions must be reasonable in light of the terms of the policy. Accordingly, although the Court of Appeals agreed that the proof of loss and other provisions of the disability policy authorized Metropolitan to require a disability claimant to undergo an independent medical examination “as often as reasonably required,” the Court of Appeals ruled that Mr. Harris’ submission to the independent medical examination was not a condition precedent to the initiation of litigation by an insured and that the “medical authorization” demanded by Metropolitan was far broader than what the policy allowed as reasonably required for the independent medical examination. Accordingly, the Court of Appeals overruled the trial court’s dismissal of the disability claim and remanded the action to the trial court for hearing.

While affirming that the HIPAA Privacy Standards don’t directly apply to disability insurers, the Harris decision also demonstrates that disability insurers should not over-estimate the effect of this exemption. While HIPAA may not apply, disability insurers generally remain bound by the reasonable construction of their policy terms, taking into account otherwise applicable laws and regulations. Accordingly, disability and other HIPAA-exempt insurers and plans should not confuse the inapplicability of the HIPAA authorization requirements for carte blanche to impose unreasonable authorization or other proof of loss requirements inconsistent with their policy terms.

If you have questions about or need assistance evaluating, commenting on or responding to this invitation or other employee benefit, employment, compensation, employee benefit, workplace health and safety, corporate ethics and compliance practices, concerns or claims, please contact the author of this article, Curran Tomko Tarski LLP Labor & Employment Practice Group Chair Cynthia Marcotte Stamer. Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association RPTE Employee Benefits & Other Compensation Group, and a Council Member on the ABA Joint Committee on Employee Benefits, Ms. Stamer has more than 22 years experience advising and assisting employers, employee benefit plan and their fiduciaries, insurers, administrators, and others about policy and plan, process, and product design, administration, documentation, risk management and defense under ERISA, COBRA, HIPAA, labor and employment, tax, state banking and insurance, and other laws. Her work includes extensive experience advising and defending employee benefit plan fiduciaries and insurers about the investigation of disability, health and other claims and appeals. She also advises, assists, trains, audits and defends employers and others regarding the federal and state Sentencing Guideline and other compliance, equal employment opportunity, privacy, leave, compensation, workplace safety, wage and hour, workforce reengineering, and other labor and employment and defends related audits, investigations and litigation, charges, audits, claims and investigations by the IRS, Department of Labor and other federal and state regulators. Ms. Stamer also speaks, writes and conducts training extensively on these and other related matters. For additional information about Ms. Stamer and her experience, see here or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Some other recent updates that may be of interested include the following, which you can access by clicking on the article title:

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.

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Posted by Cynthia Marcotte Stamer

Rising Enforcement and Changing Rules Require Prompt Review & Update of Health Plan Privacy & Data Security Policies & Procedures

December 25, 2009

Health plans and their business associates should review and update their practices and policies concerning the use access and disclosure of protected health information in response to changing requirements and expanding enforcement exposures under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) Privacy and Security Rules.

A series of Office of Civil Rights (OCR) enforcement action against health plans highlights the need for group health plans and insurers to exercise care to comply with HIPAA’s Privacy & Security Rules. For example, OCR recently required a HMO to take a series of corrective actions based on findings from its investigation of a complaint that the HMO impermissibly disclosed a member’s protected health information by sending her entire medical record to a disability insurance company without her authorization. Based on its investigation, OCR found the HMO violated HIPAA by relying on a form to make the disclosure that failed to meet the Privacy Rule requirements to qualify as a valid authorization under the Privacy Rule. Based on these findings, OCR required the HMO among other things:

To create a new HIPAA-compliant authorization form that specifies what records and/or portions of the files will be disclosed, that the respective authorization will be kept in the patient’s record, together with the disclosed information and otherwise to meet the content requirements of the Privacy Rule for an authorization; and
To implement a new policy that directs staff to obtain patient signatures on these forms before responding to any disclosure requests, even if patients bring in their own “authorization” form.

Another action resulted after a national health maintenance organization sent explanation of benefits (EOB) by mail to a complainant’s unauthorized family member. OCR’s investigation determined that a flaw in the health plan’s computer system put the protected health information of approximately 2,000 families at risk of disclosure in violation of the Privacy Rule. To resolve this case, OCR required among other things that the insurer to correct the flaw in its computer system, review all transactions for a six month period and correct all corrupted patient information.

In yet another case, OCR found an employee of a major health insurer impermissibly disclosed the PHI of one of its members without following the insurer’s authorization and verification procedures. Among other corrective actions to resolve the specific issues in the case, OCR required the health insurer to train its staff on the applicable policies and procedures, to take action to mitigate the harm to the individual and to counsel and give a written warning to an employee who made the disclosure.

While OCR declined to impose any civil penalties in any of these three instances, violations of the Privacy Rules have resulted in both criminal prosecutions by the Department of Justice and the payment of large civil settlements to OCR. See, e.g., 2 New HIPAA Criminal Actions Highlight Risks From Wrongful Use/Access of Health Information HIPAA Risks Soar As CVS Agrees to Pay $2.25 Million To Resolve HIPAA Charges & Stimulus Bill Amends HIPAA. Furthermore, recent amendments to the Privacy Rules increase the likelihood that health plans and other covered entities violating the Privacy Rules will incur civil penalties. The American Recovery and Reinvestment Act of 2009 (ARRA) amended the Privacy Rules effective October, 2009 to increase the civil penalties for Privacy Rule violations and to include new breach notification requirements for covered entities. Additional ARRA amendments to HIPAA scheduled to take effect February 17, 2010 will further tighten the conditions under which covered entities may use, access or disclose PHI under the Privacy Rules, will expand the circumstances under which health plans and other covered entities will be required to account for dealings with PHI under HIPAA, and will extend the duty to comply with and liability for violations of the Privacy Rules to business associates. In the meanwhile, employees increasingly are alleging Privacy Rule violations as part of their whistleblower or other wrongful discharge claims. See, e.g. Retaliation For Filing HIPAA Complaint Recognized As Basis For State Retaliatory Discharge Claim.

In light of these changing rules and expanding liabilities, health plans and their business associates need to review and update their Privacy and Security practices, business associate agreements and privacy notices for compliance in light of the expanding enforcement activities of OCR and these evolving Privacy and Security Rules. These and other developments make it imperative that health plans and other covered entities and their business associates immediately review and update their HIPAA and other data security and privacy practices to guard against growing liability exposures under HIPAA and other federal and state laws.

If your organization needs assistance reviewing, updating, administering or defending privacy and data security practices under HIPAA, state data breach or other laws, Curran Tomko Tarski LLP can help. The author of this update, Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer has extensive experience advising and assisting health plans, health insurers, and other covered entities and business associates to review, update, document, enforce and defend their HIPAA and other privacy and data security policies and practices. The author of numerous publications on HIPAA and other privacy and data security rules, she also speaks and conducts training extensively on these concerns.

Ms. Stamer is experienced with assisting employers, insurers, administrators, and others to design and administer group health plans cost-effectively in accordance with HIPAA and other applicable federal regulations as well as well as advising and defending employers, health plans, insurers and others against privacy, tax, employment discrimination and other labor and employment, and other related audits, investigations and litigation, charges, audits, claims and investigations by the OCR, DOJ,IRS, Department of Labor and other federal and state regulators.. Chair of the American Bar Association RPTE Employee Benefits & Other Compensation Group, a representative to the ABA Joint Committee on Employee Benefits Council, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, Ms. Stamer has advised and represented employers on these and other labor and employment, compensation, employee benefit and other personnel and staffing matters for more than 22 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 access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Some other recent updates that may be of interested include the following, which you can access by clicking on the article title:

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.

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Posted by Cynthia Marcotte Stamer

President Signs Law Extending & Expanding Temporary AARA COBRA Subsidy Requirements For Group Health Plans

December 22, 2009

By Cynthia Marcotte Stamer

Employer and union sponsored group health plans, their sponsors and administrators must act quickly to comply with the extension and expansion of temporary “COBRA Subsidy Rules” for “assistance eligible individuals” originally added to the group health plan medical coverage continuation requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”) by the American Recovery and Reinvestment Act of 2009 (“AARA”) last February.

The Department of Defense Appropriations Act (H.R. 3326) signed into law by President Obama on December 19, 2009 extended the period that employer and union-sponsored group health plans must allow employees and members of their family that lose group health plan coverage due to an involuntary employment loss to continue their group medical coverage under the reduced premium and other temporary ARRA COBRA Subsidy Rules and lengthened the period during which an involuntary employment loss can qualify an otherwise COBRA-eligible employee or dependent as an assistance eligible individual.

Original COBRA Subsidy Rules

As originally enacted, the ARRA COBRA Subsidy Rules limited the COBRA premium that a COBRA-covered group health plan could charge a COBRA-eligible employee or dependent whose group health plan eligibility ended due to an involuntary employment loss between September 1, 2008 and December 31, 2009 (“assistance eligible individual”) to 35% of the otherwise applicable COBRA premium (the “Reduced ARRA Premium”) for a period of up to 9 months (the “Subsidy Period”). ARRA dictated that employers sponsoring these group health plans must pay the remaining 65% of the COBRA premium (the “COBRA Subsidy”) for the assistance eligible individual during the Subsidy Period, but allowed employers to seek reimbursement by claiming a payroll tax credit for these COBRA Subsidy payments by complying with applicable IRS procedures. AARA also mandated that group health plans offering a choice of coverage options offer assistance eligible individuals the option to switch coverage options and required group health plans to notify assistance eligible individuals of the special COBRA Subsidy Rules.

H.R. 3326 COBRA Subsidy Rules Extension

As signed into law on December 19, 2009, H.R. 3326:

Extends the period during which an involuntary employment loss can qualify an otherwise COBRA-eligible employee or dependent as an assistance eligible individual for an additional two months (from December 31, 2009 to February 28, 2010);
Adds an additional six months (from 9 to 15 months) the Subsidy Period during which an assistance eligible individual experiencing an involuntary loss of employment between September 1, 2008 and February 28, 2010 is entitled to pay the Reduced AARA Premium;
Requires group health plans to notify assistance eligible individuals of the extension; and
Requires group health plans to allow additional time for assistance eligible individuals who had exhausted their original 9-month Subsidy Period before H.R. 3326 extended the Subsidy Period to 15 months to pay the Reduced AARA Premium related to the extension.

Group health plans, their employer or union sponsors, administrators, insurers and service providers will need to act quickly to prepare and provider required updated notifications to assistance eligible individuals of these extended eligibility periods and their resulting rights, and otherwise update their plan documents, procedures, and COBRA notifications in light of these new rules.

If you have questions about or need assistance evaluating, commenting on or responding to these or other employment, health or other employee benefit, workplace health and safety, corporate ethics and compliance or other concerns or claims, please contact the author of this article, Curran Tomko Tarski LLP Labor & Employment Practice Group Chair Cynthia Marcotte Stamer. The author of the “Health Plan Eligibility Toolkit,” Ms. Stamer is experienced with assisting employers, insurers, administrators, and others to design and administer group health plans cost-effectively in accordance with COBRA and other applicable federal regulations as well as advising and defending employers and others against tax, employment discrimination and other labor and employment, and other related audits, investigations and litigation, charges, audits, claims and investigations by the IRS, Department of Labor and other federal and state regulators.. Chair of the American Bar Association RPTE Employee Benefits & Other Compensation Group, a representative to the ABA Joint Committee on Employee Benefits Council, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, Ms. Stamer has advised and represented employers on these and other labor and employment, compensation, employee benefit and other personnel and staffing matters for more than 22 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 access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Some other recent updates that may be of interested include the following, which you can access by clicking on the article title:

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.

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Posted by Cynthia Marcotte Stamer

Employer H1N1 Virus Risk Management Requires Employer Care To Manage Virus Risks Without Violating Employment Discrimination or Other Laws

November 30, 2009

As the Centers for Disease Control (CDC) continues cautioning Americans to expect a resurgence of the H1N1 virus, employers should continue to take prudent steps to defend their organization and their workers against a widespread H1N1 outbreak and the attendant lost time, health and disability costs, OSHA and other liability exposures and other personal and financial consequences likely to result from an outbreak.

Employers wishing to deter the spread of the disease in their workplace should educate workers about these recommendations and consider taking steps to encourage workers to comply with these recommendations. When planning or taking steps to protect their workplaces from the H1N1 virus pandemic or other outbreaks of communicable diseases, however, employers must use care to avoid violating the Americans With Disabilities Act or other employment laws.

Preventing, Recognizing & Mitigating Risks of H1N1

Although the number of reported cases of H1N1 virus cases has declined in many states in recent weeks, CDC officials are warning American’s that the crisis is not over yet. CDC officials last week warned Americans to expect H1N1 infection to rise as the holiday approaches and the winter progresses. With flu activity already higher than what is seen during the peak of many regular flu seasons and the H1NA virus accounting for almost all of the flu viruses identified so for this season, Accordingly, the CDC continues to encourage Americans to be alert for symptoms of H1N1 or other flu and to take other precautions including to get vaccinated.

