If a state law regulates insurance It’s saved from being pre-empted by ERISA, but a self-funded plan is not treated as an insurer, so they don’t have to follow state regulation But now many of those state law protections have become Federal law under the ACA, so now they apply to all plans 1. 2. 3. Gives other relief (injunction) p. 370 - State law says they must provide an independent review…Ct says it’s more like a second Rush Prudential, determining whether something is covered by the plan & that’s all v. Davla, p. 387 Note that if it relates to an employee benefit plan goes to federal court, under ERISA To the extent a plan enlarges upon ERISAs remedies It’s pre-empted e.g., if law allows more DAS As a coverage decision, Federal law Only get reimbursement. ERISA protects them from paying punitive DAS, etc Peagram When a mixed treatment and eligibility decision being made, then the Ct will look at it as a treatment decision. e.g., when physician provides an HMO plan and wears 2 hats—one as a doctor, one as an insurer and thus is divided b/w their treatment decisions and their coverage decisions [ABSENT Week before spring break, studying for midterm] A. B C. D. Eligibility Categories Payment Systems MSDRG: Dx Medical Groups Individual mandate 1% or $9500, whichever is higher. out of refund p. 434 - 475 (medicaid; CHIP) Medicare Medicaid A welfare program for the poor An insurance program for the elderly & disabled Paid for by…. Employment tax revenue Paid for by jointly Fed & by general tax revenue e.g., 50/50 States may exceed fed min. funding guidelines e.g., 60/40
If a state law regulates insurance It’s saved from being pre-empted by ERISA, but a self-funded plan is not treated as an insurer, so they don’t have to follow state regulation But now many of those state law protections have become Federal law under the ACA, so now they apply to all plans 1. 2. 3. Gives other relief (injunction) Rush Prudential, p. 370 - State law says they must provide an independent review…Ct says it’s more like a second determining whether something is covered by the plan & that’s all v. Davla, p. 387 Note that if it relates to an employee benefit plan goes to federal court, under ERISA To the extent a plan enlarges upon ERISAs remedies It’s pre-empted e.g., if law allows more DAS As a coverage decision, Federal law Only get reimbursement. ERISA protects them from paying punitive DAS, etc Peagram When a mixed treatment and eligibility decision being made, then the Ct will look at it as a treatment decision. e.g., when physician provides an HMO plan and wears 2 hats—one as a doctor, one as an insurer and thus is divided b/w their treatment decisions and their coverage decisions [ABSENT Week before spring break, studying for midterm] A. B C. D. Eligibility Categories Payment Systems MSDRG: Dx Medical Groups Individual mandate 1% or $9500, whichever is higher. out of refund p. 434 - 475 (medicaid; CHIP) Medicare Medicaid A welfare program for the poor An insurance program for the elderly & disabled Paid for by…. Employment tax revenue Paid for by jointly Fed & by general tax revenue e.g., 50/50 States may exceed fed min. funding guidelines e.g., 60/40
dodge-health-law-sandra-carnehan-2014.docx