Q. How do you get a medical leave of absence?

A. If you work for a company with fifty or more employees you may qualify for the Family Medical Leave Act, which typically allows up to twelve weeks for unpaid leave, or more if you are in the military. Also, your state may have its own laws that complement FMLA or add to this leave. Check with the Department of Labor in your state.

Q. What are the basic maternity leave laws?

A. This depends on the state, but the Family Medical Leave Act typically allows up to twelve weeks for unpaid leave. Also, your state may have its own laws that complement FMLA or add to this leave. Check with the Department of Labor in your state.

Q. What is the difference between claims-made & occurrence malpractice?

A. Claims-made covers you for claims submitted while the policy is in force, and also for a tort that occurred from the retro date through the date of the current policy. Occurrence policy covers claims that occurred during the policy period, and the policy does not have to be in force.

Q. Do IPA’s need medical malpractice insurance?

A. No, but they do need industry specific errors and omissions, and directors and omissions insurance that include vicarious malpractice, which cover the IPA’s risk for malpractice.

Q. What’s the difference between medical malpractice and errors and omissions?

A. They both cover errors; but, Medical Malpractice covers physicians for direct medical care and Errors and Omissions cover a business if it makes an error.

Q. What do statutory limits mean on a worker’s comp policy?

A. In many states you cannot sue an employer for more than $1 million by law, excepting gross negligence; therefore, it is a law, so the insurance policy models the statute’s limits.

Q. What is an excess worker’s comp policy?

A. It is for employers who self insure their worker’s comp. They buy excess or stop loss insurance. This insurance limits the employer’s exposure to unexpected total claims, or the specific claims of one person.

Q. What is excess of limit losses in workers compensation?

A. This can refer to an excess policy, which you can buy over a fully insured policy. Normally, workers compensation is limited to the statute, but if gross negligence can be proven then a claimant can sue for more than the limits of statute. If this happens, and the employer has an Umbrella policy, it may respond to the claim that exceeds the limit of the workers compensation policy.

Q. What is worker’s compensation aggregate retention?

A. This is the total amount of claims that you, the employer, pays until the insurer starts paying.

Q. How do you account for workers compensation aggregate stop loss deductible?

A. When you purchase aggregate stop loss for your self-insured workers compensation, the insurer will define upfront what the aggregate is. Your TPA, or third party administrator, should give you periodic aggregate reports showing the total amount of claims paid as they accumulate toward meeting the aggregate stop loss deductible.

Q. What are reinsurance triggers in healthcare?

A. It depends. Health insurers can have a defined dollar amount where they are laying risk off to a reinsurer. For example, a health insurer may buy a $100K of specific reinsurance coverage; thus, if one patient hits a $100K, then every dollar above that amount will be reimbursed by the insurer.
Q. What are the two types of stop loss in hospitals?

A. 1.Specific stop loss covers the hospital for claims that exceed a defined dollar amount for a patient. For example, the hospital for its self insured health plan, or its capitated members, can buy a $100K of specific stop loss deductible, which means the insurer will pay all claims that exceed $100K.

2. The other is aggregate stop loss which covers the hospital for all the claims it pays out in its self insured plan. For example, the insurer will cover you if your total claims paid in the year exceed $5 million. The insurer will reimburse the amounts that exceed that amount.

Q. Does a third party FMLA administrator have the right to contact your healthcare provider?

A. Yes, they have the right to ask for a second opinion, and/or have your doctor complete a form. But contacting them directly, I doubt, would be effective because the MD cannot talk with them due to HIPAA.

Q. What does it mean if your HMO sent a letter saying you have reached the catastrophic portion of your policy?

A. This can possibly mean that you have reached the maximum out of pocket limit.

Q. Can my employer stop my health care when on workers compensation?

A. Yes, they need to put you on COBRA. Health insurance requires that you are to actively working full time. When you are out on a worker’s compensation claim, you cannot meet this requirement.

Q. How can a company process employees’ medical claims?

A. The employer, if it is big enough, can take their claims in house and act as a TPA. Most companies do not do this anymore due to HIPAA concerns; most outsource this to an independent TPA.