Employers should continue to encourage workers and their families to take precautions to avoid catching the virus, to be on the watch for H1N1 virus or other flu infection and to respond appropriately if they, members of their families or others in the workplace exhibit these symptoms. To help promote health habits within their workforce, many businesses may want to download and circulate to employees and families the free resources published by the CDC here. Businesses and other concerned parties also can track governmental reports about the swine flu and other pandemic concerns at here.

For those not already suffering from the virus and particularly for those at higher risk, the CDC continues to recommend vaccination. People recommended by the CDC to receive the vaccine as soon possible include: health care workers; pregnant women; people ages 25 through 64 with chronic medical conditions, such as asthma, heart disease, or diabetes; anyone from 6 months through 24 years of age; and people living with or caring for infants under 6 months old. As the vaccine becomes available, many employers are encouraging workers and their families to get vaccinated by offering vaccination clinics at or near their worksites, arranging for health plan coverage for vaccinations with reduced or no co-payments or deductibles, and/or sharing information about government sponsored or other vaccination clinics.

Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too;
Stay home when you are sick to help prevent others from catching your illness;
Cover your mouth and nose;
Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick;
Clean your hands to protect yourself from germs;
Avoid touching your eyes, nose or mouth;
Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth; and
Practice other good health habits. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

Employers also should encourage workers and their families to be alert to possible signs of H1N1 or other flu symptoms and to respond appropriately to possible infection. According to the CDC, all types of flu including H1NA typically include many common symptoms, including:

Fever
Coughing and/or sore throat
Runny or stuffy nose
Headaches and/or body aches
Chills
Fatigue

Patients suffering from H1N1 flu usually report these same symptoms, but the symptoms often are more severe. In addition to the above symptoms, a number of H1N1 flu cases reported vomiting and diarrhea.

CDC recommends individuals diagnosed with H1N1 flu should:

Stay home and avoid contact with others for at least 24 hours after a fever (100°F or 37.8°C) is gone without the use of fever reducing medicine except to get medical care or for other things that must be done that no one else can do;
Avoid close contact with others, especially those who might easily get the flu, such as people age 65 years and older, people of any age with chronic medical conditions (such as asthma, diabetes, or heart disease), pregnant women, young children, and infants;
Clean hands with soap and water or an alcohol-based hand rub often, especially after using tissues or coughing/sneezing into your hands;
Cover coughs and sneezes;
Wear a facemask when sharing common spaces with other household members to help prevent spreading the virus to others. This is especially important if other household members are at high risk for complications from influenza;
Drink clear fluids such as water, broth, sports drinks, or electrolyte beverages made for infants to prevent becoming dehydrated;
Get plenty of rest;
Follow doctor’s orders; and
Watch for signs for a need for immediate medical attention. Suffers should get medical attention right away if the sufferer has difficulty breathing or chest pain, purple or blue discoloration of the lips, is vomiting and unable to keep liquids down, or shows signs of dehydration, such as feeling dizzy when standing or being unable to urinate.

In seeking to contain the spread of the virus within their workplace, employers also should be sensitive to workplace policies or practices that may pressure employees with a contagious disease to report to work despite an illness and consider whether the employer should adjust these policies temporarily or permanently in light of the ongoing pandemic. For instance, financial pressures and the design and enforcement of policies regarding working from home and/or qualifying for paid or unpaid time off significantly impact the decisions employees make about whether to come to work when first experiencing symptoms of illness. Employers of workers who travel extensively – may wish to delay or restrict travel for some period.

Employers Must Employment Discrimination & Other Legal Compliance Risks

Many employers may want to evaluate and appropriately revise existing policies with an eye to better defending their workforce against a major outbreak. Whether or not the disease afflicts any of its workers, businesses can anticipate the swine flu outbreak will impact their operations – either as a result of occurrences affecting their own or other businesses or from workflow disruptions resulting from safeguards that the business or other businesses implement to minimize swine flu risks for its workforce or its customers. Many businesses also will want to prepare backup staffing and production strategies to prepare for disruptions likely to result if a significant outbreak occurs.

Employers planning for or dealing with an H1N1 or other epidemic in their workplace should exercise care to avoid violating the nondiscrimination and medical records confidentiality provisions of the Americans with Disabilities Act (ADA) and/or the Genetic Information Nondiscrimination Act (GINA), the Family & Medical Leave Act of 1990 (FMLA), the Fair Labor Standards Act (FLSA) and applicable state wage and hour laws, and other employment and privacy laws.

Improperly designed or administered medical inquiries, testing, vaccination mandates and other policies or practices intended to prevent the spread of disease may expose an employer to disability discrimination liability under the ADA or GINA. For instance, the ADA generally prohibits an employer from making disability-related inquiries and requiring medical examinations of employees, except under limited circumstances permitted by the ADA. Likewise, improperly designed or communicated employer inquiries into family medical status which could be construed as inquiring about family medical history also may raise exposures under genetic information nondiscrimination and privacy mandates of GINA that took effect November 21, 2009.

During employment, the ADA prohibits employee disability-related inquiries or medical examinations unless they are job-related and consistent with business necessity. Generally, a disability-related inquiry or medical examination of an employee is job-related and consistent with business necessity when an employer has a reasonable belief, based on objective evidence, that:

An employee’s ability to perform essential job functions will be impaired by a medical condition; or
An employee will pose a direct threat due to a medical condition.

This reasonable belief “must be based on objective evidence obtained, or reasonably available to the employer, prior to making a disability-related inquiry or requiring a medical examination.”

Additionally, the ADA prohibits employers from making disability-related inquiries and conducting medical examinations of applicants before a conditional offer of employment is made. It permits employers to make disability-related inquiries and conduct medical examinations if all entering employees in the same job category are subject to the same inquiries and examinations. All information about applicants or employees obtained through disability-related inquiries or medical examinations must be kept confidential. Information regarding the medical condition or history of an employee must be collected and maintained on separate forms and in separate medical files and be treated as a confidential medical record. The EEOC Pandemic Preparedness In The Workplace and The Americans With Disabilities Act Guidance makes clear that employer inquiries and other H1N GINA’s inclusion of information about the “manifestation of a disease or disorder in family members” is likely to present a liability trap door for many unsuspecting employers H1N1 and other epidemic planning and response activities should be carefully crafted to avoid violating these proscriptions.

GINA’s inclusion of information about the “manifestation of a disease or disorder in family members” also could present a liability trap door for some employers designing pandemic or other workplace wellness, disease management or other programs. GINA defines “genetic information” broadly as including not only information about genetic tests about an individual or his family member as well as information about the “manifestation of a disease or disorder in family members of such individual, GINA also specifies that any reference to genetic information concerning an individual or family member includes genetic information of a fetus carried by a pregnant woman and an embryo legally held by an individual or family member utilizing an assisted reproductive technology. For more information about the new GINA genetic information employment discrimination rules, see here.

As part of their pandemic planning, employers also generally should review their existing wage and hour and leave of absence practices. Employers should ensure that their existing or planned practices for providing paid or unpaid leave are designed to comply with the FLSA and other wage and hour and federal and state leave of absence laws. Employers also should review and update family and medical leave act and other sick leave policies, group health plan medical coverage continuation rules and notices and other associated policies and plans for compliance with existing regulatory requirements, which have been subject to a range of statutory and regulatory amendments in recent years. If considering allowing or requiring employees to work from home, employers also need to implement appropriate safeguards to monitor and manage employee performance, to protect the employer’s ability to comply with applicable wage and hour, worker’s compensation, OSHA and other safety, privacy and other legal and operational requirements.

Businesses, health care providers, schools, government agencies and others concerned about preparing to cope with pandemic or other infectious disease challenges also may want to review the publication “Planning for the Pandemic” authored by Curran Tomko Tarski LLP partner Cynthia Marcotte Stamer available at here. FLU.gov is a one-stop resource with the latest updates on the H1N1 flu. An additional resource is CDC INFO, 1-800-CDC-INFO (1-800-232-4636), which offers services in English and Spanish, 24 hours a day, 7 days a week. Schools, health care organizations, restaurants and other businesses whose operations involve significant interaction with the public also may need to take special precautions. These and other businesses may want to consult the special resources posted here.

Cynthia Marcotte Stamer and other members of Curran Tomko and Tarski LLP are experienced with advising and assisting employers with these and other labor and employment, employee benefit, compensation, and internal controls matters. If your organization needs assistance with assessing, managing or defending these or other labor and employment, compensation or benefit practices, please contact the author of this article, Curran Tomko Tarski LLP Labor & Employment Practice Group Chair Cynthia Marcotte Stamer. 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 is experienced with assisting 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, as well as advising and defending employers and others against tax, employment discrimination and other labor and employment, and other related audits, investigations and litigation, charges, audits, claims and investigations by the IRS, Department of Labor and other federal and state regulators. Ms. Stamer has advised and represented employers on these and other labor and employment, compensation, health and other employee benefit and other personnel and staffing matters for more than 22 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 access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Examples of other recent updates you may have missed include:

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.

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Posted by Cynthia Marcotte Stamer

Congress Considering Extending & Expanding Group Health Plan COBRA Subsidy Mandates On Heels of Enactment of Expanded Military Leave-Related Family Leave Mandates

November 5, 2009

Following up on its October expansion of federal requirements that employers and their group health plans provide family leave rights in relation to certain military related absences, Congress now is considering extending and expanding the “COBRA Premium Subsidy” rules for group health plans enacted by Congress on February 17, 2009 as part of the American Recovery and Reinvestment Act of 2009 (ARRA) beyond their currently scheduled December 31, 2009 expiration date and further to restrict the amount that group health plans can charge former employees and their dependents covered by the COBRA Premium Subsidy rules to maintain coverage under the coverage continuation mandates of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”).

COBRA generally allows employee and dependents who otherwise would lose eligibility for group health benefits under union or employer sponsored plans temporarily to continue enrollment in the group health plan by paying up to 102 percent of the full cost of that coverage (the “COBRA premium”) and fulfilling certain other conditions set forth in COBRA. Under ARRA’s COBRA Premium Subsidy Rules, Congress among other things amended COBRA through December 31, 2009 to require that employers “subsidize” 65% of the otherwise applicable COBRA premium for employees or dependents electing COBRA coverage following a loss of eligibility due to the involuntary employment termination between September 15, 2008 and December 31, 2009 who otherwise qualify as “assistance eligible individuals” under ARRA. The COBRA Premium Subsidy rules created a mechanism through which employers providing the required COBRA Premium Subsidy can claim a payroll tax credit for COBRA Premium Subsidy amounts paid with respect to assistance eligible individuals in accordance with ARRA’s mandates.

Senator Sherrod Brown (D-Ohio) and Robert P. Casey (D-PA) now are proposing that Congress extend and expand ARRA COBRA Premium Subsidy requirements applicable to group health plans as proposed by the “COBRA Subsidy Extension and Enhancement Act” (S. 2730). Introduced on November 5, 2009, the Government Printing Office had not published the text of S. 2730 as of the release of this publication. However, It is expected that the official text of S. 2730 will be made available for review soon here. In the meanwhile, the reading of S. 2730 into the record when introduced in the Senate on November 4, 2009 and its sponsors’ news releases, the “COBRA Subsidy Extension and Enhancement Act” (S. 2730) proposes that Congress:

Extend the COBRA Premium Subsidy requirements an extra six months to 15 months;
Increase the required subsidy amount during the extended COBRA Premium Subsidy period from 65 percent to 75 percent of the COBRA premium; and
Clarify that the employees and dependents eligible to qualify as assistance eligible individuals under ARRA includes those losing group health plan eligibility due to an employment loss, whether from an actual employment termination or a decline in hours of employment.

Expanded FMLA Military Leave Related Mandates Added Under Defense Appropriations Laws Already Require Immediate Action

The proposal in S. 2730 to extend the ARRA COBRA Premium Subsidy mandates is the latest in a series of recently enacted and proposed federal laws and implementing regulations imposing an ever-expanding list of federal eligibility mandates on employment based group health plans. These include not only an expanding list of federal mandates that group health plans make available continued coverage to individuals whose eligibility for coverage otherwise would end on account of an employment decline or loss such as those enacted as part of the National Defense Authorization Act for Fiscal Year 2010, Public Law 111-84 (“2010 NDAA”), signed into law by President Obama on October 28, 2009 and the National Defense Authorization Act for Fiscal Year 2008 the (“2008 NDAA”) signed into law by President Bush in January, 2008. These FMLA military leave-related mandates are in addition to separate group health coverage continuation mandates separately imposed upon employers and group health plans under the Uniformed Services Employment and Reemployment Rights Act (USERRA).

For instance, the 2008 NDAA amended the Family and Medical Leave Act (“FMLA”) to add new family military-leave provisions, which were further expanded by the 2010 NDAA. The 2008 NDAA adds two new qualifying circumstances under which eligible employees must be allowed to take FMLA leave and to continue group health plan coverage during that FMLA:

“Qualifying exigency leave” and
“Military caregiver leave,” also referred to as “leave to care for a covered servicemember.”

Final regulations implementing the 2008 NDAA FMLA mandates and other FMLA requirements took effect on January 16, 2009. The NDAA for 2010 further amended these family military-leave mandates to expand the circumstances under which the FMLA leave mandates employers and their group health plans extend FMLA leave rights in relation to military members.

