Phia Group Media

rss

Phia Group Media


A Joint Final Rule: Extending COBRA, HIPAA , and Claims / Appeal Deadlines

On May 20, 2020

By: Kevin Brady, Esq.
 

Earlier this month, the U.S. Department of Labor (DOL) and the Internal Revenue Service (IRS) jointly issued a Final Rule extending a number of deadlines and timeframes relevant to group health plans. The Final Rule recognizes that as a result of the National Emergency, plan participants “may encounter problems in exercising their health coverage portability and continuation coverage rights, or in filing or perfecting their benefit claims. As such, the stated purpose of the Final Rule is “to minimize the possibility of individuals losing benefits because of a failure to comply with certain pre-established timeframes.”
 

The Final Rule essentially requires plans to disregard a designated period of time when determining whether certain deadlines or timeframes are satisfied. Consistent with the Final Rule’s stated purpose, the extension of these timeframes will provide additional opportunities for employees and their dependents to maintain existing, or enroll in, coverage as well as provide additional opportunities for participant’s to submit and appeal claims. This designated period of time is succinctly described as the “Outbreak Period” which entails “the period from March 1, 2020 until sixty (60) days after the announced end of the national emergency period or such other date announced by the Agencies in a future notification.”
 

HIPAA

Special Enrollment

Under HIPAA, employees who experience certain special enrollment events generally have a limited period of time (following the event) to request coverage under their employer’s plan. Under the Final Rule, the Outbreak Period must be disregarded when considering whether a HIPAA special enrollment request is timely.
 

COBRA

Electing Continuation Coverage

Plan participants who experience “qualifying events” are generally eligible for continued coverage under COBRA subject to certain conditions. After receipt of the COBRA election notice, “qualified beneficiaries” have 60 days to elect continuation coverage. Under the Final Rule, plans must disregard the Outbreak Period when determining whether a qualified beneficiary’s election is timely.
 

Timely Payment of Premiums

After electing COBRA continuation coverage, qualified beneficiaries must pay their first premium payment with 45 days of their election. Furthermore, qualified beneficiaries must pay premiums in a timely fashion (a premium is considered paid timely “if it is made not later than 30 days after the first day of the period for which payment is being made.” Under the Final Rule, the Outbreak Period cannot be considered when determining whether payment of the premium is timely. 
 

Notice of Qualifying Event

Under certain circumstances (generally divorce or a child losing dependent status), plan participants will bear the responsibility for notifying the group health plan of the qualifying event under COBRA. While COBRA typically requires this notice to be provided within 60 days, the Final Rule requires plans to disregard the Outbreak Period when determining whether notice is timely.
 

Claims and Appeals

Filing of Claims

Group health plans will generally limit the period of time in which a claim may submitted and considered eligible for coverage. Under the Final Rule, plans must disregard the Outbreak Period when considering whether a claim has been timely filed. This will undoubtedly lead to additional, and potentially significant exposure, for plans as claims that could have been properly denied previously, may now be payable under the plan.

Appealing an Adverse Benefit Decision

Group health plans must provide participants at least 180 days to appeal an adverse benefit decision. Whether a plan provides the required 180 days, or more, plans must disregard the Outbreak Period when determining this deadline. Similar to the extension of the deadline for filing claims, this extension may also lead to additional, and potentially significant, exposure for plans.

External Reviews

For claimants enrolled in non-grandfathered group health plans, those claims which are otherwise eligible for external review (only certain types of appeals are eligible), are entitled to additional time to request an external review under ERISA’s appeals procedure rules. Under the Final Rule, the Outbreak Period is disregarded when considering the deadline to file an external review.

Further, if a claimant’s external review request is not “complete” (meaning that the request for review is not sufficient to be considered by the Independent Review Organization) the claimant is typically limited to the duration of the filing period to perfect the request. However, the Final Rule also requires the plan to disregard the Outbreak Period when determining whether additional information, provided to perfect a request for external review, is timely.

There’s a New Notice on the Block

On July 31, 2019

By: Nick Bonds, Esq.

On July 17, 2019 the Internal Revenue Service issued Notice 2019-45, and, if our consulting question inbox is any indication, caused quite a stir in our community. At least among the groups offering HSA-qualified high deductible health plans.

We have been inundated with a deluge of inquiries, ranging from the vaguely curious to the slightly manic: Are they changing the definition of preventive services? Does this change what we have to cover? How do we account for this in our plan document? What is the airspeed velocity of an unladen swallow?

Okay, that last one might be from Monty Python, but seriously everyone – relax.

This new rule essentially stems from an executive order President Trump issued on June 24, his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First,” which tasked the Treasury Department with a few homework assignment. Among these was Section 6(a), which called for guidance to expand the ability of patients to select high-deductible health plans (HDHPs) that can be used alongside an (HSA), and that these plans cover low-cost preventive care, before the deductible, to help maintain the health of people with chronic conditions, all within 120 days.

