Dependent Health Care Coverage

Foundation Publication Search Results

These summaries were compiled from Foundation Publications Search, a database of articles, research reports and books published by the International Foundation and the International Society of Certified Employee Benefit Specialists.


Claims Administrator Improperly Denied Inpatient Psychiatric Care.
Benefits Magazine; v54 no4 p 57 Apr 2017; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The U.S. District Court for the Western District of Washington held that the defendant medical plan and claims administrator incorrectly denied inpatient psychiatric benefits to the plaintiff plan beneficiaries.
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Other Recent Decisions.
Benefits Magazine; v53 no11 pp 73-75 Nov 2016; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Summarizes cases on severance, withdrawal liability, benefit denials and retirement benefits.
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A Baker's Dozen of Practical Ways to Reduce Medical Claims Costs.
Ryan, Daniel W.; Stephens, Ryan T.; Benefits Magazine; v53 no5 pp 14-19 May 2016; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Many of these suggested administrative actions for health plans require only small changes but have the potential to generate big savings.
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You Asked, We Aswered.
Gleason, Lois A.; Olecheck, Sharon T.; Wilke, Amanda S.; Benefits Magazine; v53 no5 pp 69-70 May 2016; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Three questions asked and answered: Can different employee groups be offered different health plans? Can an employer impose a dependent surcharge? Can an employee waive health coverage without the employer being penalized under ACA?
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Employee Benefits Survey: 2016 Results
Held, Justin; Mrkvicka, Neil; Stich, Julie; 70 pp 2016; survey

Availability : International Foundation of Employee Benefit Plans
Abstract : Results of the fifth comprehensive benchmarking survey conducted by the International Foundation. Includes data on pension and retirement plans, health care benefits and other benefits, such as life insurance, work/life benefits and time off, for three distinct sectors in the U.S.—corporations (including professional service firms), public employers and multiemployer benefit plans. Responses were gathered from members of the Foundation and the International Society of Certified Employee Benefit Specialists during 2016.
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Health Plan's Claims for Reimbursement Not "Appropriate Equitable Relief".
Benefits Magazine; v52 no3 pp 61, 63 Mar 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The Second Circuit Appeals Court upheld the lower court in finding a multiemployer benefit plan was not entitled to relief through ERISA Section 502(a)(3) but would have to turn to state court. The plaintiff in Central States, Southeast and Southwest Area Health and Welfare Fund et al. v. Gerber Life Insurance Company et al. provided accident benefits to injured student athletes indirectly, in coordination with the defendant insurance company. The plaintiffs' coordination of benefits provision stated it provided secondary coverage, while the defendant saw itself as secondary, paying only any excess left by a primary insurer. After paying claims, the plaintiffs sought reimbursement from the defendant. The court noted the monetary or legal relief sought by the plaintiffs was not available to plan fiduciaries and the defendant did not hold the money sought apart from general assets.
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Plan Prevails in Coordination-of-Benefits Dispute but Is Not Entitled to Monetary Relief.
Benefits Magazine; v51 no11 pp 56, 58 Nov 2014; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The plaintiff in Central States, Southeast and Southwest Areas Health and Welfare Fund v. First Agency, Inc. et al. is a multiemployer welfare plan suing the defendant insurance company for compensation of payments made to 13 student athletes over a three-year period. Policies of both the plaintiff and defendant state the insurer has primary coverage responsibility for an insured who is not a dependent. The district court ruled for the plaintiff and ordered the defendant to pay the claims for the students plus attorney fees. The Sixth Circuit Court of Appeals ruled the students were covered as dependents through a union policy but under their own names through the defendant policy, making the defendant the primary insurer. However, the court reversed the monetary award since it could be applied only as equitable relief through a constructive trust or lien on specific funds under the defendant's control.
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Domestic Partner Does Not Satisfy Plan's Definition of Dependent.
