Health Care Benefits Law

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Health Care Benefits Law explains how current laws affect the design and day-to-day administration of health care plans. It also helps you identify—and deal with—hidden areas of liability.

Making sense of the nonstop parade of federal and state legislation, regulation and decisional law governing health care benefits is not an easy task. For professionals in the field, however, it is an essential one. Fortunately, there is a comprehensive and practical guide to this complex, evolving area that clarifies the legal framework, including the most recent developments, and keeps you on top of every important issue.

Health Care Benefits Law explains how current laws affect the design and day-to-day administration of health care plans. It also helps you identify—and deal with—hidden areas of liability. You'll find detailed coverage of such topics as: ERISA reporting and disclosure requirements; the Patient Protection and Affordable Care Act (PPACA) and the regulations clarifying its provisions; negotiating ASO (Administrative-Services-Only) contracts; tax treatment of health benefits; auditing utilization review; health and welfare benefit plans and ERISA fiduciary requirements; managed care liability; COBRA (including all the sample notices and forms that an employer needs to comply effectively); Medicare Secondary Payer issues; provision of benefits by professional employer organizations (PEOs); the Americans with Disabilities Act; the Health Maintenance Organization Act; HIPAA; the Family and Medical Leave Act; health care and employee benefit provisions of the 2005 Bankruptcy Act; the Tax Relief and Health Care Act of 2006; and more.

You'll get sample forms, checklists, drafting tips, and the perspective you need to cope with any challenge. Whether you are an attorney, health care plan sponsor, employer or multi-employer trustee, insurance company, HMO, or other health care provider, this guide will save you hours of painstaking work and greatly simplify compliance.

Book #00660; looseleaf, one volume, 1,564 pages; published in 2001, updated as needed; no additional charge for updates during your subscription. Looseleaf print subscribers receive supplements. The online edition is updated automatically. ISBN: 978-1-58852-096-8

Additional Information
Division Name Law Journal Press
Volumes 1
Product Types Books
Brand Law Journal Press
Jurisdiction National
ISBN 978-1-58852-096-8
Page Count 1564
Edition 0
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Jeffrey D. Mamorsky
Jeffrey D. Mamorsky is a partner in the New York office of the international law firm of Greenberg Traurig, LLP. He is the editor of the Employee Benefits Handbook, as well as the founder and editor-in-chief of theJournal of Compensation and Benefits. He is the author of Employee Benefits Law: ERISA and Beyond and Health Care Benefits Law, both published by Law Journal Press.Mr. Mamorsky graduated from New York University College of Arts Sciences and holds a J.D. from New York Law School and an LL.M. in taxation from New York University Law School.
ERISA Fiduciary Responsibilities

§ 1.01 Introduction
§ 1.02 Identifying the ERISA Fiduciary
[1] Responsibility Determines Status
[2] Directors as Fiduciary
[3] Third Party Administrator as Fiduciary
[4] Company Not De Facto Co-Administrator
[5] ERISA Liability for Nonfiduciary Advisers
§ 1.03 Rules Prohibiting Transactions Between Plan and Party-in-Interest
[1] Parties-in-Interest
[2] Internal Revenue Service’s Disqualified Person Definition
[3] Prohibited Transactions
[4] Adoption and Expansion of the DOL Voluntary Fiduciary Correction Program (“VFCP”)
§ 1.04 Particular Plan Requirements
[1] Introduction
[2] Mandatory Plan Requirements
[3] Mandatory Trust Requirements
[4] Plan Assets Must Be Held for the Exclusive Benefit of Participants
§ 1.05 Fiduciary Standards
[1] Prudent-Man Rule
[2] Adherence to Plan Documents
[3] Allocating Fiduciary Responsibility
[4] Providers Must Pass Along Discounts
§ 1.06 Claims Procedure
[1] Filing a Claim for Benefits
[2] Failure to Process Claims Promptly
[3] Misrepresentation by Third Party Claims Administrator
[4] Misrepresentation by Employee
[5] Duty to Notify
[6] Failure to Provide Complete and Accurate Information to Beneficiary
[7] Failure to Notify Plan of Termination
[8] Denial of Benefits
§ 1.07 Litigation Standard of Review
[1] Why Written Criteria Are Important
[2] Exclusions Unenforceable
[3] Clinical Trial Not Excluded
[4] Experimental Treatment Not Covered
[5] In Vitro Not Covered
[6] Vicarious Liability
[7] Conflict of Interest
§ 1.08 Plan Procedures Litigation
§ 1.09 Litigation Involving Medical Service Providers
[1] Claims by Medical Service Providers
[2] Claims Against Medical Service Providers
§ 1.10 Litigation Involving Prescription Drug Overcharging
[1] Mohr v. UnitedHealth Group Inc.
[2] Negron v. Cigna Corp.

