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Published byRichard Mosley Modified over 9 years ago
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Click to edit Master title style Compliance: Can’t This Be Easier for Us All? What We Wish Carriers (and TPAs) Knew about Employer Obligations
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Fiduciary Discretion – Where are the Lines to be Drawn? Eligibility (& employer concerns) Versus administrative role of carrier / TPA “Written plan document” requirements and “sole benefit” rules of ERISA Claims determinations and discretion / overriding claims conclusions Self-funded client concerns Delegation versus involvement at various levels Avoiding red flags and setting of precedents
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Flexibility Needed in the (Ugly) Face of PPACA Communications to employees Preferred approaches Interpretation of new rules & perspective Keep in mind who is at greatest risk Flexibility in design Example of annual limit rules Business integrity and competitiveness
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Tell Us Your Business Plan for Reform Preparation for future and new responsibilities… or not National carrier approach Prevent ugly surprises
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Change in Status Rules Common carrier failures in group insurance area: Service center phone responses Impact on clients --IRS audit area Training (and retention) issue
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Transparency State & federal concerns and reporting Example of egregious, avoidable mistake Rebating Media attention
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Written Materials: ERISA Disclosures and PPACA Requirements Completeness PPACA Coverage reporting Mini-summary Defining “plan” Voluntary benefits & special issues
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Proper Payment Concerns under Medicare Secondary & Emerging Rules Overview of Medicare Secondary Rules Emerging rules Non-compliant carrier due to implementation CMS audits & approach to penalties Impact on client & relationship
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Claims Administration Federal Agency Focus on “Enforcement Examples” ERISA Standards New PPACA requirements New claims and appeals rules – what is your approach? Minimum Loss Ratios – what is your approach?
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Client Relationships: Liability & Responsibility One should flow from the other Assume liability & responsibility where proper E&O coverage and practical outcomes
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