Benefits Magazine; v51 no2 pp 64-65 Feb 2014; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : An employee enrolled her domestic partner in a group health insurance plan, completing a Domestic Partnership Enrollment Form Addendum and paying premiums. After the partner incurred $750,000 in bills from an injury, the plan administrator rescinded coverage, saying the partner was never eligible as a spouse dependent and was married to another person at the time. The partner assigned rights to pursue claims to the hospital, but the district court dismissed the hospital's claim, finding it lacked standing to sue under ERISA since it was not a plan participant or beneficiary. The partner also lacked standing since she did not meet the plan's clear definition of spouse nor was she legally married to the employee. The Tenth Circuit Appeals Court upheld the lower court, denying the hospital's claim under ERISA.
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Plan Design After United States v. Windsor: What Happens When Employers Ask and Employees Tell.
Schwallie, Daniel P.; Steinberg, Allen; Benefits Quarterly; v30 no1 pp 58-61 1st Qtr 2014; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In United States v. Windsor, the Supreme Court ruled that the U.S. government can no longer treat same-sex marriages differently from opposite sex marriages. Employers should examine their benefit plans to determine which are affected by Windsor, what changes are required and what optional changes might be appropriate. While most defined benefit plans will likely expand their benefits to equally cover same-sex spouses, Windsor leaves open the possibility that explicitly giving deferential treatment to opposite-sex spouses might be legal. While defined contribution plan balances are not typically affected by marital status, spousal minimum distributions and spousal consent rules must still be addressed. Since proposed Affordable Care Act (ACA) regulations explicitly exclude spouses from the definition of dependents, neither pre- nor post-ACA health plans are directly affected, but again some ancillary issues may arise. Similarly, most other health and welfare benefits, with the exception of retiree health plans, will not be directly affected by the Windsor decision. The proposed Employment Non-Discrimination Act (ENDA) would explicitly prohibit discrimination in hiring and employment based on sexual orientation and require equal treatment of same-sex spouses in more cases, but ENDA seems unlikely to pass the House of Representatives as of early 2014.
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What Is New and Just Around the Corner in 2014 for Health Plans?
Goodman, Sharon M.; Benefits Magazine; v50 no11 pp 32-37 Nov 2013; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Several Affordable Care Act (ACA) provisions take effect in 2014, regardless of the postponed employer responsibility mandate. No plan may apply a waiting period longer than 90 days for employees who are otherwise eligible for coverage. This may require amendments to collective bargaining agreements and multiemployer plan documents. Annual limits on ten categories of essential health benefits, limits on out-of-pocket maximums and other cost sharing in nongrandfathered plans and exclusions for preexisting medical conditions are prohibited. Grandfathered plans must start covering dependents up to age 26. Nongrandfathered plans must cover clinical trials and may not discriminate against qualified care providers or against participants on the basis of their medical status. Annual reinsurance fees start and the summary of benefits and coverage (SBC) must describe minimum essential coverage and minimum value. SBC changes typically require participant notification at least 60 days in advance.
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What's Working: Cost-Containment Efforts Paying Off.
Vogel, Chris; Benefits Magazine; v50 no5 pp 8-10 May 2013; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Ken Stuart's work as Chief Financial Officer for the San Diego Electrical Health and Welfare Trust is paying off, holding the health plan's medical cost trend to a third of the national trend and seeing average monthly claims per employee drop for three years. Key changes include use of a quality-based tiered physician network, incentives to seek a second opinion, a stronger disease management program with in home telephonic monitoring, dependent verification and third-party screening of insurance claims. Cost differentials fueled the use of preferred providers, and the opt out approach for disease management saves $3.50 to $4 for each dollar spent. Aggressive plan design changes and sufficient education of participants led to informed and cost-effective decisions. The plan covers 5,000 participants in San Diego County, California.
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Health Care Reform 2011: Group Plan Mandates.
Church, Sarah Lockwood; Landy, Joni; Benefits Magazine; v48 no2 pp 24-29 Feb 2011; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Sponsors of group health plans must be ready for mandates under the Patient Protection and Affordable Care Act. Some took effect September 23, 2010, six months after the law was enacted, and more become effective on various dates in the coming years. Some mandates are based on whether a plan is grandfathered. Grandfather status is determined separately for each plan an employer sponsors. There are special rules for insurance provided through collective bargaining agreements. All plans are subject to some mandates including coverage of dependent children up to age 26, prohibitions on exclusions for preexisting conditions and restrictions on lifetime and annual limits. Other PPACA mandates apply only to nongrandfathered plans.
