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Retiree Eligibility for Group Medical Benefits



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Retiree Eligibility for Group Medical Benefits

Most active, permanent, full-time employees are eligible for group coverage. Employers that offer group medical insurance are required to offer it to active workers over age sixty-five, under the Age Discrimination in Employment Act (ADEA) discussed above. For these employees, Medicare becomes a secondary payer. Some employers choose to offer continuation of group medical benefits to employees who have retired. This coverage is like Medigap insurance (discussed in Chapter 22 "Employment and Individual Health Risk Management"), where Medicare is the primary payer and the group plan is secondary. Typically, the retiree plan is less generous than the plan for active workers because it is designed simply to fill in the gaps left by Medicare.


Historically, employers have paid medical premiums or benefits for retirees out of current revenues, recognizing the expense in the period that it was paid out. However, in 1993 the Financial Accounting Standards Board (FASB 106) began phasing in a requirement that employers recognize the present value of future retiree medical expense benefits on the balance sheet during the employees’ active working years rather than the old pay-as-you-go system. The negative effect of these new rules on corporate earnings has been significant. Consequently, most employers have been cutting back on health benefits promised to retirees, and only about a third of the companies that had retiree health care in 1990 still had them a decade later.
Portability: HIPAA

Title I of the Health Insurance Portability and Accountability Act (HIPPA) of 1996 protects employees who change jobs from having to start a new waiting period before a preexisting condition is covered. For example, before HIPAA, a person with diabetes might not want to change jobs, even for a much better position, because it would mean going for a time without coverage for daily insulin shots and possible complications of the illness. Many employees were trapped in such situations before HIPAA. After the enactment of HIPAA, a person with diabetes could change jobs, and health insurance providers, without fear of losing coverage on that specific condition.


HIPAA provides protection for both group and individual health insurance. In essence, it provides portability of coverage: when an employee leaves one job and starts a new job, the coverage of health insurance under the new employer’s program cannot exclude benefits for preexisting condition, as long as the break in health coverage is no longer than sixty-three days. Portability does not mean carrying the actual coverage of the old employer to the new one, but rather carrying forward the qualification for preexisting conditions. For example, Joe was employed by Company A for ten years and had health coverage under that employer. He accepted a job offer from Company B. One month before changing his job, he broke his leg in a skiing accident. Under HIPAA, the new company cannot limit coverage for the injured leg. If Joe needs surgery on this leg in three months, the health coverage under Company B will pay for the surgery. Before HIPAA, Joe would have had to stay covered under his old employer, paying the full amount himself through COBRA, until the preexisting condition period of the new employer was met. That could have been six months, a year, or even longer.
Under HIPAA, an employer can impose only up to twelve months preexisting conditions exclusions for regular enrollment and up to eighteen months for late enrollment. During an exclusion period, the health plan has to pay for all other conditions except the preexisting condition. Prior group health coverage applies to these limits. Thus, if an employee’s only previous group health coverage was for six months with Company A, the preexisting conditions exclusion from new Company B would last for just six additional months rather than the full twelve. Under HIPAA, a preexisting condition is defined as a condition for which the employee received any treatment within the six-month period before enrolling with the new employer.
The details of HIPAA are complex, but the gist is that an employee without a break in health coverage will never have to meet a preexisting condition period more than once in a lifetime, if at all. When an employee leaves a job, the employer is required to provide a certificate of health coverage. This certificate is then taken to the next employer to ensure that no preexisting conditions are imposed on the employee. Employers who neglect to give the certificate are subject to penalties of $100 per day. More on HIPAA and other recent health care-related laws is featured in the box “Laws Affecting Health Care.” Further, the application of HIPAA for military reservists called to active duty is detailed in the box “Individual Coverage Rights When Called to Military Duty.”
Laws Affecting Health Care

The Health Insurance Portability and Accountability Act (HIPAA)


The Health Insurance Portability and Accountability Act (HIPAA) provides rights and protections for participants and beneficiaries in group health plans. HIPAA was signed into law on August 21, 1996, and became effective for all plans and issuers beginning June 1, 1997. The act protects workers and their families by doing the following:


  • Limiting exclusions for preexisting medical conditions

  • Providing credit against exclusion periods for prior health coverage and a process for showing periods of prior coverage to a new group health plan or health insurance issuer

  • Providing new rights that allow individuals to enroll for health coverage when they lose other health coverage, get married, or add a new dependent