Beyond these military-leave related group health plan mandates, group health plans also are required to comply with a host of other recently-expanded federal eligibility and other mandates such as new mandates to offer up to 12-months coverage continuation for dependents whose coverage otherwise would terminate due to a medically required break in school enrollment, expanded group health plan special enrollment and nondiscrimination rules imposed under ARRA, the Genetic Information and Nondiscrimination Act (“GINA”) and the Health Insurance Portability & Accountability Act (“HIPAA”) and various others. Congress is considering further amendments to these and other federal mandates under proposals included in the various health care bills being heavily debated in Congress, as well as others included in legislation proposed separately from these broader health care reform proposals.

Take Prompt Action to Manage Risks

In addition to monitoring and sharing their input with Congress about S. 2730 and other proposed legislation impacting their group health plans, group health plans, their sponsoring employers or unions, insurers, fiduciaries and administrative service providers also should take prompt action to ensure that their group health plan documents, notices and other communications, processes and procedures have been properly updated in response to the statutory regulatory changes to federal group health plan eligibility and other mandates.

If you have questions about or need assistance reviewing or sharing your input with Congress about S. 2730 or other proposed legislation, evaluating and updating, administering or defending your group health plan in light of these or other federal regulations, or with other employee benefit, employment, compensation, workplace health and safety, corporate ethics and compliance practices, concerns or claims, please contact the author of this article, Curran Tomko Tarski LLP Labor & Employment Practice Group Chair Cynthia Marcotte Stamer. Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization and Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group and past chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer has more than 20 years experience advising and representing employee benefit plans, employers, plan sponsors and fiduciaries, administrative services providers, insurers and others about these and other related matters. Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions 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.

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Posted by Cynthia Marcotte Stamer

November 15, 2009 Is Deadline To Send Required Group Health Plan Medicare Part D “Creditable Coverage” Notice

November 3, 2009

November 15, 2009 is the deadline for group health plans providing prescription drug coverage to send the annually-required notification (the “Part D Notice”) to Medicare-eligible participants whether the plan’s prescription drug coverage is or is not “creditable coverage” (“Creditable Coverage”) for purposes of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (the “MMA”) “Part D” prescription drug coverage program. Before distributing the required Part D Notice, group health plan sponsors and administrators should review and update the Part D Notice as needed in light of 2009 revisions to the Part D Notice requirements issued earlier this year by CMS.

The MMA generally mandates that covered employer-sponsored group health plans send a Part D Notice that complies with the form and content requirements established by the Centers for Medicare & Medicaid Services (“CMS”) to all Medicare Part D-eligible individuals covered under, or who apply for, enrollment in a group health plan providing prescription drug coverage at each of the following times:

Before the Medicare Part D annual coordinated election period (November 15 – December 31) each year;
Within the 12 months before an individual’s initial enrollment period for Medicare;
Before the effective date of coverage for a Medicare-eligible individual beginning participation in the group health plan;
When the plan’s prescription drug coverage ends or is no longer creditable; and
Upon a beneficiary’s request.

Because CMS posted revised model notices and updated guidance regarding creditable coverage disclosures earlier this year, plan sponsors and administrators before distributing their Part D Notice generally will need to:

Determine whether their group health plan does or does not provide creditable coverage for purposes of Medicare Part D regulations;
Determine which Medicare Part D notification should be provided in light of the existing group health plan design; and
Review and update, if necessary, the content and form of the Part D Notice to comply with the updated guidance issued earlier this year.

The Annual Part D Notice requirement generally applies to all group health plans not otherwise specifically excluded from coverage even those that do not provide retiree coverage. The MMA generally requires notification to Medicare Part D-eligible employees and dependents, regardless of whether the member is enrolled under active or retired coverage or whether the group health plan coverage is primary or secondary to Medicare.

A group health plan must determine if its prescription drug coverage is “creditable coverage” in accordance with rules contained in the Medicare Part D regulations. These regulations generally specify that prescription drug coverage qualifies as creditable coverage if the actuarial value of the coverage equals or exceeds the actuarial value of the Part D prescription drug coverage, as demonstrated through the use of generally accepted actuarial principles in accordance with CMS actuarial guidelines. This actuarial determination measures whether the expected amount of paid claims under the group health plan’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. In lieu of an actuarial assessment, the Medicare Part D regulations alternatively allow group health plans to rely upon a safe harbor rule. Under this safe harbor, group health plans offering prescription drug coverage qualify as providing Creditable Coverage without an actuarial assessment if the standards of the safe harbor rule are met.

This determination of creditable coverage for Medicare Part D purposes is separate and distinct from the requirement that group health plans determine and provide notification of “creditable coverage” when group health plan coverage ends pursuant to the group health plan portability requirements imposed by the Health Insurance Portability & Accountability Act of 1996, as amended (“HIPAA”).

When distributing the Part D Notice, group health plan sponsors and administrators also generally will want to make arrangements to ensure that separately required notifications to CMS regarding the creditable coverage status of the group health plan under Medicare Part D will be timely made as well as calendar reminders to prepare and provide the Part D Notice expected to be required in November, 2010. The Medicare Part D regulations also generally require group health plans also to provide a “Disclosure Notice” to CMS informing it whether the applicable group health plan provides Medicare Part D Creditable Coverage on an annual basis during the first 60 days of the plan year, and upon any change that affects whether the group health plan provides prescription drug coverage that is or is not creditable coverage for Medicare Part D purposes..

In addition to the Medicare Part D notice requirements, group health plans also are required to provide various other annual and other notifications by ERISA, the Health Insurance Portability & Accountability Act of 1996, as amended (“HIPAA”), Newborns’ and Mothers’ Health Protection Act, medical coverage e continuation requirements under the Consolidated Omnibus Budget Reconciliation Act, as amended (“COBRA”), the Family & Medical Leave Act and a host of other federal laws, many of require updates in response to statutory and/or regulatory changes in the past year. In addition to updating and providing the required Medicare Part D Notice, many group health plan sponsors and administrators also should review and update their group plan language, notifications and processes in response to amendments affecting these practices as well as a series of other recent changes to federal mandates affecting group health plans. For more information about these and other developments affecting group health plans, checkout some of the writings and recorded presentations of Ms. Stamer available here.

If you need assistance reviewing or updating your group health plan’s implications of the MMA on your group health plans or other health or employee benefit plan requirements, please contact the author of this article, Curran Tomko Tarski LLP Labor & Employment Practice Group Chair Cynthia Marcotte Stamer. 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 past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer is nationally recognized for her more than 20 years work, writing and leadership advising employers and other plan sponsors, plan administrators and fiduciaries, insurers, administrative services providers, brokers, and others about the design, documentation, administration and defense of health and other employee benefit, insurance, and other compensation and employment practices. Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. 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 participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here. Some other recent updates that may be of interested include the following, which you can access by clicking on the article title:

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.

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Posted by Cynthia Marcotte Stamer

Register Now For HITECH Act Health Data Security & Breach Update: Learn What You Must Do This Month To Comply With New Health Data Breach Regulations

September 2, 2009

September 10, 2009 – Noon to 1:30 P.M. Central Time Participate In Person or Via Remote!

Health care providers, health plans, health clearinghouses and their business associates (Covered Entities) must comply with the new “Breach Notification For Unsecured Protected Health Information” regulation (Breach Regulation) by September 23, 2009.

Catch up on what the Breach Rule means for your organization and how it must respond by participating in the “HITECH Act Health Data Security & Breach Update” on Thursday, September 10, 2009 from Noon to 1:30 P.M. Central Time for a registration fee of $45.00. Registrants will have the option to participate via teleconference or in person at the offices of Curran Tomko Tarski LLP, 2001 Bryan Street, Suite 2050, Dallas Texas 75201. For information about registering for this program or other questions here,

The Breach Rule requires Covered Entities to notify affected individuals following a “breach” of “unsecured” protected health information. Just published August 24^th, the Breach Regulation is part of a series of guidance that HHS is issuing to implement new and stricter personal health information privacy and data security requirements for Covered Entities added to HIPAA under the Health Information Technology for Economic and Clinical Health (HITECH) Act signed into law on February 17, 2009 as part of American Recovery and Reinvestment Act of 2009 (ARRA). The briefing will cover:

Who must comply, health plans, employers, others?
What your organization must do
How to qualify protected health information as exempt from the breach regulations as “secure” protected health information
What is considered a breach of unsecured protected health information
What steps must a covered entity take if a breach of unsecured protected information happens
What liabilities do covered entities face for non-compliance
What new contractual requirements, policies and procedures Covered Entities and Business Associates will need
How the Breach Regulation, the Privacy Regulation, impending FTC red flag rules and state data breach and privacy rules interrelate
Other recent developments
Practical tips for assessing, planning, moving to and defending compliance
Participant questions
More

About The Presenter

The program will be presented by Curran Tomko and Tarski LLP Health Care & Employee Benefits Practice Leader and Partner Cynthia Marcotte Stamer. Ms. Stamer is nationally known for her work, publications and presentations on privacy and security of health and other sensitive information in health and managed care, employment, employee benefits, financial services, education and other contexts. Chair of the ABA RPTE Employee Benefits & Other Compensation Committee, a ABA Joint Committee on Employee Benefits Council Representative, Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 20 years experience advising clients about health and other privacy and security matters. A popular lecturer and widely published author on privacy and data security and other related health care and health plan matters, Ms. Stamer is the Editor in Chief of the forthcoming 2010 edition of the Information Security Guide to be published by the American Bar Association Information Security Committee in 2010, as well as the author of “Protecting & Using Patient Data In Disease Management: Opportunities, Liabilities And Prescriptions,” “Privacy Invasions of Medical Care-An Emerging Perspective,” “Cybercrime and Identity Theft: Health Information Security Beyond HIPAA,” and a host of other highly regarded publications. She has continuously advises employers, health care providers, health insurers and administrators, health plan sponsors, employee benefit plan fiduciaries, schools, financial services providers, governments and others about privacy and data security, health care, insurance, human resources, technology, and other legal and operational concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry privacy, data security and other technology, regulatory and operational risk management matters. Her insights on health care, health insurance, human resources and related matters appear in the Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

We hope that this information is useful to you. If you need assistance monitoring, evaluating or responding to these or other compliance, risk management, transaction or operation concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (214) 270-2402, cstamer@cttlegal.com or another Curran Tomko Tarski LLP Partner of your choice.

Other Helpful Resources & Other Information

If you find this of interest, you also be interested in one or more of the following other recent articles published on our electronic Curran Tomko Tarski LLP publications 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 provided by Curran Tomko Tarski LLP attorneys and get information about its attorneys’ experience, briefings, speeches and other credentials here.

Comments Off on Register Now For HITECH Act Health Data Security & Breach Update: Learn What You Must Do This Month To Comply With New Health Data Breach Regulations | Corporate Compliance, Data Security, Disease Management, Employers, GINA, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Privacy, Protected Health Information | Tagged: Corporate Compliance, Employee Benefits, Employer, Employers, Employment, ERISA, GINA, Health Care Reform, Health Insurance, Health Plans, Human Resources, Insurance, Insurer, Internal Controls, Managed Care, Medical Coverage, Privacy | Permalink
Posted by Cynthia Marcotte Stamer

Employer & Other Health Plans & Other HIPAA-Covered Entities & Their Business Associates Must Comply With New HHS Health Information Data Breach Rules By September 23

August 24, 2009

Employer and other health plans, health care providers, health clearinghouses and their business associates must start complying with new federal data breach notification rules on September 23, 2009.

The new “Breach Notification For Unsecured Protected Health Information” regulation (Breach Regulation) published here in today’s Federal Register requires health plans, health care providers, health care clearinghouses and their business associates (Covered Entities) covered under the personal health information privacy and security rules of the Health Insurance Portability & Accountability Act (HIPAA) to notify affected individuals following a “breach” of “unsecured” protected health information.The Breach Regulation is part of a series of guidance that HHS is issuing to implement new and stricter personal health information privacy and data security requirements for Covered Entities added to HIPAA under the Health Information Technology for Economic and Clinical Health (HITECH) Act signed into law on February 17, 2009 as part of American Recovery and Reinvestment Act of 2009 (ARRA).

You are invited to catch up on what these new rules mean for your organization and how it must respond by participating in the “HITECH Act Health Data Security & Breach Update” on Wednesday, September 9 2009 from Noon to 1:30 P.M. Central Time.

HITECH Act Data Breach and Unsecured PHI Rules

Published in the August 24, 2009 Federal Register, the new Breach Regulation implements the HITECH Act requirement that Covered Entities and their business associates notify affected individuals, the Secretary of HHS, and in some cases, the media, when a breach of “unsecured protected health information” happens and the form, manner, and timing of that notification. Covered Entities must begin complying with the new Breach Regulation on September 23, 2009.

Part of a series of new HHS rules implementing recent changes to HIPAA enacted under the HITECH Act to strengthen existing federally mandates requiring Covered Entities to safeguard protected health information, the Breach Regulation will obligate Covered Entities and business associates to provide certain notifications following a breach of “protected health information” that not secured at the time of the breach through the use of a technology or methodology meeting minimum standards issued by HHS pursuant to other provisions of the HITECH Act.

