LibGuides: Health Care Claims Disputes: Employer Provided Healthcare

Employer Provided - ERISA

ERISA
Employee Retirement Income Security Act of 1974 (ERISA)
Affordable Care Act - ERISA Preemption Applicable to Group Plans
Nothing in the Act “shall be construed to affect or modify the provisions of section 1144 of Title 29 [ERISA] with respect to group health plans.”

17 Fla. Prac., Insurance Law § 13:11 (2012-2013 ed.)

ERISA Law Blog

Managed Care Contracting

Secondary Reference Materials

43 Am Jur 2d Insurance § 355 provides an excellent overview of ERISA vs Commercial Insurance and how to distinguish the two. ERISA claims will almost always be in Federal jurisdiction because of ERISA's preemption provisions. Commercial Insurance will almost never be in Federal Jurisdiction because Individual Insurance policies are primarily governed by state law. Thus there is no Federal Question. And, there will almost never be diversity between the patient (the insured), the insurance company and the provider.

Rooney. ERISA: preemption challenged by state strategies and health care reform. 7 Benefits LJ 127, Summer 1994.

States, Congress, or the Courts: Who Will Be First to Reform ERISA Remedies, Annals of Health Law, Vol. 7, pp. 73-106, Rooney, Curtis D. 7 Annals Health L. 73 (1998)

Law Journal Article re ERISA vs State Insurance
7 Annals Health L. 73 (1998)
States, Congress, or the Courts: Who Will Be First to Reform ERISA Remedies; Rooney, Curtis D.
Law Journal Article re Impact of PPACA on Preemption Doctrine
13 J. Health Care L. & Pol'y 393 (2010)
ERISA Preemption of State Play or Pay Mandates: How PPACA Clouds an Already Confusing Picture; Chirba-Martin, Mary Ann
Health Law Practice Guide
Health Law Practice Guide, Database updated July 2013, American Health Lawyers Association by J. PETER RICH and SUSAN M. NASH, provides at Chapter 18. An Overview of Insurance Payment for Health Care Services and Employee Welfare Benefit Plans.

2 Health L. Prac. Guide § 18:3 (2013)
Life and Health Insurance Law by William F. Meyer and Franklin L. Best,
Life and Health Insurance Law by William F. Meyer and Franklin L. Best, Database updated August 2012

Chapter 1. The Lawyer and Insurance

1 Life & Health Insurance Law § 1:2 (2d ed.)
Medicare and Medicaid Claims and Procedures
Medicare and Medicaid Claims and Procedures by Harvey L. McCormick, Database updated November 2011

Part I. MEDICARE
Part II. MEDICAID
Appendix A. List of Medicare Forms
Appendix B. List of Fiscal Intermediaries
Appendix C. List of Medicare Carriers
Appendix D. List of Medicare Quality Improvement Organizations
Appendix E. List of State Medical Assistance Contacts
1 Medicare and Medicaid Claims and Proc. A Ch. 1 I Refs. (4th ed.)
more...less...
Appendix A. List of Medicare Forms
Appendix B. List of Fiscal Intermediaries
Appendix C. List of Medicare Carriers
Appendix D. List of Medicare Quality Improvement Organizations
Appendix E. List of State Medical Assistance Contacts
How Are Hospitals Organized - Here's a good reference.
Attorneys Medical Deskbook 4th

Database updated October 2012

Dan J. Tennenhouse, MD, JD, FCLM

Chapter 8. Hospitals

A. Units and Departments of a Hospital

1 Attorneys Medical Deskbook § 8:1

Federal Tax Coordinator, Second Edition - Discussion of Employer Health Insurance

H-1170.1 DETERMINING THE ACTUARIAL VALUE OF A QUALIFIED HEALTH PLAN.

Federal Tax Coordinator, Second Edition at ¶ H-1325 GROUP HEALTH PLAN REQUIREMENTS., discusses group health plans as impacted by the implementation of ACA

Group health plans are subject to numerous requirements that were enacted by (1) the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to foster access, portability, and renewability of coverage, and (2) the Patient Protection and Affordable Care Act (PPACA), which incorporated Public Health Service Act (PHSA) requirements into the Code. The HIPAA rules limit preexisting condition exclusions, prohibit the exclusion of certain individuals based on health status, and guarantee the renewability of health insurance coverage. The PHSA rules limit lifetime and annual limits, require coverage of certain preventive services, extend dependent coverage, and impose various other market requirements on group health plans and health plan issuers.