  • Prohibiting discrimination in enrollment and in premiums charged to employees and their dependents based on health status-related factors

  • Guaranteeing availability of health insurance coverage for small employers and renewability of health insurance coverage for both small and large employers

Newborns’ and Mothers’ Health Protection Act


The Newborns’ and Mothers’ Health Protection Act of 1996 requires plans that offer maternity coverage to pay for at least a forty-eight-hour hospital stay following childbirth (a ninety-six-hour stay in the case of a cesarean section). It was signed into law on September 26, 1996, and became effective for group health plans for plan years beginning on or after January 1, 1998.
All group health plans that provide maternity or newborn infant coverage must include a statement in their summary plan description advising individuals of the Newborns’ Act requirements: a mother may not be encouraged to accept less than the minimum protections available to her under the Newborns’ Act, and an attending provider may not be induced to discharge a mother or newborn earlier than forty-eight or ninety-six hours after delivery.
Women’s Health and Cancer Rights Act
The Women’s Health and Cancer Rights Act (WHCRA) contains protections for patients who elect breast reconstruction in connection with a mastectomy. It was signed into law on October 21, 1998, and became effective immediately. WHCRA requires that any plan offering mastectomy coverage must also include coverage for the following:


  • Reconstruction of the breast on which the mastectomy was performed

  • Surgery and reconstruction of the other breast to produce a symmetrical appearance

  • Prostheses and physical complications at all stages of mastectomy, including lymphedemas

Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage. Group health plans covered by the law must notify individuals of the coverage required by WHCRA upon enrollment, and annually thereafter.


Mental Health Parity Act
The Mental Health Parity Act (MHPA), signed into law on September 26, 1996, requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan. The law does not apply to benefits for substance abuse or chemical dependency.
American Recovery and Reinvestment Act
Signed by President Barack Obama on February 17, 2009, the American Recovery and Reinvestment Act (ARRA, or H.R. 1) authorizes $787 billion in federal spending toward infrastructure, direct aid, and tax cuts as a stimulus for the U.S. economy in recession. Within the framework of that objective, it includes provisions affecting health care. H.R. 1 allows up to nine months of COBRA premiums to be subsidized at 65 percent for workers involuntarily terminated between September 1, 2008, and December 31, 2009, whose income is under $125,000 for individuals or $250,000 for families (to receive full benefits). Workers involuntarily terminated during this period who could not initially afford COBRA continuation are given an additional sixty days to elect COBRA coverage through the subsidy. This provision is designed to help an estimated 7 million people maintain health insurance and is expected to account for $24.7 billion of the ARRA funds. H.R. 1 also directs about $338 million in Medicare payment reductions for teaching hospitals, hospice care, and long-term-care hospitals. In another provision, the act aims to invest $19 billion in health information technology, thus encouraging the use of electronic health records for the exchange of patient health information. Ideally, this would see 90 percent of doctors and 70 percent of hospitals convert to electronic health records over the next decade, saving taxpayers $12 billion in the long run. Finally, ARRA sets aside $1.1 billion for federal agencies to draw upon for conducting studies on cost-benefit comparisons of various health care treatments.

Sources: Publications of the U.S. Department of Labor, Employee Benefits Security Administration athttp://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html; “Link to H.R. 1 Conference Report Summary,” National Underwriter Online News Service, February 13, 2009,http://www.lifeandhealthinsurancenews.com/News/2009/2/Pages/Link-To-HR-1-Conference-Report-Summary.aspx, accessed March 13, 2009; Allison Bell, “Obama Signs H.R. 1,” National Underwriter, Life/Health Edition, February 19, 2009,http://www.lifeandhealthinsurancenews.com/News/2009/2/Pages/House-Passes-HR-1-Ball-On-To-Senate.aspx, accessed March 13, 2009.

Individual Coverage Rights When Called to Military Duty

With so many U.S. armed forces in Iraq and Afghanistan, the Department of Labor answers the following questions about the benefits-related rights and responsibilities of those called to active duty and their civilian employers.


