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Jennifer's experience in economics, finance, actuarial consulting and wellness make an excellent foundation for building solid employee programs. Her drive to resolve inefficiencies and to empower employees in the workplace is a testament to her skill and passion to do what she loves doing best.
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What is meant by the term medical necessity?
All health care plans limit their payments to treatments which are considered “medically necessary.” Of course, this seems reasonable on the surface. After all, who would ever want medical treatment that was not necessary, let alone pay for it.
Problems arise in how health care plans define and apply the term medically necessary. For example, some health insurers will not pay for anesthesia connected with the performance of an endoscopy. Many physicians will not perform this procedure without administering anesthesia, as they consider doing so to increase the patient’s risks. The result can be a significant anesthesia bill for the plan participant.
When contemplating a change in medical plans, it is often quite difficult to determine if the prospective replacement insurer defines medical necessity different the current one does. For many treatments, both insurers could view what is medically necessary the same, while for others it may be completely different.
The best way to see what differences, if any your participants may face, is for the client to examine several diagnostic categories heavily utilized by their plan participants and see how each carrier approaches them.
Ask a Consultant Archives
May 2013
April 2013
- Who is exempt from the individual mandate?
- How much will the individual mandate penalty cost me?
- How does an administrator of a Top-Hat Plan participate in the DFVCP?
- What is the applicable penalty amount under the Delinquent Filer Voluntary Compliance Program?
- How does an administrator of an apprenticeship & training plan participate in the DFVCP?
- Does a plan administrator waive any rights upon filing under the DFVCP?
March 2013
- Is participation under the DFVCP available to all Form 5500 Series filers?
- Who is eligible to participate in the DFVCP?
- What is the DFVCP?
- What do I need to do if I want to be sure I have minimum essential coverage or an exemption for 2014?
- Are children subject to the individual shared responsibility provision?
- Are all individuals living in the United States subject to the individual shared responsibility provision?
- What are the statutory exemptions from the requirement to obtain minimum essential coverage?
- What counts as minimum essential coverage?
- When does the individual shared responsibility provision go into effect?
- Who is subject to the individual shared responsibility provision?
- What is the individual shared responsibility provision?
February 2013
- How will amounts that are credited or made available under HRAs under terms that were in effect prior to Jan. 1, 2014, be treated?
- May an HRA used to purchase coverage on the individual market be considered integrated with that individual market coverage and therefore satisfy the requirements of PHS Act section 2711?
- Are there special recordkeeping requirements for employers in the airline industry?
- Does the Final Rule allow eligible family members to take FMLA military caregiver leave for all veterans with a serious injury or illness?
- What is a serious injury or illness for a covered veteran?
- Why is the Department of Labor revising the Family and Medical Leave Act regulations?
- If an employer that does not offer coverage or offers coverage to less than 95 percent of its employees owes an employer shared responsibility payment, how is the amount of the payment calculated?
- If an employer offers coverage to at least 95 percent of its employees and, nevertheless, owes the employer shared responsibility payment, how is the amount of the payment calculated?
- How does an employer know whether the coverage it offers provides minimum value?
- How does an employer know whether the coverage it offers is affordable?
- Is more detailed information available about the employer shared responsibility provisions?
January 2013
- Under what circumstances will an employer owe an employer shared responsibility payment?
- Do the employer shared responsibility provisions apply only to large employers that are for-profit businesses or to other large employers as well?
- Are companies that employ U.S. citizens working abroad subject to the employer shared responsibility provisions?
- Are companies with employees working outside the United States subject to the employer shared responsibility provisions?
- When do the employer shared responsibility provisions go into effect?
- Which employers are not subject to the employer shared responsibility provisions?
- How does an employer know whether it employs enough employees to be subject to the employer shared responsibility provisions?
- What are the employer shared responsibility provisions?
December 2012
- Is the coverage for my adult dependent taxable?
- What are Nondescrimination Laws?
- What information about insurance companies is going to be posted on the Web?
- Can my insurance company terminate my coverage if I get sick?
- Did the Health Care Reform legislation eliminate COBRA?
- Can you explain what this "voucher" is that I keep hearing about through Health Care Reform updates?
- Can I now get coverage for my child who has a pre-existing condition?
