There have been many listserv discussions regarding employer groups,
sponsors, self-insured, and insured.
However, I don't believe I have seen the scenario listed below. Therefore,
I would invite all of you to consider this scenario. I would welcome any
comments regarding this scenario, especially those that are not in agreement
to this scenario.
Scenario:
1) Sponsors and employer groups are not Covered Entities and are not
required to send the 834.
2) ABC Health Plan is licensed as an HMO in a state. ABC Health Plan is,
also, licensed as a Third Party Administrator (TPA) in the same state.
3) When an employer group provides its employees health insurance, under
ERISA the employer group must establish a Group Health Plan (see partial
definition below).
4) Enrollment sent from the employer group to a Health Plan is actually
being sent on behalf of the Group Health Plan. Although the person sending
the enrollment is probably unaware of this.
5) Therefore, when ABC Health Plan, acting in their HMO capacity, is
receiving enrollment from a Group Health Plan, the enrollment is required to
be in the standard format. This is because both the Health Plan and the
Group Health Plan are Covered Entities in this scenario.
6) When ABC Health Plan, acting in their Third Party Administrator
capacity, is receiving enrollment from a Group Health Plan, the enrollment
is not required to be in the standard format. This is because the Health
Plan is not a Covered Entity in this scenario.
Thank you for the opportunity to discuss.
Stacy
Questions or comments contained herein are not the opinion or position of
John Deere Health Care, Inc. or John Deere Health Plan, Inc.
Sec. 160.103 Definitions.
1) Group health plan (also see definition of health plan in this section)
means an employee welfare benefit plan (as defined in section 3(1) of the
Employee Retirement Income and Security Act of 1974 (ERISA), 29 U.S.C.
1002(1)), including insured and self-insured plans, to the extent that the
plan provides medical care (as defined in section 2791(a)(2) of the Public
Health Service Act (PHS Act), 42 U.S.C. 300gg- 91(a)(2)), including items
and services paid for as medical care, to employees or their dependents
directly or through insurance, reimbursement, or otherwise, that:
1) Has 50 or more participants (as defined in section 3(7) of
ERISA, 29 U.S.C. 1002(7)); or
2) Is administered by an entity other than the employer that
established and maintains the plan. HHS stands for the Department of Health
and Human Services. Health care means care, services, or supplies related to
the health of an individual. Health care includes, but is not limited to,
the following:...
