What is ELAP?
ELAP protects employers acting as sponsors of self-funded health plans,
and it also supports the TPA’s who administer these plans on behalf of
employers. ELAP provides a clear-cut (outsourced) strategy to deal with
the responsibilities of being a Plan Fiduciary.
Why ELAP?
• Court decisions have defined and heightened Fiduciary responsibility
under ERISA.
• Fiduciaries must be reasonable, prudent, diligent, and unbiased – with
an undivided loyalty to the plan beneficiaries.
• The Dept of Labor enacted new claims-handling and appeal regulations on
July 1, 2002. The DOL requires all benefit decisions and appeals to be
made within strict timeframes AND in consultation with an appropriate
medical professional.
• HIPAA requires proper protection of confidentiality.
• If a plan FAILS to establish and follow compliant claims procedures, the
aggrieved plan participant can by-pass the appeals process within the plan
and go directly to court with a lawsuit.
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How does ELAP Work?
The Program addresses three critical areas:
1. Legal – ELAP provides plan sponsors and TPA’s with access
to legal advice from an experienced ERISA attorney. Focus areas include
document review, DOL & HIPAA compliance, and general consultation on any
legal matter relative to a specific health plan.
2. Medical – ELAP clients and their TPA’s have access to a
nationally recognized and URAC accredited Independent Review Organization.
This allows plans to comply with the DOL Regulations regarding medical
consultation and further assures that benefit decisions are based on
rational (and defensible) medical protocol.
3. Liability Transfer – ELAP will assume Claims Fiduciary
Status in the plan-doc of the self-funded employer. We are liable for
decisions we make at the final level of appeal – a “Referred Appeal.” *
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How much does ELAP cost?
All of these services are included in the charge of less than $1.00 PE/PM
(no deductibles apply). NO EXTRA CHARGES (hourly or fee-for service) when
ELAP must consult with an attorney or physician due to the nature of the
appeal.
Liability and compliance issues are not going away. You must comply, and
you will incur a cost to comply. The American Association of Health Plans
(AAHP) estimates that compliance (alone) with the DOL Reg’s will cost $.57
PE/PM. ELAP allows plan sponsors to enjoy the advantages of self-funding
while managing the compliance, regulatory, and legal risks.
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* A “Referred Appeal” of a
benefit denial is described in the
ELAP Plan Amendment
and DDM Service
Agreement, which were both drafted to comply with ERISA and the DOL Claims
Regulations of 7/1/2002.
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