Tax Treatment of Health Benefits

§ 2.01 Introduction
§ 2.02 General Rules for Health Plans
[1] Exclusion from Taxation of Premiums and Benefits
[2] Eligible Medical Expenses
[3] Employer Tax Deduction
[4] Federal Tax Withholding
[5] Disability Income Benefits Taxed as Deferred Compensation
§ 2.03 Health Plan Qualification Requirements
[1] Written Plan
[2] Employees vs. Self-Employed Individual
[3] Coverage of Dependents
§ 2.04 Nondiscrimination Tests for Health Plans
[1] Identification of Self-Insured Arrangement
[2] Highly Compensated Individuals
[3] Eligibility Testing
[4] Nondiscriminatory Benefits
[5] Taxation of Excess Reimbursements Under a Discriminatory Health Plan
§ 2.05 Cafeteria Plans
[1] Qualification Requirements
[2] Flexible Spending Accounts
[3] Nondiscrimination Tests
[4] Effect of the Family and Medical Leave Act on the Operation of Cafeteria Plans
[5] IRS Modifies FSA “Use-or-Lose” Rule
§ 2.06 Health Reimbursement Accounts
[1] Basic Design and Rules
[2] Advantages of HRAs
[3] Disadvantages of HRAs
[4] Design Considerations
[5] Other Important Considerations
[6] Private Letter Rulings
[7] Summary
§ 2.07 Health Savings Accounts
[1] IRS Guidance
[2] DOL Guidance
[3] Interaction of Health Savings Accounts with Other Employer-Provided Health Reimbursement Plans
[4] The Tax Relief and Health Care Act of 2006
[5] Employer Comparable Contributions to Health Savings Accounts and the Requirement of Filing Return for the Excise Tax—IRS Regulations
§ 2.08 Defense of Marriage Act (DOMA) Supreme Court Decision
[1] Introduction
[2] Background
[3] Majority Decision
[4] Dissenting Opinions
§ 2.09 All Legal Same-Sex Marriages Recognized for Federal Tax Purposes
[1] Introduction
[2] Details of Revenue Ruling 2013-17

Health Benefit Plans and ERISA Preemption

§ 3.01 Introduction
§ 3.02 ERISA Preemption
§ 3.03 Court Decisions Interpreting Preemption
[1] State-Mandated Benefits
[2] Plan Administration
[3] Workers’ Compensation Statute Preempted
[4] State Surcharges Not Preempted
§ 3.04 Health Plan Funding Alternatives and Preemption
[1] Conventional Insurance
[2] Minimum Premium Plans
[3] Self-Insurance
[4] Stop-Loss Coverage
§ 3.05 U.S. Supreme Court: ERISA Preempts Vermont Law Requiring Health Data Reporting
[1] Summary
[2] District Court Opinion
[3] Second Circuit Opinion
[4] Supreme Court Decision

Employer Liability in Managed Care

§ 4.01 Introduction
[1] Elements of Managed Care
§ 4.02 Theories of Liability Arising from Managed Care
[1] Liability Arising from Selection or Retention of Health Care Providers
§ 4.03 Impact of ERISA on Employer Liability for Managed Care
[1] Preemption of State Laws
[2] Limitation of the Preemption Doctrine
[3] Impact of ERISA on Potential Damage Awards
§ 4.04 Potential Employer Liability Under ERISA
[1] Plan Requirements
[2] Employer Guidelines
[3] Communication of Plan Provisions
[4] Employer Guidelines
[5] Claims Procedures
[6] Fiduciary Standards
§ 4.05 Employer Contracting Strategies to Avoid Liability
[1] Selecting and Contracting with a Managed Care Vendor

Plan Administration

§ 5.01 Auditing Claims Administration Performance
[1] Introduction
[2] Defining Audit Objectives
[3] Auditing Claims
[4] Assessing the Claims Office and Reviewing Procedures
[5] Evaluating Claims Systems
[6] Managed Care Program Integration
[7] Improving Administrator Performance
§ 5.02 Negotiating Administrative-Services-Only Contracts
[1] Introduction
[2] ERISA Considerations
[3] Common Provisions in Administrative-Services-Only Contracts
[4] Less Common Features in Administrative-Services-Only Contracts
§ 5.03 [Reserved]
§ 5.04 Auditing Utilization Review and ERISA Compliance
[1] Introduction
[2] Agency Theory
[3] Corporate Negligence Theory
[4] Medical Management Liability
[5] Liability Based on Provider Incentives
[6] ERISA Liability
§ 5.05 Subrogation: The Plan Administrator’s Duty to Recover Plan Assets from Tortfeasors
[1] Introduction
[2] The Right of Subrogation: How Health Care Plans Recover from Tortfeasors
[3] Some Practical Issues in a Recovery Program
[4] Reasonable Expectations of an Effective Recovery Program
[5] Background on Legal History
[6] Restrictions on Tort Recovery
[7] Restrictions on Subrogation
[8] ERISA and Federal Common Law
[9] Significance of the Legal Principles
[10] Well-Designed Plan Language
[11] The Reimbursement Agreement
[12] Are These Plan Provisions Effective?
[13] A Program for Effective Administration of Third-Party Recoveries

Qualified Medical Child Support Orders

§ 6.01 QMCSO
[1] Definition
[2] Required Information
§ 6.02 The Plan Administrator’s Responsibilities
§ 6.03 Rights of Alternative Recipients
§ 6.04 Enforcement
§ 6.05 SSA Amendments Enabling State Enforcement
[1] Requirements for Insurers
[2] Requirements for Employers
[3] Additional Requirements
§ 6.06 Unanswered Questions
[1] Preexisting Conditions
[2] Open Enrollment
[3] Interim Coverage
[5] Nonparticipating Employees
§ 6.07 What Employers Should Do
§ 6.08 Procedures
[1] Determining If a Medical Child Support Order is Qualified


§ 7.01 COBRA Continuation Coverage
[1] Overview
[2] Penalties for Failure to Comply with COBRA
§ 7.02 Plans That Are (and Are Not) Subject to COBRA
[1] What is a Group Health Plan?
[2] What is a Small-Employer Group Health Plan?
[3] How Many Plans Does a Plan Sponsor?
[4] “Packaged” Health Care Plans
[5] COBRA and Cafeteria Plans
§ 7.03 Qualified Beneficiaries and Qualifying Events
[1] Who is Entitled to COBRA Continuation Coverage, Why and for How Long
[2] Employees and 18-Month Qualifying Events
[3] “Renegade Dependents” and 36-Month Qualifying Events
[4] Multiple Qualifying Events
[5] Disabled Individuals and 29-Month Qualifying Events
[6] Retirees

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