Under the HITECH Act, the breach notification obligations contained in the Breach Notification only apply to a breach of “unsecured protected health information.” The Breach Regulation exempts breaches of protected health information that qualify as “secured” under separately issued HHS and Federal Trade Commission (FTC) standards for encryption and destruction of protected health information from its breach notification requirements.

For purposes of the HITECH Act, electronic protected health information is considered “unsecured” unless the Covered Entity has satisfied certain minimum standards for the protection of that data established pursuant to the HITECH Act. Earlier this year, HHS and the FTC issued interim rules defining the minimum encryption and destruction technologies and methodologies that Covered Entities must use to render protected health information unusable, unreadable, or indecipherable to unauthorized individuals for purposes of determining when protected health information is “unsecured” for purposes of the HITECH Act. Concurrent with its publication of the Breach Regulation, HHS also released guidance updating and clarifying this previously issued guidance.

Read the Breach Regulation here . To review the HITECH Act Breach Notification Guidance and Request for Information, see here .

Register For September 9, 2009 “HITECH Act Health Data Security & Breach Update”

Interested persons are invited to register here now to learn what these new rules mean for your organization and how it must respond by participating in the “HITECH Act Health Data Security & Breach Update” on Wednesday, September 9, 2009 from Noon to 1:30 P.M. Central Time. For a registration fee of $45.00, registrants will have the option to participate via teleconference or in person at the offices of Curran Tomko Tarski LLP, 2001 Bryan Street, Suite 2050, Dallas Texas 75201. For questions or other information about this program, e-mail here.

Conducted by Curran Tomko and Tarski LLP Partner Cynthia Marcotte Stamer, the briefing will cover:

Who must comply
What your organization must do
How to qualify protected health information as exempt from the breach regulations as “secure” protected health information
What is considered a breach of unsecured protected health information
What steps must a covered entity take if a breach of unsecured protected information happens
What liabilities do covered entities face for non-compliance
What new contractual requirements, policies and procedures Covered Entities and Business Associates will need
How the Breach Regulation, the Privacy Regulation, impending FTC red flag rules and state data breach and privacy rules interrelate
Other recent developments
Practical tips for assessing, planning, moving to and defending compliance
Participant questions
More

About The Presenter

The program will be presented by Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer. Ms. Stamer is nationally known for her work, publications and presentations on privacy and security of health and other sensitive information in health and managed care, employment, employee benefits, financial services, education and other contexts.

Past Chair of the ABA Health Law Section Managed Care & Insurance Section and currently the Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Section and a Council Representative of the ABA Joint Committee On Employee Benefits, Ms. Stamer has more than 20 years experience advising clients about health and other privacy and security matters. A popular lecturer and widely published author on privacy and data security and other related health care and health plan matters, Ms. Stamer is the Editor in Chief of the forthcoming 2010 edition of the Information Security Guide to be published by the American Bar Association Information Security Committee in 2010, as well as the author of “Protecting & Using Patient Data In Disease Management: Opportunities, Liabilities And Prescriptions,” “Privacy Invasions of Medical Care-An Emerging Perspective,” “Cybercrime and Identity Theft: Health Information Security Beyond HIPAA,” and a host of other highly regarded publications. She has continuously advises employers, health care providers, health insurers and administrators, health plan sponsors, employee benefit plan fiduciaries, schools, financial services providers, governments and others about privacy and data security, health care, insurance, human resources, technology, and other legal and operational concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry privacy, data security and other technology, regulatory and operational risk management matters. Her insights on health care, health insurance, human resources and related matters appear in the Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

We hope that this information is useful to you. If you need assistance monitoring, evaluating or responding to these or other compliance, risk management, transaction or operation concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (214) 270-2402, cstamer@cttlegal.com or another Curran Tomko Tarski LLP Partner of your choice.

Other Helpful Resources & Other Information

If you found these updates of interest, you also be interested in one or more of the following other recent articles published on our electronic Curran Tomko Tarski LLP publications 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 provided by Curran Tomko Tarski LLP attorneys and get information about its attorneys’ experience, briefings, speeches and other credentials here.

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Posted by Cynthia Marcotte Stamer

Health Plans Must Comply with New HHS Interim Final Data Breach Rules Beginning September 24; Register to Participate In September 10th Briefing on New Rules In Person or Via Telephone

August 20, 2009

Employers and other health plan sponsors, fiduciaries, insurers and service providers need to move quickly to prepare to comply with “breach notification” regulations issued by the U.S. Department of Health and Human Services (HHS) yesterday (August 19, 2009). The new data breach regulations will require health plans, as well as health care providers, business associates and other covered entities (Covered Entities) under the personal health information privacy and security rules of the Health Insurance Portability & Accountability (HIPAA) to notify affected individuals following a “breach” of “unsecured” protected health information. Scheduled for publication in the Federal Register on August 24, 2009, the new breach notification regulations are part of a series of new rules that implement new electronic personal health information data security and data breach notification requirements for Covered Entities added to HIPAA under the Health Information Technology for Economic and Clinical Health (HITECH) Act signed into law on February 17, 2009 as part of American Recovery and Reinvestment Act of 2009 (ARRA). Covered entities must begin complying with the new rules no later than September 24, 2009.

Curran Tomko Tarski, LLP Health Practice leader Cynthia Marcotte Stamer will conduct a briefing on these new protected health information data security and data breach rules on Thursday, September 10, 2009 from Noon to 1:30 P.M. Central Time. For a registration fee of $45.00, registrants will have the option to participate via teleconference or in person at the offices of Curran Tomko Tarski LLP, 2001 Bryan Street, Suite 2050, Dallas Texas 75201. For more information, e-mail here.

HITECH Act Data Breach and Unsecured PHI Rules

The new data breach notification rules are part of a series of recent HIPAA enacted under the HITECH Act to strengthen the federal rules requiring HIPAA covered entities to safeguard electronic and certain other protected health information. Enhanced data security and data breach rules added as part of these HITECH Act amendments obligate covered entities and business associates to provide certain notifications following a breach of “unsecured” “protected health information” within the meaning of HIPAA, as amended. “Unsecured protected health information” is defined as protected health information that is not secured through the use of a technology or methodology specified by the HHS Secretary.

The new data breach regulations implement the HITECH Act requirement that Covered Entities and their business associates notify affected individuals, the Secretary of HHS, and in some cases, the media, of a breach and the form, manner, and timing of that notification. For purposes of the HITECH Act, electronic protected health information is considered “unsecured” unless the covered entity has satisfied certain minimum standards for the protection of that data established pursuant to the HITECH Act. HHS and the Federal Trade Commission previously issued certain initial guidance concerning the HITECH Act standards for determining when electronic personal health information qualifies as secure. To help further define when electronic health information is treated as “unsecured” and therefore subject to the breach notification requirements, the data breach rules also update and clarify the previously issued existing HHS guidance specifying encryption and destruction as the technologies and methodologies that render protected health information unusable, unreadable, or indecipherable to unauthorized individuals published earlier this year by HHS to for purposes of determining when protected health information will be considered “unsecured” for purposes of the HITECH Act data breach rules. Entities subject to the HHS and FTC regulations that secure health information as specified by the guidance through encryption or destruction are relieved from having to notify in the event of a breach of such information.

The HHS interim final regulations are effective September 24, 2009, which is the date 30 days after the date they will be published on the Federal Register and include a 60-day public comment period. To review the interim final data breach regulations, see here. To review the HITECH Act Breach Notification Guidance and Request for Information, see here.

For More Information

The author of this article, Curran Tomko and Tarski LLP Labor and Employment and Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting employer and other health plan sponsors, insurers, managed care providers and other health and insurance industry clients about HIPAA and other privacy and data security matters, as well as a diverse range of health care, employment, and emplyee benefit policy, regulatory, compliance, risk management and operational concerns.

Current Chair of the American Bar Association (ABA) Real Property, Trusts & Estates Employee Benefit & Other Compensation Committee, an ABA Joint Committee on Employee Benefits Council member, past chair of the American Bar Association Health Law Section Managed Care & Insurance Section, Martindale Hubble AV-rated and recognized in International Who’s Who of Professionals, Ms. Stamer continuously advises health care providers, health care payers and administrators, employers, governments and others about health care, insurance, human resources, privacy and data security, technology, and other legal and operational concerns. A popular lecturer and widely published author on privacy and data security and other related health care and health plan matters, Ms. Stamer also writes and speaks extensively on health and managed care industry privacy, data security and other technology, regulatory and operational risk management matters. She currently serves as the Editor in Chief of the forthcoming 2010 edition of the Information Security Guide to be published by the American Bar Association Information Security Committee in 2010. Examples of her other works include “Protecting & Using Patient Data In Disease Management: Opportunities, Liabilities And Prescriptions,” “Privacy Invasions of Medical Care-An Emerging Perspective,” “Cybercrime and Identity Theft: Health Information Security Beyond HIPAA,” and a host of others. Her insights on health care, health insurance, human resources and related matters appear in the Atlantic Information Service Privacy Report, The Wall Street Journal, Business Insurance, the Dallas Morning News, Managed Healthcare, Health Leaders, and a various other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

We hope that this information is useful to you. If you need assistance monitoring, evaluating or responding to these or other proposed health care or other regulatory reforms or with other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270-2402, cstamer@cttlegal.com or your other favorite Curran Tomko Tarski LLP Partner.

We also encourage you and others to join the discussion about these and other health care reform proposals and concerns by joining the Coalition for Responsible Health Care Reform Group on Linkedin, registering to receive these updates here.

Other Helpful Resources & Other Information

We hope that this information is useful to you. If you found these updates of interest, you also be interested in one or more of the following other recent articles published on our electronic Solutions Law Press Health Care Update publication available here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please register to receive this Solutions Law Press Health Care Update here and 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 provided by Curran Tomko Tarski LLP attorneys and get information about its attorneys’ experience, briefings, speeches and other credentials here.

Comments Off on Health Plans Must Comply with New HHS Interim Final Data Breach Rules Beginning September 24; Register to Participate In September 10th Briefing on New Rules In Person or Via Telephone | Corporate Compliance, ERISA, GINA, Health Plans, HIPAA, Human Resources, Insurance, Internal Controls, Internal Investigations | Tagged: Corporate Compliance, Data Breach, Data Security, Date Security, Employee Benefits, Employers, ERISA, GINA, Health Plans, HIPAA, Human Resources, Insurance, Insurer, Internal Controls, Managed Care, PHI, Privacy, Privacy Rule, Protected Health Information, Security Rule | Permalink
Posted by Cynthia Marcotte Stamer

House Democratic Majority Hopes To Iron Out Differences In Key Health Care Reform Legislation During August Recess

August 4, 2009

Democratic Leaders in the House of Representatives plan to hammer out differences three versions of the America’s Affordable Health Choices Act (H.R. 3200) as separately passed by three key House Committees in July before House members return from their August recess in hopes of bringing the agreed to version of H.R. 3200 to the full house in September. Each version of H.R. 3200 would impose significant new obligations, regulations and costs on employers, health insurers and health plans, and employees.

After negotiating a last minute pre-August recess deal with certain Blue Dog Democrat Committee members, the House Energy and Commerce Committee on July 31, 2009 passed its version of H.R. 3200, the America’s Affordable Health Choices Act (H.R. 3200). The version of H.R. 3200 passed by the House Energy and Commerce Committee incorporates a series of amendments to the language of H.R. 3200 as originally introduced. For instance, this version of H.R. 3200 provides incentives for states to adopt certain tort reforms, provides for a public plan option that would reimburse physicians based on negotiated rates rather Medicare rates, and would allow states to offer both state-based heath insurance exchanges and health insurance co-ops. To review H.R. 3200 as amended by the House Energy and Commerce Committee, see here.

The approval by the Energy and Commerce Committee of its version of H.R. 3200 follows the July 17, 2009 approval by the House Ways and Means Committee and Education and Labor Committee of their own versions of H.R. 3200. For details on the version of H.R. 3200 approved by the House Ways and Means Committee, see here. For details on the version of H.R. 3200 approved by the House Education and Labor Committee, see here.

Leading House Democrats have announced their intention to work to resolve differences between these three versions of H.R. 3200 as passed by these Committees during August recess in hopes of bringing the agreed to version of H.R. 3200 to a vote of the full House of Representatives in September.

Meanwhile, House members from both parties also generally are using the August recess as an opportunity to reconnect with local constituents on health care reform and other core issues.

For More Information

The author of this article, Curran Tomko and Tarski LLP Partner Cynthia Marcotte Stamer has extensive experience advising and assisting employers and other health plan sponsors, insurers and others about health benefit and other benefits, human resources and health care matters. The current Chair of the American Bar Association Real Propoerty, Probate & Trust Section Employee Benefit Plans and Other Compensation Committee and former Chair of the ABA Health Law Section Managed Care & Insurance Group, she regularly advises these and other clients about the design, administration, defense and regulation of health benefit, wellness and disease management, managed care, onsight wellness, and other benefit and insurance regulations, legislative and regulatory reforms impacting these and other arrangements, and related matters.

