Life & Health Underwriters, Inc.

Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protection for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct specified in the law.

Is an employer required to provide health benefits?

Employers are not generally required to provide any health benefits. Only the state of Hawaii requires employers in the private sector to cover employees who work over 20 hours per week. It is not illegal to provide health benefits only to some classes of employees (for example, only to full time employees but not to part time employees). But once the eligible classes are established, an employer cannot withhold insurance from some members of the class while offering it to others.

Do workers have a right to their health plan information?

Yes. Under ERISA, workers and their families are entitled to receive a Summary Plan Description (SPD). The SPD is the primary document that gives information about the plan, what benefits are available under the plan, the rights of participants and beneficiaries under the plan and how the plan works.

What does HIPAA cover?

The Health Insurance Portability and Accountability Act (HIPAA) mandates significant changes in the legal and regulatory environments governing the provision of health benefits, the delivery and payment of healthcare services, and the security and confidentiality of individually identifiable, protected health information.

I'm getting married. Will I be covered under my spouse's health care plan?

Whenever an employee incurs a "Change in Family Status" such as marriage, a birth, an adoption, divorce, etc., they have 30 days to notify their employer that they wish to enroll in one or more benefit plans and complete the necessary enrollment forms.

What is a Certificate of Credible Coverage?

A certificate of creditable coverage is a statement of your past health care coverage with your employer. The certificate is available upon request, even if you still have health coverage and will be provided automatically when your health coverage ceases.

Is childbirth considered a pre-existing condition?

HIPAA places limits on the amount of time a pre-existing condition exclusion period may apply. In addition, health care plans no longer consider pregnancy as a pre-existing condition, even if the woman did not have previous coverage.

What does the Family Medical Leave Act (FMLA) cover?

In order to be "eligible" for FMLA leave, an employee must:

Be employed by a covered employer
Work at a worksite within 75 miles at which his employer employs at least 50 employees
Have worked at least 12 months (which don't have to be consecutive) for the employer
Have worked at least 1,250 hours during the 12 months immediately before starting FMLA leave

What is a "cafeteria" plan?

A cafeteria plan can be very simple, merely offering employees the ability to pay their share of healthcare premiums with pre-tax dollars, or it can have a very elaborate menu of benefit election choices. Common benefits include health plans, group term life insurance, accidental death and dismemberment insurance, long term disability benefits, dependent care reimbursements, or health care expenses deductible under IRC Section 213.

What are flexible spending arrangements and health reimbursement arrangements?

Flexible spending arrangements (FSAs) and health reimbursement arrangements (HRAs) are special accounts that may be part of a cafeteria plan. An FSA, typically funded by employees, provides employees with pre-tax dollars to pay for predictable medical or dependent care expenses. An HRA is an employer funded account that reimburses employees for medical expenses. Employer contributions and reimbursements are generally excluded from income. Both these accounts are subject to the discrimination rules of self insured medical reimbursement plans under IRC Section 105.

What are health savings accounts (HSAs)?

HSAs are essentially tax-sheltered, individual deferred compensation plans for health care combined with a high deductible insurance plan.

Is there a health care alternative for employees without an employer-sponsored plan?

Most major insurance companies offer individual plans. Depending on the coverage requested, you will find some plans to be rated by gender, age, pre-existing conditions and subject to Evidence of Insurability.

What role does the Age Discrimination in Employment Act (ADEA) play in employee benefits?

The ADEA prohibits employers with more than 20 employees from discriminating against any individual with respect to compensation or the terms, conditions, or privileges of employment because the individual is age 40 or over. The ADEA, ERISA and IRC have some duplicate provisions, including a prohibition on reducing benefits because of age or ceasing benefit accruals or contributions because of age.

What are activities of daily living (ADLs)?

These are basic activities and functions performed on a daily basis that are usually done without assistance. The six ADLs are:

Eating
Dressing
Bathing
Toileting
Transferring
Continence

If you have additional questions, please call us at (206) 728-1314 or send an e-mail to jolie@lhui.com.