NOTE: THE ABOVE IS A GENERAL DISCUSSION ABOUT HOW COVERAGES MAY WORK. YOUR INSURANCE POLICY AND ALL ADDENDA ARE THE ONLY AUTHORITY OF HOW YOUR COVERAGE WORKS. DO NOT RELY ON THIS ARTICLE AS AN EXPLANATION OF YOUR COVERAGE. HAVE YOUR ATTORNEY REVIEW YOUR ENTIRE POLICY WITH YOU TO DETERMINE WHAT IS AND IS NOT COVERED.

By William D. Dyer

HIPAA, or Health Insurance Portability and Accountability Act of 1996, according to the HHS or U.S. Department of Health and Human Services, “provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information is the federal protection health information privacy.” This means that any company with any access to one’s personal health information is legally liable for breach or disclosure of this information.

HITECH, or Health Information Technology for Economic and Clinical Health Act of 2009, is a supplement to HIPAA. Due to advancements in technology, especially in the health field in the form of systems such as EHR or electronic health records, this privacy and security rule went into effect to provide an extra layer of protection for one’s personal health information. HITECH provides further privacy and security protection by enforcing increased financial penalties to violators.

HIPAA and HITECH are enforced to prevent healthcare service providers or any organization with access to personal health information from unauthorized use, disclosure, security breach, or loss due to misplacement or theft of people’s personal health information. These laws are provided to protect patients from anything from identity theft to integrity entitlement.

HIPAA and HITECH compliance comes in the form of three required safeguards: administrative, physical, and technical, to ensure that one’s personal health information is kept confidential. Non-compliance will result in a fine of up to $50,000 per violation to a maximum of $1.5 million per year.

Below is a chart done by @radartweets at the cost of not being compliant with Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health Act.

HCP National provides HIPAA compliance training as well as HIPAA and HITECH liability insurance. HCP National is the liability insurance expert for healthcare: Medical Malpractice, Tech E & O, D & O and Employment Practices Liability. This article is not meant to be legal advice. HCP National is an insurance and risk management training company, not a law firm.

Some things to consider when implementing a group health insurance plan.
There are not that many red flags when it comes to group health insurance; all health insurance is heavily regulated by the state so there are a few gotcha items. The only one that might apply is a pre-existing limitation which limits coverage for medical conditions that an employee received treatment for prior to coming onto the plan.

If you run into this with any of your employees, there is a way around it. If the employee had medical coverage from another group health insurance plan prior to coming onto your plan, they can request from their former plan a Certificate of Group Health Coverage (CGHC). Under HIPAA (Health Insurance Portability & Accountability Act) if they present a CGHC to your new insurer, and if they met the pre-existing condition limitation on their former plan then they will not have to meet a new one under your new plan.

If you do not plan to pay for 100% of the employee and family premiums, you will want to buy a section 125 premium only plan document (one-time fee of about $300). By having this document all premiums that your employees pay can be deducted from their pay checks on a pre-tax basis. Aside from the employee tax savings, this also lowers their gross taxable salary so you can save money on payroll taxes.

In terms of group insurance health plans ask your broker for quotes from every health/HMO insurance company in your area. I would recommend that you consider either high co pay HMO which will cost $25 to $40 for office visits and a hospitalization co pay as well, or a high deductible health plan.

High deductible health plans (HDHP) are a good option because it allows the employee to have medical coverage for the high end losses and pay for the smaller items themselves. If you do a HDHP I would definitely combine it with a HSA (Heath Savings Account) or HRA (Health Reimbursement Account).

HSA allows the employer to contribute and the employees can contribute on a pre-tax basis to the HSA account (again everyone saves on taxes like they do on the 125 premium plan document). This money can be used to pay for the employees out of pocket expenses as they meet their deductible. The HSA also can be used for other healthcare expenses such as dental, vision and chiropractors. The bank who handles the banking for the HSA will issue a debit visa card for the employees to use to pay for these expenses.
If you have Kaiser in your area, then check to see if they have an HSA. If they do then it is the cheapest deal. From my own experience, I find Kaiser to be the best healthcare model available. Ask for a tour of the Kaiser facility. You will be surprised.
HCP National is not a law firm and does not provide legal advice. We are a group health insurance broker and risk manager.