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 or e-mailing this information to cstamer@cttlegal.com. If you prefer not to receive these updates via e-mail in the future, e-mail your request with “remove” in the subject to support@solutionslawyer.net.

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Posted by Cynthia Marcotte Stamer

HHS Reassignment Of HIPAA Enforcement Duties Signals Rising Seriousness of Enforcement Commitment

August 3, 2009

The Department of Health & Human Services (HHS) today (August 3, 2009) transferred authority for the administration and enforcement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule to the Office for Civil Rights (OCR). Prior to this announcement, responsibility for interpretation and enforcement of the Security Rule rested with the Centers for Medicare & Medicaid Services (CMS). The change reflects the growing seriousness of HHS and others about enforcing federal privacy and data security mandates for health information. HHS anticipates the transfer of authority will eliminate duplication and increase efficiencies in how the department ensures that Americans’ health information privacy is protected.

HHS has the authority for administration and enforcement of the federal standards for health information privacy called for in HIPAA. The Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. OCR has been responsible for enforcement of the Privacy Rule since 2003. The Security Rule specifies a series of administrative, technical, and physical security procedures for covered entities to use to assure the confidentiality of electronic protected health information. The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009 (ARRA), mandated improved enforcement of the Privacy Rule and the Security Rule.

Through a separate delegation, CMS continues to have authority for administration and enforcement of the HIPAA Administrative Simplification regulations, other than privacy and security of health information.

The transfer of Security Rule enforcement authority comes as guidance about new data breach rules for electronic protected health information is impending. This impending guidance relates to the implementation of new breach notification rules for covered entities and their business associates concerning their obligation to use of technologies and methodologies that render protected health information unusable, unreadable, or indecipherable to unauthorized individuals, as required by amendments to HIPAA enacted under the Health Information Technology for Economic and Clinical Health (HITECH) Act passed as part of the American Recovery and Reinvestment Act of 2009 (ARRA) last February. OCR officials have stated that they are working to publish the next set of regulations regarding these new breach notifications before the end of August, 2009.

In addition to adding the breach notification requirements, the HITECH Act also tightened the HIPAA mandates in several other respects. Among other things, it amended HIPAA to:

Broaden the applicability of the HIPAA’s Privacy Rules and penalties to include business associates;
Clarify that HIPAA’s criminal sanctions apply to employees or other individuals that wrongfully use or access PHI held by a covered entity;
Increase criminal and civil penalties for HIPAA Privacy Rules violators;
Allow State Attorneys General to bring civil damages actions on behalf of certain state citizens who are victims of HIPAA Privacy and Security Rule violations;
Modify certain HIPAA use and disclosure and accounting requirements and risks;
Prohibits sales of PHI without prior consent;
Tighten certain other HIPAA restrictions on uses or disclosures;
Tighten certain HIPAA accounting for disclosure requirements;
Clarify the definition of health care operations to excludes certain promotional communications; and
Expand the Business Associates Agreement Requirements.

These and other developments make it imperative HIPAA covered entities and their business associates take prompt action to immediately review and update their data security and privacy practices to guard against growing liability exposures under HIPAA and other federal and state laws. Covered entities must update policies and practices to avoid these growing liabilities. Business associates that have not already done so also must appoint privacy officers and adopt and implement privacy and data security policies and procedures fully compliant with HIPAA and other applicable federal and state rules, including amendments enacted as part of the American Recovery and Reinvestment Act of 2009 signed into law on February 17, 2009.

For more information about today’s announcement, see here. See here for the initial guidance and request for comments issued by HHS regarding these new security standards.

Chair Elect of the American Bar Association RPTE Employee Benefits & Compensation Committee, an ABA Joint Committee on Employee Benefits Council member, and Chair of the Curran Tomko Tarski Labor, Employment & Employee Benefits Practice, Cynthia Marcotte Stamer is nationally and internationally recognized for her work assisting businesses, employee benefit plan fiduciaries and vendors, governments, and other entities to develop administer and defend cost-effective employee benefit other human resources programs, policies and procedures to meet their budgetary, risk management and compliance and other objectives. Board certified in Labor & Employment law, Ms. Stamer applies her extensive experience regarding employment, employee benefit, tax, privacy and data security and other related laws to assists clients in a wide range of business and litigation contexts. The co-founder of the Solutions Law Consortium, Ms. Stamer also makes extensive use of cloud computing and other technology in her own practice and provides input to human resources and other clients others about the use of these and other technology tools to manage employee benefit, human resources, internal controls and other operations. In connection with this work, Ms. Stamer has works, writes and consults extensively with a diverse range of clients about the development, use technology and other processes to streamline health and other benefit, payroll and other human resources, employee benefits, tax, compliance and other business processes and the management and protection of sensitive personal and other information and data.

If your organization or employee benefit plan needs assistance managing or evaluating options or responsibilities associated with the use of technology and data in connection with its health care, employee benefits, tax or other operation or other human resources, employee benefits or and compliance concerns, please contact Ms. Stamer at cstamer@cttlegal.com, (214) 270-2402; or your favorite Curran Tomko Tarski, LLP attorney. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi, LLP team, see here.

More Information & Resources

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of Ms. Stamer here /the Curran Tomko Tarski LLP attorneys 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 or e-mailing this information to Cstamer@CTTLegal.com or registering to participate in the distribution of these and other updates on our Solutions Law Press HR & Benefits Update distributions 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 support@SolutionsLawyer.net.

Comments Off on HHS Reassignment Of HIPAA Enforcement Duties Signals Rising Seriousness of Enforcement Commitment | Employee Benefits, HIPAA, Human Resources, Insurance, Internal Controls, Privacy | Tagged: Employee Benefits, Employer, Employers, ERISA, GINA, Health Care Reform, Health Insurance, Health Plans, HIPAA, Human Resources, Insurance, Insurer, Internal Controls, Managed Care, Medical Coverage, Privacy, Risk Management | Permalink
Posted by Cynthia Marcotte Stamer

Speak Up America: Where & How To Read & Share Your Feedback About The Health Care Reform Legislation

August 1, 2009

As the health care reform policy debate continues, Americans increasingly are asking where to read the text of the health care reform legislation that members of Congress are debating and how to share their input.

While numerous alternatives presently are pending before Congress, much of recent discussion and debate has focused around one of the following bills:

H.R. 3200: America’s Affordable Health Choices Act of 2009, introduced in the House by Rep Dingell, John D. on July 14, 2009 the text of which as originally introduced may be reviewed here. It has been the focus of significant mark up negotiation through out July before the following House Energy and Commerce, House Ways & Means, and House Education & Labor Committees; and
S. __, the Affordable Health Choices Act approved by the Senate Committee on Health, Education, Labor and Pensions, the text of which as approved may be reviewed here.

When reviewing these bills, Americans should keep in mind that members of Congress are engaged in ongoing negotiations about the specific provisions and language of these bills, as well as other legislation. Official developments generally may be monitored here.

Many American businesses and individuals also are asking about how and where to share their views, how to organize others to do the same and other questions about getting the word out. Here a some quick ideas. We encourage others to share.

The Coalition For Patient Empowerment and the Coalition for Responsible Health Care Reform linkedin group are two one of many resources where individuals are sharing information about these matters.
Concerned individuals should share their views both by faxing, e-mailing or telephoning key decisionmakers in Congress, as well as joining and participating in activities of other individuals and groups that share their concerns. Contact and get involved with this and other groups that share your concerns.
Contact the offices of your Congressional representatives in the House and Senate as well as other members of Congress that support your views and ask them about other groups and ways that you can share your views. They will welcome your input and involvement.
If you are aware of or involved in a group that shares your views, we encourage you to share it on the Coalition for Responsible Health Care Reform linkedin group. If you or others are planning a town hall or other health care reform meeting, use this or other linked in groups to spread the word.
If you are interested in volunteering to plan events in your region, let us know.

When communicating, consider targeting your messages to members of Congress whose votes are likely to be impacted by your communications.

For instance, with both the House and Senate in the majority in Congress, Democrats generally have greater control over what legislation moves forward. The Democratic Leadership of the House and Sentate generally can get legislation passed by their members as long as they can maintain consensus among the members of their parties. In connection with the health care reform proposals, however, cost and other considerations have made maintaining a consensus more difficult than on other legislation. Certain fiscally moderate members of the Democratic Party have expressed concern about the expense and other aspects of their Leadership proposed health care reform proposals. These Democrats in Congress generally the members of Congress whose votes are most likely to be impacted by public input and feedback generally and from voters in their districts and contributors specifically.

In the House of Representatives, these members likely are the “Blue Dog Democrats.” Read about Blue Dog Democrats here.

The fiscal conservatism of Blue Dog Democrats makes them more likely to listen to concerns about the cost and other concerns relating to the health care reform bills touted by the Democrat Leadership in the House and Senate. In fact, many Blue Dog Democrats already are speaking out about their concerns about the cost and other aspects of the Bill.

Contact from voters and contributors in their districts and others could make a major difference in the ability that the House Democrat Leadership needs to pass their Bill. Immediately contacting these members and getting others – particularly voters and contributors in the districts that elect these members – is one of the most important steps that concerned Americans can do to position their concerns to be heard.

For most concerned voters, telephone or fax contact is the best means to convey these messages. To minimize spam, most members only accept e-mail submitted through their website links. Security concerns can delay receipt of written correspondence for weeks.

For persons interested in making their voices heard and sharing information with others who wish to do the same, the following contact information may be of interest:

The number of the Capital Switchboard is 202-224-3121.

The Blue Dog Leadership Team and there telephone and fax numbers are:

Rep. Stephanie Herseth Sandlin (SD), Blue Dog Co-Chair for Administration, Telephone: 202.225.2801 , Fax: 202.225.5823

Rep. Baron Hill (IN-09), Blue Dog Co-Chair for Policy,Telephone: 202-225-4031, Fax: (202) 226-6866

Rep. Charlie Melancon (LA-03), Blue Dog Co-Chair for Communications, Telephone: 202-225-4031, Fax: (202) 226-3944

Rep. Heath Shuler (NC-11), Blue Dog Whip, Telephone: 202-225-6401, Fax: (202) 226-6422

The Blue Dog Members and their telephone numbers are :

Altmire, Jason (PA-04),(202)225-2565
Arcuri, Mike (NY-24), (202)225-3665
Baca, Joe (CA-43),(202)225-6161
Barrow, John (GA-12), (202) 225-2823
Berry, Marion (AR-01), (202) 225-4076
Bishop, Sanford (GA-02), (202) 225-3631
Boren, Dan (OK-02), (202) 225-2701
Boswell, Leonard (IA-03), (202) 225-3806
Boyd, Allen (FL-02), (202) 225-5235
Bright, Bobby (AL-02), (202) 225-2901
Cardoza, Dennis (CA-18), (202) 225-6131
Carney, Christopher (PA-10), (202) 225-3731
Chandler, Ben (KY-06), (202) 225-4706
Childers, Travis (MS-01), (202) 225-4306
Cooper, Jim (TN 5^th), (202) 225-4311
Costa, Jim (CA 20^th), (202) 225-3341
Cuellar, Henry (TX 28^th), (202) 225-1640
Dahlkemper, Kathleen A. (PA 3^rd), (202) 225-5406
Davis, Lincoln (TN 4^th),(202) 225-6831
Donnelly, Joe (IN 2^nd), (202) 225-3915
Ellsworth, Brad (IN 8^th), (202) 225-4636
Giffords, Gabrielle (AZ 8^th), (202) 225-2542
Gordon, Bart (TN 6^th), (202) 225-4231
Griffith, Parker (AL 5^th), (202) 225-4801
Harman, Jane (CA 36^th), (202) 225-8220
Herseth Sandlin, Stephanie (SD At Large), (202) 225-2801
Hill, Baron P. (IN 9^th), (202) 225-5315
Holden, Tim (PA 17^th), (202) 225-5546
Kratovil, Frank Jr. (MD 1^st), (202) 225-5311
McIntyre, Mike (NC 7^th), (202) 225-2731
Marshall, Jim (GA 8^th), (202) 225-6531
Matheson, Jim (UT 2^nd), (202) 225-3011
Melancon, Charlie (LA 3^rd), (202) 225-4031
Michaud, Michael H. (ME 2^nd), (202) 225-6306
Minnick, Walt (ID 1^st), (202) 225-6611
Mitchell, Harry E. (AZ 5^th), (202) 225-2190
Moore, Dennis (KS 3^rd), (202) 225-2865
Murphy, Patrick J. (PA 8^th), (202) 225-4276
Nye, Glenn C. (VA 2^nd), (202) 225-4215
Peterson, Collin C. (MN 7^th), (202) 225-2165
Pomeroy, Earl (ND At Large), (202) 225-2611
Ross, Mike (AR 4^th), (202) 225-3772
Salazar, John T. (CO 3^rd), (202) 225-4761
Sanchez, Loretta (CA 47^th), (202) 225-2965
Schiff, Adam B. (CA 29^th), (202) 225-4176
Scott, David (GA 13^th), (202) 225-2939
Shuler, Heath (NC 11^th), (202) 225-6401
Space, Zachary T. (OH 18^th), (202) 225-6265
Tanner, John S. (TN 8^th), (202) 225-4714
Taylor, Gene (MS 4^th), (202) 225-5772
Thompson, Mike (CA 1^st), (202) 225-3311
Wilson, Charles (OH-06), (202) 225-5705

You and others also are invited to join the discussion about these and other health care reform proposals and concerns by:

Joining the Coalition for Responsible Health Care Reform Group on Linkedin and registering to receive these updates here; and
E-mailing Cstamer@cttlegal.com to participate in the Coalition for Patient Empowerment.

