Welfare Benefit Plan ERISA News
March 2014

Affordable Care Act to Eliminate 2,000,000+ Jobs
In 2010, the Congressional Budget Office (CBO) estimated that the ACA could lead to a loss of 800,000 full-time equivalent jobs by 2021. It has recently issued a new report indicating that the ACA could lead to a loss of about 2,000,000 full-time jobs by 2017, rising to 2.3 million jobs by 2021 and 2.5 million by 2024. The decline in full-time equivalent employment stemming from the ACA will consist of some people not being employed at all, and other people working fewer hours. The CBO also stated that total employment and compensation will increase, but the increase will be smaller than it would have been in the absence of the ACA. The Budget and Economic Outlook: 2014 to 2024, Appendix C, page 117
Clinical Trials Mandate vs. Experimental Exclusion
The Clinical Trials Mandate is effective for plan years beginning on or after 1/1/2014. However, health care reform does not require that plans cover clinical trials; it merely prohibits non-grandfathered health plans from denying a participant the right to participate in an approved clinical trial and/or imposing additional restrictions on coverage for "routine patient costs" connected to them.
"Routine patient costs" are charges typically covered for a participant that is not enrolled in a clinical trial. They include costs related to the direct clinical management of the patient. They do not include:
  • the item, device, or service deemed experimental,
  • items and services provided in connection with data collection and analysis, or
  • a service clearly not consistent with widely accepted and established standards of care for the particular diagnosis.
Employers sponsoring self-insured plans should confirm that the Experimental/Investigational exclusion in their Plan and SPD does not exclude items or services related to clinical trials that are required to be covered as routine patient costs. They should also check how their stop-loss policies will treat such expenses. If the stop-loss policy does not cover routine patient costs connected to clinical trials, the employer may be responsible to pay for them.
There's No Substitute for a Good Self Advocate
Do you check out a restaurant's ratings before going? Why not do the same for doctors, dentists, hospitals, and urgent care clinics? Here are a few websites that offer useful information about providers that you may want to research before going: Healthgrades, Vitals, and RateMDs.
Hospitals are typically rated on patient safety, clinical quality, patient experience, readmission rates, and timely and effective care. This information is obtained from sources such as the Centers for Medicare and Medicaid Services.
Doctors are rated on patient satisfaction surveys that ask about the doctor and his office. Questions concerning the doctor relate to his promptness, your level of trust, how well he explains medical conditions, listens, and answers questions, did he diagnose accurately, did he spend an appropriate amount of time, does he have modern medical equipment, and whether he followed-up after a visit. One website even provides information on Sanctions, Malpractice, Board Actions, and other Medical Board Records.
Questions about the doctor's office focus on its environment, the ease of getting an appointment, the wait time, and the staff's knowledge, helpfulness, punctuality, friendliness, and courtesy. Narrative reviews can be particularly illuminating. Generally, the more patient reviews there are, the more credible will be the doctor's overall rating.
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© 2017 ERISAPros, LLC, All rights reserved. Information on ERISAPros' website, its newsletter, “News & Views,” and its blog, “ERISA Wonk,” is published as a general informational source. Information and articles are general in nature and are not intended to constitute legal or tax advice in any particular matter. Blog posts and comments reflect the personal views of their respective authors - not those of ERISAPros. Transmission of this information does not create an attorney-client relationship. ERISAPros, LLC is not a law firm and is not giving legal or tax advice. It does not warrant and is not responsible for errors or omissions in the content on its website or in its newsletters. ERISA is a complicated and confusing law. Summary Plan Descriptions (SPDs), Wrap Plan Documents, and Form 5500s require review and updating by qualified ERISA compliance professionals.


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