My family had health coverage through my employer when I was called for active duty in the military. What are my rights concerning health coverage now?
If you are on active duty for more than thirty days, you and your dependents should be covered by military health care. For more information on these programs, contact your military unit.
In addition, two laws protect your right to continue health coverage under an employment-based group health plan. The Consolidated Omnibus Budget Reconciliation Act (COBRA) provides health coverage continuation rights to employees and their families after an event such as a reduction in employment hours. Also, the Uniformed Services Employment and Reemployment Rights Act (USERRA) of 1994 is intended to minimize the disadvantages that occur when a person needs to be absent from civilian employment to serve in the uniformed services.
Both COBRA and USERRA generally allow individuals called for active duty to continue coverage for themselves and their dependents under an employment-based group health plan for up to eighteen months. If military service is for thirty or fewer days, you and your family can continue coverage at the same cost as before your short service. If military service is longer, you and your family may be required to pay as much as 102 percent of the full premium for coverage. You should receive a notice from your plan explaining your rights.

The Health Insurance Portability and Accountability Act (HIPAA) may give you and your family rights to enroll in other group health plan coverage if it is available to you (e.g., if your spouse’s employer sponsors a group health plan). You and your family have this opportunity to enroll regardless of the plan’s otherwise applicable enrollment periods. However, to qualify, you must request enrollment in the other plan (e.g., your spouse’s plan) within thirty days of losing eligibility for coverage under your employer’s plan. After special enrollment is requested, coverage is required to be made effective no later than the first day of the first month following your request for enrollment. If you are on active duty more than thirty days, coverage in another plan through special enrollment is often cheaper than continuation coverage because the employer often pays part of the premium. For more information on the interaction of COBRA and HIPAA, see IRS Notice 98-12: “Deciding Whether to Elect COBRA Health Care Continuation Coverage After the Enactment of HIPAA,” on the Employee Benefits Security Administration (EBSA) Web site athttp://www.dol.gov/ebsa, which can be found at the link Publications. You can also call toll-free ( 1.866.444.EBSA[3272]) for a free copy.


Note: When considering your health coverage options, you should examine the scope of the coverage (including benefit coverage and limitations, visit limits, and dollar limits); premiums; cost-sharing (including copayments and deductibles); and waiting periods for coverage.
My family and I had health coverage under my employer’s group health plan before I was called on active duty. We let this coverage lapse while I was away and took military health coverage. When I return to my employer from active duty, what are our rights to health coverage under my old plan?
Under USERRA, you and your family should be able to reenter your employer’s health plan. In addition, your plan generally cannot impose a waiting period or other exclusion period if health coverage would have been provided were it not for military service. The only exception to USERRA’s prohibition of exclusions is for an illness or injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, performance of service in the uniformed services, which is covered by the military health plan.

While I am on active duty, is my employer required to continue to make employer contributions to my 401(k) plan?
There is no requirement for your employer to make contributions to your 401(k) plan while you are on active duty. However, once you return from military duty and are reemployed, your employer must make the employer contributions that would have been made if you had been employed during the period of military duty. If employee contributions are required or permitted under the plan, the employee has a period equal to three times the period of military duty or five years, whichever ends first, to make up the contributions. If the employee makes up the contributions, the employer must make up any matching contributions. There is no requirement that the employer contributions include earnings or forfeitures that would have been allocated to the employee had the contributions been made during his or her military service.

Sources: Adapted from “Reservists Being Called to Active Duty,” U.S. Department of Labor, Employee Benefits Security Administration, December 2007,http://www.dol.gov/ebsa/newsroom/fsreservists.html, accessed April 13, 2009.

Multinational Employee Benefit Plans

Multinational corporations manage the human resource risk across national boundaries. The most common concern of multinational employers is the benefit needs of expatriates, U.S. citizens working outside the United States. However, the employer is also concerned with managing benefits for employees who are not U.S. citizens but who are working in the United States. In addition, benefits must be considered for employees who are not U.S. citizens and who work outside the United States.


The corporation designs multinational benefit policy to achieve several objectives. First, the plans need to be sufficient to attract, retain, and reward workers in locations around the world where a corporate presence is required. The plan needs to be fair for all employees within the corporation itself, within the industry, and within the country where employees are located. In addition, the multinational benefit policy needs to facilitate the transfer of workers across national boundaries whenever necessary with a minimum of overall transaction costs.
Typically, the multinational employer tries to protect the expatriate from losing benefits when the employee transfers outside the United States. A premium may be paid at the time of the move to compensate the employee for international relocation. The corporation often provides the expatriate with the same life, long-term disability, medical, and pension benefits as those provided to their U.S. employees. However, in some cases the employee may receive medical care or short-term disability benefits like those of the host country. When employers provide benefits in several international locations, they may use an international benefit network to cover employees across countries under one master insurance contract. This can simplify international benefit administration. The employer must also consider the social insurance systems of the host country and coordinate coverage as necessary with the employee’s home country’s system.
Cultural and regulatory factors differ among countries and affect benefit design, financing, and communication. This makes international employee benefits management a dynamic and challenging field. With the continued globalization of business in the new millennium, career opportunities in international benefits management are likely to grow.
KEY TAKEAWAYS