Curran Tomko Tarski LLP Can Help

If your business needs assistance monitoring or providing input on health care reform or other human resources, employee benefit or compensation legislation or regulations, or auditing, updating or defending its health or other employee benefit, human resources, or compensation arrangements, or responding to employee benefits, employment or compensation related charges or suits, please contact Ms. Stamer at cstamer@cttlegal.com, (214) 270-2402; or your favorite Curran Tomko Tarski, LLP attorney. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi, LLP team, see here.

The author of this article, Curran Tomko Tarski LLP Labor & Employment Practice Group Chair Cynthia Marcotte Stamer and other members of Curran Tomko and Tarski LLP are experienced with assisting employer and employee benefit plan sponsors, administrators and others about labor and employment, compensation and employee benefit compliance and risk management concerns, as well as advising and defending these and other clients in labor and employment, compensation, and employee benefit related audits, investigations and litigation, charges, audits, claims and investigations.

Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization, Chair of the ABA RPTE Employee Benefit Plans and Other Compensation Group, a 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 has extensive experience with health and retirement, work force and other employee benefit and employment matters. She is nationally and internationally known for her innovative work with employers, associations, churches, insurers and others to develop health benefit, onsight medical, wellness and other employee benefit and employment arrangements, as well as her involvement in health care, pension and other public policy advocacy.

More Information & Resources

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of Ms. Stamer here /the Curran Tomko Tarski LLP attorneys 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 or e-mailing this information to Cstamer@CTTLegal.com or registering to participate in the distribution of these and other updates on our Solutions Law Press HR & Benefits Update distributions 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 support@SolutionsLawyer.net.

Comments Off on Speak Up America: Where & How To Read & Share Your Feedback About The Health Care Reform Legislation | Employee Benefits, Employers, Employment Tax, ERISA, Health Care Reform, Health Plans, Human Resources, Immigration, Income Tax, Insurance, Malpractice, Preemption, Professional Liability, Tax, Uncategorized | Tagged: Corporate Compliance, Employee Benefits, Employer, Employers, ERISA, Health Care Reform, Health Insurance, Health Plans, Human Resources, Insurance, Insurer, Labor, Managed Care, Medical Coverage | Permalink
Posted by Cynthia Marcotte Stamer

House Democrats Introduce Their Version of Health Care Reform, the “America’s Affordable Health Choices Act of 2009”

July 15, 2009

House Democrats introduced their proposal for health care reform this afternoon (July 14, 2009), the “America’s Affordable Health Choices Act of 2009 (the “House Bill”). Introduced under the sponsorship of three key House committees -Energy and Commerce, Ways and Means, and Education and Labor — the 1018 page House Bill details the sweeping and comprehensive health care reforms that Democrat Leaders in the House are touting. A copy of the House Bill as introduced may be reviewed here.

The House Bill proposes sweeping reforms built around the establishment of a public plan option while technically continuing to permit private plans to operate but in a federally regulated form allowing for little meaningful plan design control to private payers, health care providers or the individuals choosing among the plan options. The Congressional Budget Office estimates that the coverage side of the bill will cost $1 trillion and cover 97 percent of the legal population within 10 years.

The following is a brief overview of certain key provisions of the House Bill drawn mostly from a series of high level summaries released by House Democrats along with the House Bill. Long on politically comforting phrasing and short on details, you can read these summaries here.

Public Plan Option. The House Bill proposes the establishment of a public health insurance option that would compete with allowable private plans, both of which would be subject to sweeping federal controls. Democrat House co-sponsors represent the House Bill:

Provides a public health insurance option that would compete with private insurers within the Health Insurance Exchange.
The public health insurance option would be made available in the new Health Insurance Exchange (Exchange) along with private health insurance plans that comply with the design dictates established in the House Bill.
The public health insurance option and private plan options meet the same benefit requirements and comply with the same insurance market reforms
The public option’s premiums would be established for the local market areas designated by the Exchange.
Individuals with affordability credits could choose among the private carriers and the public option.
Require that the public health plan and private health plan options and private options each must be financially self-sustaining
Promote primary care, encourage coordinated care and shared accountability, and improve quality.
Institute new payment structures and incentives to promote these critical reforms.
Specify health care provider participation in the plans will be voluntary; Medicare providers are presumed to be participating unless they opt out.
Provides for provider reimbursements for services from the plans initially will be established using “rates similar to those used in Medicare with greater flexibility to vary payments.
Speaker of the House Nancy Pelosi has announced plans to proceed immediately on mark up on the House Bill with the intention to of scheduling a vote on the House Bill by the end of July. Assuming that House leaders adhere to this schedule, the planned timetable leaves little opportunity for critical evaluation and input by members of Congress or the public who may have questions or concerns about the proposed legislation. Prompt and coordinated action is required for individuals with concerns about any of the proposed reforms.

Federal Mandates Health Plan Benefits. In order to achieve affordable, quality health care for all, the House Bill would impose federal standards regulating the benefits that the public health plan and private health plans would be required and permitted to offer. Under these provisions, the House Bill would:

Establish a standardized benefit package that covers essential health services.
Vest the power in the Secretary of Health & Human Services to decide the coverage that would be included in this mandated standardize benefit package.
Eliminate cost-sharing for preventive care (including well baby and well child care)
Impose caps annual out-of-pocket spending for individuals and families.
Create a new independent Benefits Advisory to recommend to the Secretary and update the core package of benefits.
Provide for the public health plan option to offer four tiers of benefit packages from which consumers can choose to best meet their health care needs. Each allowable plan would be required to provide the dictated core benefits.
- The Basic Plan would include the federally mandated core set of covered benefits and cost sharing protections;
- The Enhanced Plan would include the federally mandated core set of covered benefits with more generous cost sharing protections than the Basic plan;
- The Premium Plan would include the federally mandated core set of covered benefits with more generous cost sharing protections than the Enhanced plan; and
- The Premium Plus Plan would include the federally mandated core set of covered benefits, the more generous cost sharing protections of the Premium plan, and additional covered benefits (e.g., oral health coverage for adults, gym membership, etc.) that will vary per plan. In this category, insurers must disclose the separate cost of the additional benefits so consumers know what they’re paying for and can choose among plans accordingly.

The House Bill empowers the Secretary of Health & Human Services to decide the federally dictated, required core set of benefits provides coverage with input from a newly created Benefits Advisory Commission. These core benefits are intended to include inpatient hospital services, outpatient hospital services, physician services, equipment and supplies incident to physician services, preventive services, maternity services, prescription drugs, rehabilitative and habilitative services, well baby and well child visits and oral health, vision, and hearing services for children and mental health and substance abuse services. However, the particular, terms and scope of these benefits is left to HHS to define.

Health Insurance Exchange. The House Bill also calls for the establishment of a “Health Insurance Exchange” meeting federal mandates through which low income individuals initially, and certain small businesses would be offered the option to purchase health care coverage through federally mandated purchasing groups. In the first year, the House Bill provides for the Health Insurance Exchange to accept those without health insurance, those who are buying health insurance on their own, and small businesses with fewer than 10 people. In the second year, the Health Insurance Exchange could accept small businesses with fewer than 20 people. After that, “larger employers as permitted by the Commissioner.” In other words, expansion is discretionary, not mandated.

Affordability & Subsidies. The House Bill provides sliding-scale affordability credits for individuals and families with incomes above the Medicaid thresholds but below 400% of poverty and imposes a cap on total out-of-pocket spending for individuals and families covered under the plans regardless of income. In addition, the House Bill would broaden Medicaid coverage to include individuals and families with incomes below 133% of poverty.

Effective 2013, sliding scale affordability credits would be provided provided to individuals and families between 133% to 400% of poverty. That means the credits phase out completely for an individual with $43,320 in income and a family of four with $88,200 in income (2009).

The sliding scale credits limit individual family spending on premiums for the essential benefit package to no more than 1.5% of income for those with the lowest income and phasing up to no more than 11% of income for those at 400% of poverty.

The affordability credits also subsidize cost sharing on a sliding scale basis, phasing out at 400% of poverty, ensuring that covered benefits are accessible.

The Health Insurance Exchange would administer the affordability credits in relationship with other federal and state entities, such as local Social Security offices and Medicaid agencies.

The essential benefit package, and all other benefit options, limit exposure to catastrophic costs with a cap on total out of pocket spending for covered benefits. Special provisions would apply to Medicaid.

Effective 2013, individuals with family income at or below 133% of poverty ($14,400 for an individual in 2009) are eligible for Medicaid. State Medicaid programs would continue to cover those individuals with incomes above 133% of poverty, using the eligibility rules states now have in place.

Paying The Tab. House Democrats propose to finance approximately half of the estimated $1 trillion bill for their proposed reforms through projected $500 billion or so in savings from Medicare and Medicaid achieved by a variety of reimbursement and benefit cutbacks and other reforms. The rest of the financing would come from a combination of revenue expections from employer and individual mandates (an estimated $200 billion over 10 years) and a surtax on the richest 1.5 percent of Americans. The surtax is 1 percent on income between $350,000 and $500,000; 1.5 percent on income between $500,000 and $1,000,000; and 5.4 percent in income above $1,000,000. The House Bill permits the amount of this surtax to vary if the bill is less or more expensive than initially anticipated.

The author of this article, Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health industry clients and others about a diverse range of health care policy, regulatory, compliance, risk management and operational concerns. You can get more information about her health industry experience here.

Other Helpful Resources & Other Information

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Posted by Cynthia Marcotte Stamer

Stamer Moderates June 25 ABA Teleconference On When Benefits Lawyers and Other Service Providers Be Sued for Malpractice for Services to ERISA Plans

June 9, 2009

Cynthia Marcotte Stamer will moderate a June 25, 2009 teleconference on “Can Benefits Lawyers and Other Service Providers Be Sued for Malpractice for Services to ERISA Plans?”

The telephone conference hosted by the American Bar Association (ABA) Joint Committee on Employee Benefits (JCEB) is scheduled for Thursday, June 25, 2009 from 1:00-2:00 pm Eastern Time, 12:00-1:00 pm Central Time, 11:00 am-12:00 pm Mountain Time, and 10:00 am-11:00 am Pacific Time.

The teleconference will feature a discussion by Hogan & Hartson LLP attorney Kurt Lawson and AARP Foundation Litigation attorney Mary Ellen Signorille about how the federal precedent governing when and how ERISA preemption affects state malpractice and misfeasance claims against accountants, lawyers, health care providers, actuaries and others has evolved during the five year period since the United State’s Aetna v. Davila decision reframed when ERISA preempts state law malpractice claims and the implications of this precedent on the viability and litigation of these state law malpractice claims.

To register or for additional information, go to here.

About Cynthia Marcotte Stamer

The immediate past Chair of the American Bar Association’s Managed Care & Insurance Section, Cynthia Marcotte Stamer is a highly regarded legal advisor, author and speaker recognized both nationally and internationally for her expertise in the areas of health benefits and other human resource compliance matters. Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, “Cindy” recently joined Curran Tomko Tarski, LLP as the Chair of its Labor & Employment and Health Care Practices April 1, 2009.

The Managing Editor of Solutions Law Press and an Editorial Advisory Board Member and author for Employee Benefit News and other publications, Ms. Stamer is a widely published author and popular speaker. In addition to hundreds of publications on health plan and other human resources, employee benefit and internal controls issues, Ms. Stamer is the author of the “Health Plan Eligibility Toolkit.” Her work has been featured and published by the American Bar Association, BNA, SHRM, World At Work, Employee Benefit News and the American Health Lawyers Association. Her insights on human resources risk management matters have been quoted in The Wall Street Journal, the Dallas Business Journal, Managed Care Executive, HealthLeaders, Business Insurance, Employee Benefit News and the Dallas Morning News.

Ms. Stamer also serves in a number of professional leadership roles including the leadership council of the ABA Joint Committee on Employee Benefits, Vice Chair of the ABA Real Property, Probate & Trust Section and Employee Benefits & Compensation Group.

Cynthia Marcotte Stamer and other members of Curran Tomko and Tarski LLP are experienced with advising and assisting employers with these and other health plan and other employee benefit, labor and employment, compensation, and internal controls matters. If your organization needs assistance with assessing, managing or defending its wage and hour or other labor and employment, compensation or benefit practices, please contact Ms. Stamer via e-mail here, or by calling (214) 270-2402. For additional information about the experience, services, publications and involvements of Ms. Stamer specifically or to access some of her many publications, see here, For more information and other members of the Curran Tomko Tarksi, LLP team, see the Curran Tomko Tarski Website.

We hope that this information is useful to you. For additional information about the experience, services, publications and involvements of Ms. Stamer specifically or to access some of her many publications, see here, For more information and other members of the Curran Tomko Tarksi, LLP team, see the Curran Tomko Tarski Website.

