Whose responsibility is it?

njjel · March 2005

When the medical insurance carrier decides to discontinue a previously covered benefit or medication, whose responsibility is it to notify the employees who participate in the plan? The insurance company or the employer's? Our carrier made a change and neither the employer or the employees were advised of the change in writing other than the fact that it is now listed on the Benefit Summary sheet that accompanies the enrollment kits which are given to new-hires only. I was astonished at this. Has anyone else encountered this issue?

lhill · March 2005

We have two carriers. One notifies both the employer and participating employees in writing, the other notifies the employer only and I in turn notify the employees. I'd check into this; it doesn't seem right. Good Luck.

Don D · March 2005

Sombody needs to be called on the carpet for this, either directly or through your third party broker. Depending on the severity and consequence of this malfeasance, perhaps a head should roll.

marc · March 2005

Our carrier notifies our EEs. They have not discontinued covering meds, but have placed some in a category that forces a higher co-pay. In those cases they directly notified all of our EEs.

HRinNH · March 2005

Ditto. One of my husband's meds was put into a 'non-forumulary' category and we were notified in writing by the carrier.

Hunter1 · March 2005

This is a complicated issue. Generally, if the benefit levels change, it is necessary to amend the plan, and this amendment has to be communicated to all employees; however, I get a monthly notice from our TPA about changes in coverage for prescription meds and don't change the plan or notify employees. There are new meds coming on the market all the time, some covered, some not, depending on FDA approval, etc or 'old' ones being sold OTC or withdrawn from the market and going off plan. I'm not about to start notifying employees every time a new med comes out. As long as I don't change the plan, even though changes might affect someone's particular med, no notification.

lnelson · March 2005

I agree with Hunter1 on this generally only changes to the prescription benefit level or co-pay would all ees be notified by both the carrier and the er in my case. But if a medication is taken off the list no one would be notified by the er but I would HOPE the carrier knowing who has been taking the said prescription would then notify only those ees taking it with a recommendation that ee see their PCP to get, if available, an alternative and covered medication.

Our carrier has a website that list all covered medication either Formulary or Non-formulary that ees can go to.

TLC Shelly · March 2005

Our broker writes the notice on his letterhead and we attach it to employee paychecks. (Okay, I write the letter and the broker drops by to sign it.) It works out well - we know the employee has been notified and they have someone to talk to right away if they have questions. Of course, the key is getting the carrier to communicate with you.

njjel · March 2005

In this case it is a surgical procedure they no longer will cover for large groups. They say we the employer was notified at renewal time however I receive the information and I never saw ANYTHING about it until I handed out a packet to a new-hire and I noticed they had listed it there as not being covered. Of course this was AFTER open enrollment and the new plan year was in progress. Now an ee wants the surgery they no longer cover and says she would have changed to our other carrier at open enrollment time had she known about it then. What would you all do?

sandra_d · March 2005

I would go through the renewal proposal by the carrier with a fine-tooth comb. If it really isn't there, you should have the right to demand that they cover this person, and then notify everyone else that from here forward, it is not covered.

I would bet it is in your renewal documents, buried deep-deep-deep, or just lightly touched on. Our carrier did something similar, tho our broker caught it and pointed it out.

It sounds like the surgery might be elective?? If so, can the employee wait until the open enrollment comes around again, and switch??

Don D · March 2005

As opposed to doing that, why not first ask the carrier to fax to you or point you to the specific exclusionary language in the renewal document. You should not have to go through the document with a fine tooth comb. If they have no substantiation that they did notify you in accordance with custom, I would demand that they cover the procedure up to the point where they give the company and employees the rider or exclusion in writing.

njjel · March 2005

Well, I guess I am done for. I just located a benefit summary dated emailed to me in November 2004 and at the top in tiny print it states, along with alot of other items such and such "not covered". Of course this was at the time that we were still "shopping" plans and my focus was on the rate schedule written below it. At no time however was I ever told by our broker or the insurance company (nor did I receive a letter from the insurance company as they say they sent w/the renewal) stating that they were no longer going to cover this procedure in 2005. So do I offer myself up on a platter?

Whatever · March 2005

Im curious.. What is the surgical procedure?

AJ SPHR · April 2005

Go back to the broker and insurance company and tell them you screwed up. You missed it in the summary sheet and therefore didn't blatantly communicate it during open enrollment period to employees. As a result, you have an employee in the situation now who needs this coverage and thinks he/she has the coverage. Ask how it can be fixed, whether you can request an exception and then communicate it clearly to all going forward. Ask if they have options for this situation.

njjel · April 2005

I'm wondering what liability our broker has if any due to the fact that they did not bring this to my attention during the "shopping" period?

Dutch2 · March 2005

We are self insured and have a great TPA that monitors our plan. The TPA is really good at notifying us (HR) of any recommended changes, but since we are self insured we make the final decision to change or not change the plan. If a change is made we announce it in advance in our weekly company newsletter and as someone else mentioned, we place a hard copy of the change in their paycheck envelope. Still very few ee's remember the change as they may not need this particular procedure for months after the change was announced. We do encourage our ee's to have their doc's check with our TPA to see if the procedure is covered before hand.
Good luck...

Whose responsibility is it?

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