Five weeks later, the Treasury delivered, and the IRS introduced Notice 2019-45 to the world. The notice’s stated purpose is to “expand the list of preventive care benefits permitted to be provided by a high deductible health plan (HDHP) . . . without a deductible, or with a deductible below the applicable minimum deductible (self-only or family) for an HDHP.”

Our interpretation of this notice is fairly straightforward: it does not create any requirements for an HDHP to cover the listed services differently. Rather it gives HDHPs the ability to cover fourteen new services and items at 100% without applying their deductible, and without endangering their HDHP status.

The whole point of this notice is to help individuals utilizing an HDHP to manage their chronic conditions, like asthma, diabetes, and heart disease. A growing majority of employers are offering their employees HDHPs in tandem with a Health Savings Account. This rule offers those employers greater flexibility and eases the strain high deductibles put on the wallets of employees with chronic conditions.

Section 6(b) gave us something else to look forward to: Treasury has 180 days to propose regulations that could potentially expand eligible medical expenses under Section 213(d) to include direct primary care and healthcare sharing ministries. Forthcoming regulations could open some exciting possibilities for employers contemplating on-site clinics. So stay tuned.

Responding to a IRS Letter 226J: Considerations and Common Mistakes

On December 5, 2018

By: Krista J. Maschinot, Esq.

If you are an applicable large employer (ALE), the Internal Revenue Service (IRS) could possibly be sending a Letter 226J notice your way. Will you be ready to respond accurately within 30 days of receipt if needed?

We discussed in a recent blog post that IRS enforcement of the Employer Shared Responsibility Provision of the Affordable Care Act (ACA) is very real and ALEs should be prepared as such.

There are two types of ESRP penalties that the IRS will assess based upon the information the ALE provided on Forms 1094-C and 1095-C:

§4980H(A) – Assessed when an employer fails to offer minimum essential coverage to enough of its full time employees

§4980H(B) – Assessed when an employee enrolls in the Marketplace and qualifies for the premium tax credit because the employer failed to offer affordable coverage

We recommend comprehensively reading and reviewing the information provided in the Letter 226J as to the reasoning for ESRP penalties and ensuring that this matches up with your internal documentation. This review is particularly significant because it will help you determine whether you have made an administrative/filing oversight or if there are larger compliance issues to deal with.

There are common mistakes to be aware of based on how Forms 1094-C and 1095-C were filled out that could trigger a Letter 226J. An ALE could, for instance, forget to check the “Section 4980H Transition Relief” box (Box C of line 22) on Form 1094-C. It may also fail to correctly code Line 14 of Form 1095-C regarding offer of coverage based on months offered coverage, as opposed to months of actual coverage. These types of errors are easy enough to make, but it is important to identify that they have been made prior to responding to the IRS. The monetary penalties will be assessed much differently based on filing mistake rather than actual ESRP non-compliance.

The Phia Group Saves an Employer Thousands of Dollars

On March 30, 2018

By: Erin Hussey, Esq.

The IRS has recently been enforcing the Employer Shared Responsibility Mandate (“employer mandate”) by sending letters to employers implicating that they may have violated the employer mandate rules and may owe a substantial penalty called an Employer Shared Responsibility Payment (“ESRP”). This employer mandate was put in place by the Affordable Care Act (“ACA”).  The ACA requires Applicable Large Employers (“ALEs”) who have 50 or more employees to (1) provide minimum essential health coverage to all full-time employees and their dependents (or the employer will face a subsection (a) penalty); or (2) offer eligible employer-sponsored coverage that is “affordable” and meets “minimum value” (or the employer will face a subsection (b) penalty). Employers who receive these letters may have to pay the ESRP, but have a chance to respond to the letter before the penalty is mandated.

A client was presented with one of these letters from an employer. The employer was facing over $50,000 dollars in penalties if they did not respond to the letter properly and explain why they were/were not at fault. The IRS has specific guidelines of how to respond to these letters. This can become very daunting and confusing for employers facing these high penalties. The client reached out to The Phia Group for consultation. Krista Maschinot and Erin Hussey analyzed the situation and explained what the employer may or may not have done wrong to receive this large employer mandate penalty, and with their consultation, the employer was able to identify their mistake and properly respond to the IRS letter. After the employer explained their mistake and properly responded to the IRS letter, the IRS sent a second letter to the employer which lowered their penalty to less than $2,500, saving the employer thousands in penalties.

Disclaimer: As these forms are heavily based in IRS regulations and taxation, we strongly recommended to the broker that the employer should discuss this with their tax advisor and/or the entity that assisted in preparing their tax forms.