You can register to receive future updates and information about upcoming programs, access other publications by Ms. Stamer and access other helpful resources here. If you or someone else you know would like to receive updates about developments on these and other human resources and employee benefits concerns, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. If you would prefer not to receive these updates, please send a reply e-mail with “Remove” in the subject line to support@SolutionsLawyer.net. You also can register to participate in the distribution of these updates by registering to participate in the Solutions Law Press HR & Benefits Update Blog here.

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Posted by Cynthia Marcotte Stamer

Registration Open For June 23 Dallas HR 2009 Health Plan Eligibility Update Program

June 9, 2009

Amid soaring health care costs and tightening corporate budgets, employers and other group health plan sponsors, fiduciaries and administrations now also must update their group health plan eligibility and enrollment practices to comply with the American Recovery and Reinvestment Act of 2009 (the “Stimulus Bill”), COBRA subsidy mandates, HIPAA special enrollment rule amendments and a host of other changes to federal eligibility mandates that already have or will take effect this year. Meanwhile, employers must keep a careful watch on Congress as it considers enacting sweeping health care reforms that are likely to place more obligations on employers.

Health plan eligibility design and administration plays a critical role in controlling health benefit costs and is a leading and growing source of health plan legal risk for employers, fiduciaries and administrators. Understanding and properly managing these concerns is imperative for employers and others sponsoring or administering these programs.

Stamer Discusses Health Plan Eligibility Rules June 23

Cynthia Marcotte Stamer will explain newly effective COBRA Subsidy Rules, genetic information nondiscrimination rules and other recent and impending changes to federal health plan eligibility mandates will be explained on June 23, 2009 during a 2009 Health Plan Eligibility Update briefing hosted by the Dallas Human Resources Management Association including:

Cynthia Stamer will explain to attendees what they need to know and do about:

New Stimulus Bill COBRA Subsidy Rules and other special COBRA rules that took effect on February 17
New GINA group health plan information scheduled to take place in 2009
Changes to HIPAA special enrollment and nondiscrimination rules
Implications for group health plans based on recent changes to FMLA and USERRA regulations
Medicare, Medicaid and CHIP nondiscrimination rules
Impending college student continuation mandates
And more….

Get details or register on line here or by telephoning Dallas Human Resources Management Association at 214-631-8775.

Stamer’s Health Plan Experience Extensive

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Posted by Cynthia Marcotte Stamer

Legislation To Exempt Health Benefits For Domestic Partners and Other Beneficiaries Introduced In House & Senate.

June 3, 2009

June 3, 2009

Domestic partner benefits provided under employer or union sponsored health plans no longer would be taxable to enrolling employees if Congress adopts legislation recently proposed in the House and Senate.

HR 2625, the Tax Equity for Health Plan Beneficiaries Act and a companion bill, S 1153 S 1153 would amend the Internal Revenue Code of 1986 to extend the exclusion from gross income for employer-provided health coverage for employees’ spouses and dependent children to coverage provided to other eligible designated beneficiaries of employees, including domestic partners. According to a press release from Rep. McDermott, the bill would eliminate federal income and payroll taxes on health benefits provided to domestic partners.

Currently, the value of health benefits provided to domestic partners of employees under an employer’s group health plan typically are taxable income to the employee for purpose of the Internal Revenue Code. Valuing and reporting taxable payments on domestic partner benefits can be a headache for employers that provide those benefits.

If you need help responding to these proposals or with other questions relating to compliance or risk management under other federal or state employment, employee benefits, compensation, or internal controls laws or regulations, please contact Curran Tomko Tarski LLP Labor & Employment Practice Group Chair, Cynthia Marcotte Stamer at (214) 270.2402 or via e-mail here. Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, “Cindy” works with businesses, speaks and publishes extensively on these and other labor and employment, employee benefit, internal controls and compensation matters. For additional information about Curran Tomko Tarski LLP see the Curran Tomko Tarski Website.

Other Information & Resources

We hope that this information is useful to you. You can register to receive future updates and information about upcoming programs, access other publications by Ms. Stamer and access other helpful resources here. For additional information about Ms. Stamer and her experience, see here or contact Ms. Stamer directly. If you or someone else you know would like to receive updates about developments on these and other human resources and employee benefits concerns, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. If you would prefer not to receive these updates, please send a reply e-mail with “Remove” in the subject line to support@SolutionsLawyer.net. You also can register to participate in the distribution of these updates by registering to participate in the Solutions Law Press HR & Benefits Update Blog here.

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Posted by Cynthia Marcotte Stamer

Tell Senate Committee Today Not To Mess Up Health Benefits

May 27, 2009

Today is the last day that individuals and businesses concerned about health care can provide feedback to Congress on health care reform proposals on the fast track for adoption by Congress and have their opinion included in the official hearing record of the May 12, 2009 Senate Finance Committee Hearing on “Financing Comprehensive Health Care Reform.” Start speaking up today and keep speaking out until you are heard.

Senate health care reform leaders have announced their intention to have the Senate vote and pass health care reform legislation that would drastically change the U.S. health care and health insurance system during June. Individuals and businesses concerned about Congressional proposals to private health benefits with federal government benefits, to tax individuals and businesses on health benefits, and to make other radical changes in our health care programs should e-mail their concerns to Congress today. Recent statements by Congressional leaders and President Obama indicate that the intend to act quickly to pass major health care reforms within the next few months, beginning with action by the Senate in June.

The Senate Finance Committee discussed the proposed changes during a “Roundtable Discussion” hearing on May 12, 2009. Among the changes that this hearing reflects to be under serious consideration by Congress are proposals:

To tax individuals on health benefits and/or coverage
Reduce or eliminate employer tax benefits for providing health coverage
Mandate individuals and/or employees pay government mandated health insurance premiums
Replace existing employer and private health insurance programs with government run or mandated benefit programs
Involve the federal government in deciding who and when Americans get care
Establish other burdensome federal requirements and regulations on health benefits and health care providers.

You can review or listen to the testimony and learn more about what Congress plans to do to your and your employees’ health benefits here.

If you or others that you know are concerned about all or any of these proposals, we urge you to share your feedback TODAY as follows and staying involved as Congress moves to act:

E-mail the Health Care Reform Leadership of the Senate Finance Committee at Health_reform@finance_dem.senate.gov
E-mail each member of the Senate Finance Committee at http://finance.senate.gov/sitepages/committee.htm
Call (202) 224-4515 and share your views with Congressional Staffers Erin Shields (Baucus) and Jill Gerber (Grassley), Committee on Finance, 219 Dirksen Senate Office Building, Washington, D.C. 20510-6200
Tell your Senators and Representatives you oppose Congressional plans to fast track health care reform the way Congress enacted the Stimulus Bill
Tell your Senators and Representatives you will support members of Congress who vote responsibly on health care reform
Tell your Senators and Representatives in Congress and political party leaders you will work to defeat members and candidates that advocate these and other irresponsible health care reform legisltation
Carry through on your promises
Keep speaking out until you are heard and Congress gets the message.

Cynthia Marcotte Stamer is an attorney, author and health care advocate known for her work and writings nationally and internationally on health care and coverage policy and legal matters . If your organization needs assistance with assessing, managing or communicating its concerns about this legislation or other health care and insurance, employment or employee benefit practices, please contact Ms. Stamer at cstamer@cttlegal.com, (214) 270-2402; or your favorite Curran Tomko Tarski, LLP attorney. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi, LLP team, see the http://www.cttlegal.com.

Other Information & Resources

We hope that this information is useful to you. You can register to receive future updates and information about upcoming programs, access other publications by Ms. Stamer and access other helpful resources at CynthiaStamer.com For additional information about Ms. Stamer and her experience, see here or contact Ms. Stamer directly. If you or someone else you know would like to receive updates about developments on these and other human resources and employee benefits concerns, please be sure that we have your Currant contact information – including your preferred e-mail- by creating or updating your profile at CynthiaStamer.com. If you would prefer not to receive these updates, please send a reply e-mail with “Remove” in the subject line to support@SolutionsLawyer.net. You also can register to participate in the distribution of these updates by registering to participate in the Solutions Law Press HR & Benefits Update Blog 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 support@SolutionsLawyer.net.

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Posted by Cynthia Marcotte Stamer

Mitigating Workplace Fallout of Pandemic Response

May 5, 2009

As the U.S. rushes to try to contain the spread of the swine influenza A (H1N1) virus infection (swine flu), businesses increasingly are facing employee leave requests and other employment and operational disruptions plans caused by school, day care or other closures and other business disruptions resulting from efforts to contain the disease while also working to take appropriate steps to prevent the spread of the disease within their own organizations.

Regardless of how deadly it ultimately proves to be, the pandemic proportion of the swine flu outbreak now ensures that most U.S. businesses will experience some disruption in operations as a result of the epidemic and efforts to contain it.

According to officials from the Centers for Disease Control and Prevention (CDC), as of 11:00 a.m. Eastern Time, 36 states had reported a total of 236 confirmed cases of swine flu and more cases are expected. That number includes the first U.S. swine flu fatality: a 22-month-old child from Mexico who died of the illness at a Houston, Texas hospital while visiting the United States last week. States currently hardest hit include New York (73 cases), Texas (41 cases), California (30 cases), Delaware (20 cases) and Arizona (17 cases). In the near future, however, CDC officials anticipate confirmed cases in all 50 states.

CDC officials and other experts continue to emphasize that the success of efforts to prevent the unnecessary spread of the disease depends largely on good health habits, limiting exposure to the virus and prompt diagnosis and treatment of afflicted persons. Employers can help reduce the risk that members of their workforce and their families will catch the virus by promoting good health habits and encouraging workers and their families to stay home and seek prompt treatment in the event of an illness. Simultaneously planning for and dealing with absences and other staffing challenges result from school, day care and other closings prevents a greater challenge for many employers, however.

Easy Preventive Safeguards

While the CDC says getting employees and their families to get a flu shot remains the best defense against a flu outbreak, it also says getting employees and family members to consistently practice good health habits like covering a cough and washing hands also is another important key to prevent the spread of germs and prevent the spread of respiratory illnesses like the flu. To help promote health habits within their workforce, many businesses may want to download and circulate to employees and families the free resources published by the CDC at http://www.cdc.gov/flu/protect/habits.htm. These and other resources make clear that Employers should encourage employees and their families to practice good health habits by telling employees and their families to take the following steps:

Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
Stay home when you are sick to help prevent others from catching your illness. Cover your mouth and nose.
Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
Clean your hands to protect yourself from germs.
Avoid touching your eyes, nose or mouth.
Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
Practice other good health habits. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

Many businesses are promoting these and other conducts that help prevent the spread of disease by sharing educational materials such as the growing range of free materials provided by the CDC and others available at the government sponsored website, http://www.pandemicflu.gov. For instance, business can access and download free copies of the following publications at http://www.cdc.gov/flu/protect/habits.htm:

Cover Your Cough
Be a Germ Stopper: Healthy Habits Keep You Well
Flu Prevention Toolkit: Real People. Real Solutions
Stopping the Spread of Germs at Home, Work & School

Dealing With Lost Time & Productivity Challenges

Businesses also should begin preparing backup staffing and production strategies to prepare for disruptions likely to result if a significant outbreak occurs. Whether or not the disease afflicts any of its workers, businesses can anticipate the swine flu outbreak will impact their operations -either as a result of occurrences affecting their own or other businesses or from workflow disruptions resulting from safeguards that the business or other businesses implement to minimize swine flu risks for its workforce or its customers.

For many employers, however, planning for and dealing with requests for time off or other workplace disruptions resulting from pandemic containment efforts presents special challenges. While most employers have well established policies and procedures for providing medical leave to employees during periods of their own or a family member’s illness under the Family & Medical Leave Act (FMLA) or otherwise, many employers are experiencing difficulty in responding to leave requests of healthy employees necessitated by school or day care closings, suspected exposures, or other pandemic response disruptions.

Certainly, whether or not legally mandated, the CDC and other official advisories make clear that sick employees should not be in the workplace. Employers of course must provide medical leave as required by the FMLA or other similar state laws as well as any contractually agreed to leave. To better insulate their workforce against potential exposure to the virus, however, many employers also may wish consider temporarily modifying existing leave or other work policies with an eye to better defending their workforce against a major outbreak. In this respect, employers need to consider both how to respond to the present wave of the virus and to plan for the possible need to respond to another potentially stronger outbreak of the swine flu virus that the CDC and other experts caution likely may arise in the Fall or Winter.

As part of their efforts to insulate their workplaces against exposure to the virus, employers generally should discourage workers from coming to work if they or a family member are experiencing symptoms or have been exposed to the virus. For this reason, businesses generally evaluate workplace policies or practices that may pressure or encourage employees with swine flu or any other contagious disease to report to work. Employers should consider whether the potential risks make advisable adjustments to their current attendance, telecommuting, leave and paid time off and other policies.

In light of the current situation, many businesses may want to consider temporarily adjust their leave, telecommuting and other policies in light of the impending health risk. For instance, recognizing that the decision to close a school or child care facility in response to a known or suspected infection seeks to minimize the spread of the disease through exposure to other then undiagnosed cases, businesses generally should think twice about allowing employees to bring these potentially exposed children into the workplace. Instead, employers may wish to consider being more flexible in allowing employees to work from home or take leave to care for children whose schools or child care facilities are closed due to concerns about possible exposure to reduce the risk of creating unnecessary exposure in their workplace.