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Communicating Benefits: The Times They Are A'Changin.
Fosbre, Leanne; Benefits & Compensation Digest; v47 no9 pp 1-3 suppl. Sep 2010; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The changes brought about by 2010 health care reform laws mean that failing to communicate employee benefits could result in a number of new problems for employees. Employers should implement a health care communications campaign for 2010, letting employees know how they will be affected by health care reform. Employees need to know about major changes, including extended coverage for adult children up to age 26, the elimination of lifetime limits and most annual restrictions, the availability of a public long term care plan, the ineligibility of over-the-counter medications as an eligible reimbursement for health care spending accounts and the need to report health coverage on W-2 forms. Plans which are not grandfathered have an even longer list of issues. Employees should also be informed of the costs, at least in the short term, that reforms will bring.
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Other Recent Decisions.
Benefits & Compensation Digest; v47 no8 pp 63-64 Aug 2010; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In Penske Logistics LLC et al. v. Freight Drivers and Helpers Local 557 Pension Fund et al., the Third Circuit Court of Appeals ruled that a letter from the defendant to the plaintiffs effectively triggered the requirement that the plaintiff submit to arbitration over partial plan withdrawal liability. In Begnaud v. Blue Cross & Blue Shield Foundation et al., the plaintiff's wife underwent an emergency delivery and neonatal services with a nonparticipating health care provider, resulting in uncovered charges. The plan increased the reimbursement amount, but not fully covering the charges. The Fifth Circuit Appeals Court upheld the administrator and district court, finding the plan provision for emergency services does not assure 100 percent reimbursement of costs. In Kolbe & Kolbe Health and Welfare Benefit Plan et al. v. The Medical College of Wisconsin Inc. et al., the defendants provided health care services to a dependent child later determined ineligible for coverage. The plan paid the defendant but then sought to recoup the payment. The District Court for the Western District of Wisconsin dismissed the plaintiffs' state law claim for breach of contract as preempted by ERISA and denied their effort to recoup payment. The plaintiff multiemployer plan in LaBarbera et al. v. Ovan Construction sought unpaid contributions from the defendant employer, following the terms of a collective bargaining agreement (CBA) with a union. The defendant refused to provide reports for an audit, as required by the CBA. The District Court for the Eastern District of New York supported the plaintiffs' right to unpaid contributions from the defendant, as assessed through a formula audit.
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Court Affirms Denial of Health Benefits.
Benefits & Compensation Legal & Legislative Reporter; v43 no3 p 12 Mar 2009; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In Love et al. v. Dell Inc. et al., the Fifth Circuit Appeals Court upheld the lower court's support for a health plan administrator denying additional mental health care benefits. The administrator initially denied but later approved payment for a plan member's son's hospitalization in an acute care facility after a suicide attempt. The administrator, however, denied subsequent treatment in a residential facility in favor of lower cost outpatient treatment. The appeals court found the administrator's review process, including review by a specialist independent organization, to comply with ERISA's requirements and sufficient to support the denial of intensive treatment as medically unnecessary.
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Insurance Company's Claim Barred by Contractual Limitations Period.
Benefits & Compensation Legal & Legislative Reporter; v43 no3 pp 6-7 Mar 2009; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In Medical Mutual of Ohio v. k. Amalia Enterprises Inc. et al., the plaintiff insurer sued the employer plan sponsor for breach of contract and negligent representations. A benefits audit revealed a plan member's dependent's hemophilia as a preexisting condition, undisclosed by the member on application. The Sixth Circuit Appeals Court upheld the lower court's summary judgment for the defendant since the plaintiff filed suit over three years after the discovery. The court observed the plaintiff, as a sophisticated insurance company, should have questioned costly medical treatment to learn of the possible fraud and file suit within the state statute of limitations.
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Plan's Limitations Provision Bars Plaintiffs' Claim.