- What are the penalties for individuals who don't have health coverage?
November 2012
- What consumer protections will I get if I obtain insurance at work?
- Do you know what the standard IRS mileage rate is for 2013 yet?
- Does the Prohibited Transaction Exemption for Eligible Investment Advice Arrangements Apply to HSAs?
- What is health care reform? What does health care reform mean for me?
- Do you think employee performance reviews are really necessary?
- What exactly does OSHA do?
- If an employee will receive tips and wages in excess of $200,000 in the calendar year, how is Additional Medicare Tax paid on the tips?
- Is Medicare Entitlement a COBRA Qualifying Event for Our Active Employees Who Do Not Lose Coverage Under Our Plan When They Become Entitled to Medicare?
October 2012
- What are the laws regarding smoking and tobacco use in the workplace in California?
- When must an employer withhold Additional Medicare Tax?
- When does the Additional Medicare Tax start, and can you tell me what rate it is at?
- Election Day is coming up soon. As an employer in California, am I required to grant my employees paid time off to vote?
- What are the rules for granting employees time off for religious holidays? Do we have to pay for the time off?
- Am I required to provide employees with reasons for terminating them? Can an employee's "wrongful termination" claim be valid?
- Do I need a prescription to use my health FSA, HRA, HSA or Archer MSA funds for insulin purchases?
- How do I prove that I have purchased an over-the-counter medicine or drug with a prescription so that I can get reimbursed from my employer's health FSA or an HRA?
- Are all employment-based wellness programs required to check for compliance with the HIPAA nondiscrimination provisions?
September 2012
- Are plans and issuers required to provide SBCs to individuals who are COBRA qualified beneficiaries?
- Some States have expressed an interest in permitting issuers to screen applicants for eligibility for alternative coverage options before offering a child-only policy. Is this allowed?
- When must plans and issuers begin providing a summary of benefits and disclosure (SBC)?
- Have the rules changed for reimbursing the cost of over-the-counter medicines and drugs from health FSAs and HRAs because of Health Care Reform?
- Can a Section 125 plan provide a grace period?
- Should I offer dental benefits? Why?
- What are the FMLA recordkeeping requirements?
- Are we allowed to require drug tests before making employment offers?
- What types of employer conduct are prohibited under federal law?
- How much, if anything, should I be charging Qualified Beneficiaries for COBRA coverage?
- How can I find out actual relevant information about candidates when checking references rather than being stuck with neutral reviews?
- What is meant by the term medical necessity?
August 2012
- Do I have to provide benefits to the spouse of a common law marriage? My state does not recognize common law marriages.
- What benefits can be included in a cafeteria plan and be excludable from taxable income? Who can participate?
- Do employers have to maintain the health benefits of employees on FMLA leave?
- How do HIPAA’s nondiscrimination rules affect my company?
- If one of my employees quits, when is his or her final paycheck due?
- Would there be any tax consequences if my company were to subsidize a pet insurance benefit for our employees?
July 2012
- When must an employer withhold Additional Medicare Tax according to Health Care Reform?
- My company has contracted employees that only work eight months out of the year. If allowed to participate in the Sec. 125 flexible spending account (FSA), is the employee’s total contribution divided by eight or by 12 to determine payroll deduction?
- How should my company handle medical loss ratio (MLR) rebates?
- What sort of preventative care coverage does the Affordable Care Act provide for adults?
May 2012
- Do I need to join the social band wagon? In our line of business, it's not really what we do.
- I hear a lot about bullying nowadays. How can I be sure it doesn't happen in our workplace?
- I'm afraid of losing our top performing employees to our competitors. Do you have any suggestions on how to keep them happy and from leaving?
- Should I require an office dress code in my company? We deal with a lot of business clients, so we need to keep a professional appearance in case one of them happens to drop in for an unexpected visit.
- My company has had to make some cuts that have affected our employees due to trying to meet the bottom line (i.e., 401(k) match reductions, pay cuts, higher health care premiums, etc.). Do you have any suggestions on how I can win back at least some employee morale without a spending budget to help???
- One of our employees is a veteran returning to work soon after serving his last tour of duty. We are excited and grateful for his return and his service to our country. How can we make the transition easier for him?
- What is the national trend on domestic partner benefits? Am I required to offer it?