In this section you studied federal legislation affecting employee benefit plans and employment changes as well as international employee benefits coverage and concerns:



  • The Age Discrimination in Employment Act (ADEA) stipulates that benefits must be continued for older workers, but it allows proportional reduction of some benefits.

  • The Civil Rights Act requires employers to provide the same benefits for pregnancy and related medical conditions as are provided for other medical conditions.

  • The Americans with Disabilities Act (ADA) states that disabled employees must have equal access to the same health benefits as other employees, with the same allowances for coverage limitations.

  • The Family Medical Leave Act (FMLA) states that employers must give eligible employees up to twelve weeks of unpaid leave during any twelve-month period for qualifying reasons.

  • COBRA requires employers to allow employees, their spouses, and their dependents to continue health coverage at the individual’s expense (up to 102 percent of group coverage and in the event that medical coverage would otherwise end) for eighteen to thirty-six months without new evidence of insurability.

  • HIPAA protects employees who change jobs from having to start a new waiting period before a preexisting condition is covered.

  • Multinational employee benefit plans covering noncitizen employees and expatriates must be sufficient to attract, retain, and reward workers; must be fair for all parties affected; and must facilitate transfer of workers internationally when necessary and at minimum cost.

DISCUSSION QUESTIONS

  1. Recall the discussion of integrated benefits in Chapter 16 "Risks Related to the Job: Workers’ Compensation and Unemployment Compensation" . How do you think a good integrated benefits program would be coordinated with workers’ compensation, FMLA, and ADA? See the box, “Integrated Benefits: The Twenty-Four-Hour Coverage Concept” in Chapter 16 "Risks Related to the Job: Workers’ Compensation and Unemployment Compensation" .

  2. In what ways can the FMLA create conflicting interpretations?

  3. The intent behind the passage of COBRA was to reduce the number of uninsured persons. How does COBRA work to achieve this objective?

  4. Now that we have HIPAA, do we need COBRA? Give an example.

  5. The Meridian Advertising Agency has 1,340 employees in six states. The main office is in Richmond, Virginia. Meridian has employed Dan Smith for the last ten years. Three months ago, Dan had a foot injury for which he is still being treated. He recently accepted a job offer from a Washington, D.C., advertising agency. Before Dan leaves, Meridian’s human resources department invites him for an exit interview. If you were Meridian’s employee benefits specialist, what would you tell Dan about his rights? Explain to Dan about COBRA and HIPAA.

  6. If Phoebe, who has a heart condition, leaves her current job (which provides group health benefits) for another one with similar benefits, will she immediately be covered for her heart condition? What if she is laid off from her job and does not find another job for eight months?

  7. Mandy’s employer will not provide coverage for claims relating to her chronic asthma until she satisfies the group health plan’s twelve month preexisting condition exclusion period. Nine months into the job, Mandy obtains employment elsewhere. The new employer also imposes a twelve-month exclusion period for preexisting conditions. When will Mandy’s condition be covered by her new employer?

  8. Why might the benefits manager of a multinational corporation use an international benefits network?

[1] Rebecca Auerbach, “Your Message to Employers: Manage FMLA with Other Benefit Programs,” National Underwriter, Life & Health/Financial Services Edition, April 22, 2002.


[2] This case, Ragsdale v. Wolverine worldwide, No. 00-6029 (U.S. March 19, 2002), hinged on the extent that employers are obligated to inform employees of their rights when they begin a leave of absence. Wolverine had given Tracy Ragsdale time off for cancer treatment, but when she was unable to return to work after thirty weeks, Wolverine ended her employment. Ragsdale filed suit, citing a FMLA regulation that a leave of absence counts against the employee’s FMLA allowance only if the employer specifically designated it as FMLA leave. She claimed she was still entitled to her twelve weeks of FMLA leave. The Court disagreed and declared that regulation invalid. One of the Court’s reasonings was that Ragsdale had not been harmed—she would not have been better off if Wolverine had designated her original leave as FMLA. See Steven Brostoff, “U.S. High Court Ruling Helps RMs,” National Underwriter Online News Service, March 20, 2002.
[3] Jerry Geisel, “COBRA Subsidy Could Increase Beneficiaries: Survey,”Business Insurance, August 30, 2002.

