Self funded insurance plans

[misintexas]

What is the name of your state? TX

Our medium-sized hospital was recently merged (bought out, rather) by a larger Health Care company. They decided to create a new entity instead of rolling us into the corporate mother. The employees were given a 30 day deadline to sign up for our new benefits package and a corporate HR person came and gave several presentations and our HR department sent out several memos and e-mails explaining and outlining the changes and our choices. They gave us until 04.01.2007 to sign up and most of the emploees were able to comply and made choices based on the information we were given. On 04.01.2007 (the date of the deadline) we received an e-mail from the HR director stating that there was a change in our providor coverage and that the Dr's who we were told would be included in a group that allowed for a no co-pay schedule (that charged more per month and most employees joined) would now be in another group that required a 15% co-pay and that NO Dr's would be in the other group. The e-mail stated that this was done "locally" and the reason given was to "assure the same quality physician services that plan participants have grown accustomed to". I guess my questions are 1. Does a self-funded insurance plan have to live up to it's previous statements, or can they simply change everything at will? 2. How transparent does a self-funded insurance plan have to be? (I asked HR who the plan's director was, but was told that would not/could not be disclosed to me.) 3. What rights do members of a self-funded insurance plan have when it comes to information regarding HOW the plan is administered?

Thank you,
MIS in Texas

 

[Beth3]

1. Does a self-funded insurance plan have to live up to it's previous statements, or can they simply change everything at will? And your plan to force doctors and medical providers to stay in the preferred provider network even if they don't want to is? It's quite likely that when the Plans were first presented to everyone, these doctors and providers were part of the network. Now, they've opted out or their contracts with the PPO expired and a decision was made not to renew them. That's just the way it is.

2. How transparent does a self-funded insurance plan have to be? (I asked HR who the plan's director was, but was told that would not/could not be disclosed to me.) You need to describe what you mean by "transparent" and what information you want your employer to share with you.

3. What rights do members of a self-funded insurance plan have when it comes to information regarding HOW the plan is administered? You don't have any right to see HOW the plan is administered. You have a legal right to a copy of the Plan Document and the SPD -Summary Plan Description. That's it. You don't have the right to view any contracts between your employer, third party administrators, PPO networks, etc.

I know you're thinking that some sort of "bait and switch" occured. Having designed and administered self-funded group health plans for a decade, I can tell you that there is absolutely no reason for your employer to do that. They weren't any happier about the change in the providers who were in-network than you were.

Your employer has almost certainly contracted with an insurance carrier or non-aligned PPO network to provide a discounted provider network as part of their self-insured group health plan. The provider contracts are between the network and the medical providers - not the medical providers and your employer. Your employer has no say on which providers are in-network and which are out-of-network. All your employer can do is contract with a different PPO network or third party administrator if they feel the providers in another network would be more beneficial to the company and its employees.