Who Oversees Self-insured Group Health Ins

[scotte]

who would be the governing body that deals with self-insured group health plans in Illinois? The Illinois insurance board claims to have no jurdiction over self-insured plans.
On on my wifes group plan that is self-insured by her school district. UMR (part of United healthcare) handles the claims. They deny everything! They say to check with the plan of benefits in your SPD. The problem is no one has access to the SPD even at the employer level, and this plan has been in affect since Januray of 2012. Is this a voilation not to have a SPD available after a certain time frame?

The internet is filled with issues with these guys!

 

[JeffM]

Here in California self-insured programs are run by the Department of Industrial Relations. Good luck.

 

[somarco]

Self funded plans are regulated by the USDOL and to a lesser extent by the IRS.

 

[leevena]

Self-funded plans are not regulated by any state, California or otherwise. They are covered under ERISA, a federal law, and to some extent COBRA, HIPAA, Newborns' and Mothers Health Protection Act, Mental Health Parity Act and Women's Health and Cancer Rights Act. You can view more detail by going to the DOL and other sites.

There are a variety of plan documents, including the SPD, that need to be developed and then issued to plan participants and vendors. There is a legal requirement that requires employers who self-fund to make plan documents available to participants, and based on your post, they should be available.

Now, some common sense things. Highly unlikely that the documents are not available. Not to say that your post is incorrect, just saying that you may be speaking to the wrong person. The requirement for distribution includes a mailing/email to your address and allows you to make a request also. Second, UHC is not denying your claims ( I don't work for them, never have ), the employer is denying the claim. UHC is nothing more than the administrator, doing what the employer wants them to do. Third, if you want redress, you will need to seek it in the federal courts, not the local/state.

Hope this helps.

 

[scotte]

Self-funded plans are not regulated by any state, California or otherwise. They are covered under ERISA, a federal law, and to some extent COBRA, HIPAA, Newborns' and Mothers Health Protection Act, Mental Health Parity Act and Women's Health and Cancer Rights Act. You can view more detail by going to the DOL and other sites.

There are a variety of plan documents, including the SPD, that need to be developed and then issued to plan participants and vendors. There is a legal requirement that requires employers who self-fund to make plan documents available to participants, and based on your post, they should be available.

Now, some common sense things. Highly unlikely that the documents are not available. Not to say that your post is incorrect, just saying that you may be speaking to the wrong person. The requirement for distribution includes a mailing/email to your address and allows you to make a request also. Second, UHC is not denying your claims ( I don't work for them, never have ), the employer is denying the claim. UHC is nothing more than the administrator, doing what the employer wants them to do. Third, if you want redress, you will need to seek it in the federal courts, not the local/state.

Hope this helps.

Yes, thankyou it does help. The employees are able to go to a website that has the SPD on it. When you click on the link it tells you they are still working on it! For I guess 6 months.

 

[leevena]

Yes, thankyou it does help. The employees are able to go to a website that has the SPD on it. When you click on the link it tells you they are still working on it! For I guess 6 months.

Working on the spd, or the website availablity? If you really want a copy of the documents, request one in writing, that will start the clock. Start with your HR department.

 

[scotte]

The HR department said it was UMR's responsibility.
The website is running but there is no SPD that you can access; it says still being worked on(the SPD).

 

[junkman]

I have never not been able to come up with a SPD. Employees have a right to them under federal law. Apparently, HR has a cleark with no knowledge or authority. I would call the TPA as an agent & start going up the channel. If the TPA is a division of UHC, they have systems and documents. You could also go to the group agent on the case.

You want claims paid, not an adversarial relationship with the employer. What do the EOBs say regarding claim denial?

The starting point with straightening out claims is always finding out why it was paid the way it was. The next step is usually to have the provider re-file correctly. You are dealing with clerks who have no power and can only give information so be nice. They can correct errors if their system shows that an error has in fact been made.

The SPD will only be helpful if the TPA has incorrect info in their claims paying system. It may also help you understand that claim has been paid according to contract.

Sometimes you can negotiate payment other than the contract for example if someone with authority at the employer agrees that the employee is getting screwed and wants it paid differently. Sometimes you can get a claim paid as in-network but the provider has to agree to the payment schedule. (Some money is better than no money and suing your patient.) In this case, you need the employer provider and TPA. You may need it kicked to the current agent with directions from the employer to get it fixed.