Benefits & Compensation Legal & Legislative Reporter; v43 no2 p 8 Feb 2009; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : A plan administrator applied a two-year statute of limitations when denying benefits for a plan member's dependent needing psychiatric care. The decision prompted Island View Residential Treatment Center et al. v. Blue Cross Blue Shield of Massachusetts Inc., heard by the First Circuit Appeals Court. Massachusetts state law controlled issues pertaining to benefits, regardless of treatment location or residence. The district court granted summary judgment for the defendant since the plan contract specified a two-year benefit appeal period. The First Circuit rejected the plaintiff's arguments for a different interpretation of the statute of limitations and supported the lower court.
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Participant Knowingly and Voluntarily Waived Dependent's Coverage.
Benefits & Compensation Legal & Legislative Reporter; v41 no9 pp 9-10 Sep 2007; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : A welfare plan participant removed his son as a dependent upon learning the son was eligible for Medicaid if not otherwise covered. Medicare later paid for the son's hospital treatment. When Medicaid coverage expired, the plan member reenrolled his son on the company plan. The hospital, the plaintiff in Cook Children's Medical Center v. The New England PPO Plan of General Consolidated Management Inc. et al., sought additional payment from the plan, but the plan administrator denied the claim since the patient was not enrolled at the time of service. The district court ruled for the defendant plan and was supported by the Fifth Circuit Appeals Court. The courts rejected the hospital's view that the plan member was not permitted to waive enrollment to rely on public funding.
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Stepchildren Denied Health Coverage Under Terms of Plan.
Benefits & Compensation Legal & Legislative Reporter; v41 no7 pp 12, 16 Jul 2007; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The U.S. District Court for the Eastern District of Wisconsin upheld a plan administrator's decision to deny health benefits to a participant's stepchildren in King et al. v. Wisconsin Pipe Trades Health Fund. The plaintiff was told by the defendant's representative that stepchildren were covered, but the plaintiff never mentioned the fact that his wife was receiving child support payments from her ex husband. The plan only covers stepchildren when the participant is providing the sole support for the child. The court found that the defendant did not act arbitrarily or capriciously in denying coverage to the plaintiff's stepchildren.
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Data Mining-Driven ROI: Health Care Cost Management.
Gerver, Howard M.; Barrett, Janice; Benefits & Compensation Digest; v43 no6 pp 1-5 suppl. Jun 2006; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Data mining can help sponsors reduce health care costs by five to ten percent or more annually. Typically, health care information is stored with various entities along the health care benefits supply chain. Data mining integrates and analyzes that information, providing sponsors with actionable information. With data mining, benefits personnel can answer questions about such factors as the number of ineligible dependents in the plan, the costs of diabetes or obesity related illness or which doctors are prescribing expensive drugs.
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Health Care Cost Management: Data Mining-Driven ROI.
Gerver, Howard M.; Barrett, Janice; Employee Benefit Issues: The Multiemployer Perspective - 2005; pp 108-114 2006; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Health care plan sponsors can use data mining to achieve insights that can be a starting point for formulating effective cost management strategies. Health care data is often voluminous but is scattered among different entities, such as providers, pharmacies and insurance companies. Each of these entities manages its data separately. Utilization of such data requires a methodical approach to integration and analysis. Data mining can answer such questions as how much Type 2 diabetes is costing the plan, and can provide a basis for action, such as implementing a disease management program.
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Spousal Surcharge Programs: An Overview.
Peters, Hudson A.; Benefits Quarterly; v21 no1 pp 19-25 1st Qtr 2005; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In an effort to control health care costs, increasing numbers of employers are imposing a surcharge for an employee's working spouse who is eligible for coverage elsewhere. A Mercer survey revealed that about five percent to 16 percent of employers have implemented a surcharge, and about 30 percent to 40 percent are considering adding a surcharge. Typical surcharges range from $30 to over $200 monthly, but are commonly $50 to $75 per month. A surcharge may be waived if the spouse meets certain conditions. Administrative, legal and financial implications and a number of advantages and disadvantages must be evaluated in consideration of a spousal surcharge. Employers in competitive industries and those with generous health care benefits can expect greater financial gains from a surcharge.
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