To help minimize financial pressures on workers to report to work when they may be ill or exposed to the virus, many employers also may want to consider providing or offering short-term disability insurance, expanding the availability of paid or unpaid leave or both.

Regardless of the specific choices a particular business makes, businesses need to take appropriate steps to document, implement, and communicate their decisions. If considering allowing or requiring employees to work from home, employers need to implement appropriate safeguards to monitor and manage employee performance, and to protect the employer’s ability to comply with applicable wage and hour, worker’s compensation, safety, privacy and other legal and operational requirements. They also should review and update family and medical leave act and other sick leave policies, group health plan medical coverage continuation rules and notices and other associated policies and plans for compliance with existing regulatory requirements, which have been subject to a range of statutory and regulatory amendments in recent years.

If considering allowing or requiring employees to work from home, for instance, employers need to implement appropriate safeguards to monitor and manage employee performance, and to protect the employer’s ability to comply with applicable wage and hour, worker’s compensation, safety, privacy and other legal and operational requirements. They also should review and update family and medical leave act and other sick leave policies, group health plan medical coverage continuation rules and notices and other associated policies and plans for compliance with existing regulatory requirements, which have been subject to a range of statutory and regulatory amendments in recent years.

In light of the growing responsibilities and exposures of business to medical privacy and disability liabilities associated with knowledge, collection, protection and use of information about the health and medical conditions of workers and their families, businesses also should review and update their procedures regarding the use, collection, disclosure, and protection of this and other sensitive information. Businesses, health care providers, schools, government agencies and others concerned about preparing to cope with pandemic or other infectious disease challenges also may want to review the publication “Planning for the Pandemic” authored by Curran Tomko Tarski LLP partner Cynthia Marcotte Stamer available at http://www.cynthiastamer.com/documents/speeches/20070530%20Pan%20Flu%20Workplace%20Privacy%20Issues%20Final%20Merged.pdf. Schools, health care organizations, restaurants and other businesses whose operations involve significant interaction with the public also may need to take special precautions. These and other businesses may want to consult the special resources posted at http://www.pandemicflu.gov/health/index.html.

Cynthia Marcotte Stamer and other members of Curran Tomko and Tarski LLP are experienced with advising and assisting employers with these and other labor and employment, employee benefit, compensation, and internal controls matters. Ms. Stamer in particular has worked extensively with health care providers, government officials, and businesses to plan for and deal with pandemic and other absence, disease management and disaster preparedness concerns. If your organization needs assistance with assessing, managing or defending its wage and hour or other labor and employment, compensation or benefit practices, please contact Ms. Stamer at cstamer@cttlegal.com, (214) 270-2402, or your favorite Curran Tomko Tarski, LLP attorney. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi, LLP team, see the http://www.cttlegal.com.

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Posted by Cynthia Marcotte Stamer

COBRA Premium Reduction and Extended Eligibility Provisions in the American Recovery and Reinvestment Act of 2009

May 2, 2009

The U.S. Department of Labor (“DOL”) today (May 1, 2009) continued its efforts to increase awareness of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provisions in the American Recovery and Reinvestment Act of 2009 (“ARRA”) by sharing information with state agencies and asking their assistance in helping dislocated workers, businesses, and partners in understanding the new law.

Under ARRA, employees involuntarily terminated between September 1, 2008 and December 31, 2009 and their dependents may be able to qualify for a 65% discount in the required premium they must pay to maintain COBRA coverage under their former employer’s group health plan for up to 9 months. Special rules also apply to former employees who qualify for Trade Adjustment Assistance or affected by certain Pension Benefit Guarantee Corporation insurance programs.

Employers must pay the remaining amount of the otherwise required COBRA premium, but can request reimbursement from the Internal Revenue Service by filing for a payroll tax credit under the provisions of ARRA.

Group health plans were required to begin complying with the new ARRA rules beginning February 17, 2009 and to notify workers of the new rules no later than April 18, 2009. Many employers and their group health plan sponsors are still working to complete the necessary arrangements to comply with these new requirements.

The communication of information about the new provisions by the DOL, group health plans, employers and the media have prompted an outpouring of questions from many employees and their dependents, confused about their eligibility for the ARRA COBRA Subsidy and its workings.

In Training And Employment Notice No. 42-08, which is addressed to state workforce agencies, labor commissioners and other state workforce regulators, the Employment and Training Administration (“ETA”):

Shared certain basic information about ARRA’s COBRA, Trade Adjustment Assistance and other workforce assistance relief;
Detailed some of the training and other resources provided by the DOL to help States and their citizens understand these new provisions and the procedures for their use; and
Asked the regulators to assist in communicating and disseminating the information to individuals who might qualify for benefits and other interested parties.

Interested persons can review the announcement at http://wdr.doleta.gov/directives/attach/TEN/ten2008/TEN42-08acc.pdf.

Cynthia Marcotte Stamer is nationally known for her knowledge and experience on COBRA and other health benefit and employee benefit matters,. You will find several of these previous publications on the new ARRA COBRA provisions on prior editions of the Solutions Law Press HR & Benefits Update. You also can access some of the many practical updates that she has prepared on these and other COBRA matters by e-mailing or contacting her. She and other members of Curren Tomko and Tarski LLP are experienced with advising and assisting employers with these and other labor and employment, employee benefit, compensation, and internal controls matters. If your organization needs assistance with assessing, managing or defending its COBRA or other employee benefit or human resources practices, please contact Ms. Stamer at cstamer@cttlegal.com, (214) 270-2402 or your favorite Curren Tomko Tarski, LLP attorney.

For additional information about the experience and services of Ms. Stamer and other members of the Curren Tomko Tarksi, LLP team, see the http://www.cttlegal.com.

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Posted by Cynthia Marcotte Stamer

Tips For Employers to Prepare for Possible Swine Flu Outbreak As 1st U.S. Death Reported

April 29, 2009

With U.S. officials confirming the first swine flu attributed death in the U.S. today and warning Americans to take precautions to guard against a likely swine flu pandemic, U.S. employers are asking what steps they should take to defend their organization and its people against the risk of a widespread outbreak among members of their workforce and the attendant lost time, health and disability costs, OSHA and other liability exposures and other personal and financial consequences likely to result from an outbreak.

Whether or not the swine flu outbreak reaches the level of an official pandemic, official reports reflect a legitimate need for concern. According to officials from the Centers for Disease Control and Prevention, victims of the virus already have been reported in 10 states, and the number of people known to be infected with the 2009 H1N1 influenza strain grew to 91 in the U.S. as of Wednesday. That number includes the first U.S. swine flu fatality: a 22-month-old child from Mexico who died of the illness Monday at a Houston, Texas hospital while visiting the United States. While swine flu victims have been reported in more than 11 countries, the majority of the incidents of the disease and deaths as of Wednesday morning had occurred in Mexico.

Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
Stay home when you are sick to help prevent others from catching your illness. Cover your mouth and nose.
Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
Clean your hands to protect yourself from germs.
Avoid touching your eyes, nose or mouth.
Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
Practice other good health habits. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

Employers also should be sensitive to workplace policies or practices that may pressure employees with a contagious disease to report to work despite an illness and consider whether the employer should adjust these policies temporarily or permanently in light of the impending health risk. For instance, financial pressures and the design and enforcement of policies regarding working from home and/or qualifying for paid or unpaid time off significantly impact the decisions employees make about whether to come to work when first experiencing symptoms of illness. Employers of workers who travel extensively – may wish to delay or restrict travel for some period.

Many employers may want to evaluate and appropriately revise existing policies with an eye to better defending their workforce against a major outbreak. If considering allowing or requiring employees to work from home, employers need to implement appropriate safeguards to monitor and manage employee performance, and to protect the employer’s ability to comply with applicable wage and hour, worker’s compensation, safety, privacy and other legal and operational requirements. They also should review and update family and medical leave act and other sick leave policies, group health plan medical coverage continuation rules and notices and other associated policies and plans for compliance with existing regulatory requirements, which have been subject to a range of statutory and regulatory amendments in recent years.

To help promote health habits within their workforce, many businesses may want to download and circulate to employees and families the free resources published by the CDC at http://www.cdc.gov/flu/protect/habits.htm. Businesses and other concerned parties also can track governmental reports about the swine flu and other pandemic concerns at http://www.pandemicflu.gov/index.html.

Businesses also should begin preparing backup staffing and production strategies to prepare for disruptions likely to result if a significant outbreak occurs. Employers also should be sensitive to workplace policies or practices that may pressure employees with a contagious disease to report to work despite an illness and consider whether the employer should adjust these policies temporarily or permanently in light of the impending health risk. For instance, financial pressures and the design and enforcement of policies regarding working from home and/or qualifying for paid or unpaid time off significantly impact the decisions employees make about whether to come to work when first experiencing symptoms of illness. Many employers may want to evaluate and appropriately revise existing policies with an eye to better defending their workforce against a major outbreak.

If considering allowing or requiring employees to work from home, employers need to implement appropriate safeguards to monitor and manage employee performance, and to protect the employer’s ability to comply with applicable wage and hour, worker’s compensation, safety, privacy and other legal and operational requirements. They also should review and update family and medical leave act and other sick leave policies, group health plan medical coverage continuation rules and notices and other associated policies and plans for compliance with existing regulatory requirements, which have been subject to a range of statutory and regulatory amendments in recent years.

Employers should begin preparing backup staffing and production strategies to prepare for disruptions likely to result if a significant outbreak occurs. Whether or not the disease afflicts any of its workers, businesses can anticipate the swine flu outbreak will impact their operations -either as a result of occurrences affecting their own or other businesses or from workflow disruptions resulting from safeguards that the business or other businesses implement to minimize swine flu risks for its workforce or its customers.

Businesses, health care providers, schools, government agencies and others concerned about preparing to cope with pandemic or other infectious disease challenges also may want to review the publication “Planning for the Pandemic” authored by Curran Tomko Tarski LLP partner Cynthia Marcotte Stamer available at http://www.cynthiastamer.com/documents/speeches/20070530%20Pan%20Flu%20Workplace%20Privacy%20Issues%20Final%20Merged.pdf. Schools, health care organizations, restaurants and other businesses whose operations involve significant interaction with the public also may need to take special precautions. These and other businesses may want to consult the special resources posted at http://www.pandemicflu.gov/health/index.html.

Cynthia Marcotte Stamer and other members of Curran Tomko and Tarski LLP are experienced with advising and assisting employers with these and other labor and employment, employee benefit, compensation, and internal controls matters. Ms. Stamer in particular has worked extensively with health care providers, government officials, and businesses to plan for and deal with pandemic and other disease management and disaster preparedness concerns. If your organization needs assistance with assessing, managing or defending its wage and hour or other labor and employment, compensation or benefit practices, please contact Ms. Stamer at cstamer@cttlegal.com, (214) 270-2402, or your favorite Curran Tomko Tarski, LLP attorney. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi, LLP team, see the www.cttlegal.com.

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Posted by Cynthia Marcotte Stamer

Subrogation Soup: The Law & Practicalities

April 7, 2009

Register Now

April 21, 2009 ABA JCEB Teleconference

1:00-2:30 pm ET / 12:00-1:30 pm CT / 11:00 am-12:30 pm MT / 10:00 am-11:30 am PT

Moderator:
Cynthia Marcotte Stamer, Curren Tomko Tarski LLP, Dallas, TX

Speakers:
James McKown, Recovery Data Connect, L.L.C., Leawood, KS
Scott Douglas Marquardt, Total Plan Services, Inc, Dallas, TX

Properly designed and administered subrogation provisions in ERISA-covered group health plans and group insurance contracts can provide invaluable tools for managing costs. Unfortunately, various legal and practical problems often prevent ERISA-covered group health plans and insurers from realizing many of these benefits. With health care costs continuing to rise, many health plan administrators, insurers and fiduciaries are placing renewed emphasis on the design and enforcement of their plan’s subrogation provisions. Listen and learn as a distinguished and experienced panel discusses the legal and practical ins and outs of the design, administration, and defense of effective group health plan policies and practices in ERISA-governed group health plans including:

ü Legal Basis of Subrogation Under ERISA

ü Why, When & When Not To Subrogate

ü The Law

ü The Process From Drafting, to Adjudication, to Recovery

ü Who Gets Hired To Do What, Why & When

ü Sticking Points & Plan Problems

ü Practical Dos & Don’t

For more information or to register, go to http://meetings.abanet.org/meeting/jceb/JCEB042109.

If you have questions or concerns about the matters discussed in this publication or other human resources, employee benefits or compensation matters, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or publication, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 270-2402 or via e-mail to Cstamer@Solutionslawyer.net.

Comments Off on Subrogation Soup: The Law & Practicalities | Employers, ERISA, Health Plans, Human Resources, Insurance | Tagged: Employee Benefits, Employer, ERISA, Health Plans, Insurance, Insurer, Managed Care, Subrogation | Permalink
Posted by Cynthia Marcotte Stamer

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