Group health plans also must comply with the COBRA continuation of coverage rules discussed at H-1250 et

A “group health plan” means a plan (including a self-insured plan) of, or contributed to by, an employer (including a self-employed individual) or employee organization to provide health care (directly or indirectly) to (i) the employees, (ii) former employees, (iii) the employer, (iv) others associated or formerly associated with the employer in a business relationship, or (v) their families (see H-1325.23).¹

Under the minimum requirements for group health plans and health insurance issuers offering group health insurance coverage, a plan or issuer offering group health insurance coverage may provide greater rights to participants and beneficiaries than those set forth in the Code.²

A tax (see H-1325.34 et) is imposed for any failure to comply with these requirements. Generally, the tax is imposed on the employer sponsoring the plan, but it may be imposed on the plan in the case of a multiemployer plan, or on a multiemployer welfare arrangement (MEWA) for violations of the requirements relating to guaranteed renewability.

¶ H-1325 GROUP HEALTH PLAN REQUIREMENTS., 1997 WL 506289

ERISA Preemption from an HR Perspective

Congress intended ERISA to make the regulation of employee benefits plans exclusively a federal concern. Therefore, it included a sweeping preemption provision that supersedes all state laws to the extent that they "relate to any employee benefit plan."

4 Compensation and Benefits § 57:53

The US Supreme Court in Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987) found a state suit for improper benefits processing under an ERISA-regulated plan was preempted by federal law because a state action for bad faith actions was not an insurance regulation and thsu not within the saving clause of in the ERISA preemption provision. Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987).

Estoppel

Use of Federal Estoppel Doctrine to Establish Coverage Under Group Health Insurance Policy

At times an insurance company will legitimately deny coverage for a claim stating that the person is not insured. In some instances, the individual may yet be entitled to coverage through the principle of estoppel.

The issue arises where an employee relies upon the assurances of a representative of the insurer, the plan administrator, or the employer that he or she is covered under a group health policy for a particular health risk, the coverage of which is unclear under the express language of the plan documents. In such instances, even though coverage may in fact be found not to exist under the plan documents, coverage can be obtained by use of the federal estoppel doctrine.

43 Am. Jur. Proof of Facts 3d 261 (Originally published in 1997)

HMO and Bad Faith Performance

Bad Faith Actions Liability & Damages
HMO's can be liable for bad faith failure to pay claims.

ERISA Cases of Interest

State Claims Typically Preempted by ERISA and thus removable to Federal Court.

In Aetna Health, Inc. v. Davila, 542 U.S. 200 (2004), the Supreme Court explained that under the "extraordinary pre-emptive power" of ERISA, "any state law cause of action that duplicates, supplements, or supplants the ERISA civil enforcement remedy is pre-empted. . . . Hence, causes of action within the scope of . . . § 502(a) are removable to federal court." Id. at 206. The Court further explained that not only does ERISA's complete preemption confer federal jurisdiction, it also limits claims and remedies exclusively to those provided by section 502(a). Id.

However, there are exceptions.

In Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355 (2002), the Court distinguished between benefits offered under a plan which are ERISA premeptive and actions based on laws "directed toward" the insurance industry which are not preempted by ERISA. To survive preemption, a statute must not enlarge a claim beyond the benefits available in any action brought under 29 U.S.C.S. § 1132(a). Id.

See also Ky. Ass'n of Health Plans, Inc. v. Miller, 538 U.S. 329 (2003), where the insurance regulation of an HMO and a KY statute requiring the insurance plan to accept any healthcare provider willing to abide by the HOM's conditions of participation was found to not be preempted by ERISA since its primary emphasis was insurance and not healthcare benefits. Id.

Litigating insurance claim disputes under ERISA

Claims Procedures Under ERISA
This is an excellent Practice Guide for handling Bad Faith Claims

Bad Faith Actions Liability & Damages by Stephen S. Ashley