20.5 Review and Practice

  1. What are the main ways in which group insurance differs from individual insurance?




  1. Why is group insurance proportionately less expense than individual insurance?




  1. Rosa Sanchez, single, age twenty-five, received two job offers after college graduation. Both were with organizations that she respected, and the nature of the work at each place sounded very interesting to her. One job was with a larger, well-established firm and offered $22,000 per year in salary plus noncontributory benefits worth $7,000 per year. The other job was with a small business and offered a salary of $30,000 per year without employer voluntary benefits (the employer is required to pay for social insurance programs). Rosa’s mother suggested that she make the choice between the two jobs based on which offered better total compensation.




    1. What factors should Rosa consider in determining the better package? Which package do you think maximizes her total compensation?

    2. Which employer is economically better off (all else being equal), the one offering salary plus benefits or the one offering salary only? Explain your answer.




  1. Henry Zantow, the comptroller for Kado Industries, was discussing the supposed advantages of a true cafeteria plan versus a traditional plan with Lloyd Olsen. Lloyd agreed with Henry that a cafeteria plan certainly seemed the better of the two plans. Both Henry and Lloyd looked at each other and in the same breath said, “I wonder why anyone would choose a traditional plan?”




    1. What is your answer to this question?

    2. If the corporation decides to use a cafeteria plan, why might it want a minimum level of core benefits?




  1. What does it mean to self-insure and have the stop-loss programs for workers’ compensation and for group health insurance?

  2. Jan Czyrmer, the employee benefits manager at Ludlow Enterprises, wants to restructure the leave policy for the company. He is concerned that employees abuse the sick leave policy, taking sick leave time for personal reasons not related to illness. He wants to abolish particular types of leave (such as sick leave, vacation leave, personal leave) and give employees a certain number of general leave days per year to use as they choose.




    1. What advantages might Jan cite to convince upper management that consolidating leave time may be helpful for Ludlow Enterprises?

    2. If upper management rejects Jan’s idea of a major restructuring of leave time, what can he do to prevent abuse of the current sick leave policy? What steps can be taken to reduce moral hazard within the traditional leave system?




  1. Knowledge Networking, Inc., provides a growing business of high-tech and electronics equipment and software. It is a specialty retail and online business that has tripled its revenues in the past seven years. The company started fifteen years ago and includes fifty outlets on both the East and West coasts. In 2005, the company went public and now, despite the major financial crisis, it is doing very well with innovation and creative offerings. The company has 5,600 full-time employees and 1,000 part-time employees. Knowledge Networking, Inc., provides all the social insurance programs and offers its employees a cafeteria plan with many choices. Employees have generous choices of health, life insurance, and disability coverages; dental and vision care; premium conversion plan; and flexible spending accounts as part of the cafeteria plan. Each employee receives $5,500 a year from the employer to pay for the benefits.




    1. Describe in detail your understanding of the structure of the cafeteria plan of Knowledge Networking, Inc. (design this cafeteria plan). What are the advantages and disadvantages of this cafeteria plan?

    2. Knowledge Networking, Inc., follows the federal laws: FMLA, ADA, Civil Rights Act, and Age Discrimination in Employment Act. If you were the employee benefits manager, how would you explain the impact of each of these acts on the employee benefits of the employees?

    3. How would the group insurance rates be computed (what factors play into the computation) for such a company?

    4. Why might Knowledge Networking, Inc., prefer to self-insure their workers’ compensation and health insurance rather than buy insurance?




  1. Yolanda Freeman is evaluating whether federal nondiscrimination laws have helped or hurt employees.




    1. Which federal laws particularly affect employee benefits? Which workers are particularly affected by each law?

    2. Who pays the cost of requiring that benefits be paid on a nondiscriminatory basis? Do additional benefit costs have any effect on employee wage levels?

    3. If federal laws did not require coverage for certain employees and their dependents, who would pay for benefits for these individuals? Do you think that social welfare is maximized by mandating coverage for certain workers and their dependents through these nondiscrimination laws?


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