The Employee Retirement Income Security Act (ERISA) affects about 83 percent of the non-Medicare and non-Medicaid claims filed every day by hospitals and physician offices. The employer that sponsors the insurance plan cannot be any form of government or church.
When ERISA Applies to Claims
However, there may be instances when a patient is employed by a government or church when ERISA does apply to their claims—typically because the patient doesn’t get insurance through their own employer, but through a family member’s policy.
This may make the issue somewhat murky for medical practices, so check out nine examples of when ERISA laws would apply to claims:
- The patient works at Costco and gets insurance through Costco.
- The patient is a government employee, but their spouse works at General Motors and they’re on a family policy through General Motors.
- The patient works for the local grocery store, which provides him with insurance.
- The patient’s spouse gets insurance through the plumber’s union and the patient is on that family policy.
- The patient is covered by his mother’s policy, and his mom works at UPS.
- The patient is a flight attendant who gets insurance through the airline.
- The patient’s father is a roofer who has a policy through the roofing company.
- The patient is a pastor, but he’s on his wife’s insurance and she has a family insurance policy through her job at Target.
- The patient gets coverage from the bank where he works.
When ERISA Doesn’t Apply to Claims
Even after reviewing examples of when ERISA applies, you still may not be able to differentiate when a non-ERISA claim hits your desk. Check out these examples of instances that don’t apply to ERISA:
- The patient works for the state highway department and gets insurance through that position.
- The patient went onto the state exchange website and took out a policy she pays for independently.
- The patient has insurance through her job as a schoolteacher at a public school.
- The patient has insurance through his job as a youth minister at the church.
- The patient has insurance through his job as a park ranger at a state park.
Needless to say, ERISA can be a confusing topic, but it’s essential to understand which claims apply to the law and which don’t. Why? Because ERISA imposes specific caps on out-of-pocket costs, protects patient rights, and protects your provider’s rights.
If you’re not confident whether ERISA applies to a particular type of insurance, you can contact the insurance representative and ask for more details.
Find out more about the complex ERISA rules by participating in the online training session, “Keep More of Your Reimbursement: Make ERISA Work for You.” During this 90-minute training,
David J. Zetter, PHR, SHRM-CP, CHC, CPCO, CPC, COC, PCS, FCS, CHBC, CMUP, PESC, CMAP, CMAPA, CMMP, CMHP, will provide you with the steps every practice must take to master the ERISA laws. Sign up today!
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