ERISA is an acronym for the “Employee Retirement Income Security Act” located at 29 U.S.C. § 1001, et seq. ERISA is federal law that regulates private sector employee pension and health benefits plans. The Congressional intent was to set forth uniform standards for employee health benefits plans. The standards include information disclosure to participants, administrator fiduciary duties, claims procedures and appeals and other remedies.
Defining Key Terms Under ERISA
- ERISA plan sponsor: usually the employer
- ERISA plan administrator: responsible for filings with the government and disclosure of information to participants (often this is the insurance company)
- Summary Plan Description (SPD): a document that describes the terms of the health benefit plan
- Participant: typically the employee or former employee who is eligible to receive the health plan benefits
- Beneficiary: a person designated by a participant, or, one who by the terms of the plan may be entitled to benefits
- ERISA fiduciary (including statutory fiduciary and de facto fiduciary): those exercising authority, control and management of the operation and administration of the plan including those who perform pre and post payment reviews and issue denials
Health Plans Governed by ERISA
Any plan that is established or maintained by an employer for the purpose of providing an enumerated benefit (medical benefits) to a participant or beneficiary.
Self Insured v. Fully Insured
When a plan is a self insured plan, the employer is responsible for paying all claims. Sometimes, the insurance company serves as a third party administrator of such plans. These plans are 100% ERISA
When a plan is a fully insured plan, the employer pays a premium to an insurer, and the insurer pays the claims out of the pools of premiums it collects from everyone it insures. These plans involve ERISA and possible state law.
ERISA broadly preempts, with certain exceptions any and all state laws insofar as they may now or hereafter related to any employee benefit plan. Factors to consider include whether the state law impacts the structure of ERISA plans; whether the state law provides an alternate course of action to participants to collect benefits protected by ERISA; whether the state law impacts the administration of ERISA plans; whether the state law provides an alternate cause of action to participants to collect benefits protected by ERISA.
ERISA Law Firm
The Martin Law Firm represents health care providers in ERISA related matters. Attorney Jason B. Martin represents all types of health care providers with post-payment reviews, pre-payment reviews and recoupment. Insurance payers must follow the ERISA standards and guidelines and understanding your ERISA rights is paramount to any successful defense. Contact the Martin Law Firm today for a free consultation.