Employee Retirement Income Security Act of 1974; rules and regulations for administration and enforcement; claims procedure--Department of Labor. Notice of proposed rulemaking

This document contains a proposed regulation revising the minimum requirements for benefit claims procedures of employee benefit plans covered by Title I of the Employee Retirement Income Security Act of 1974 (ERISA or the Act). This proposed regulation would establish new standards for the processing of group health disability, pension, and other employee benefit plan claims filed by participants and beneficiaries. In the case of group health plans, as well as certain plans providing disability benefits, the new standards are intended to ensure more timely benefit determinations, improved access to information on which a benefit determination is made, and greater assurance that participants and beneficiaries will be afforded a full and fair review of denied claims. If adopted as final, the proposed regulation would affect participants and beneficiaries of employee benefit plans, plan, fiduciaries, and others who assist in the provision of plan benefits, such as third-party benefits administrators and health service providers or health maintenance organizations that provide benefits to participants and beneficiaries of employee benefit plans.

Eligibility and exclusion of hemochromatosis patients as voluntary blood donors

BACKGROUND

Hereditary hemochromatosis patients are excluded in many countries as voluntary blood donors. In 1991, changes in the Canadian Red Cross policy allowed healthy hemochromatosis patients to become voluntary donors.

STUDY DESIGN AND METHODS

The medical histories of 208 hemochromatosis patients were evaluated for eligibility for blood donation from a large prospective database of hemochromatosis patients. A survey that determined the success or exclusion of 81 patients for blood donation and the reasons for their exclusion based on Canadian Red Cross donor exclusion criteria was analyzed.

RESULTS

Of 208 hemochromatosis patients, 140 (67%) were eligible for blood donation. Criteria for exclusion were other illnesses excluded by Canadian Red Cross criteria and the use of contraindicated medications. Fifty-one per cent of patients had attempted to donate blood, with only 7% being successful.

CONCLUSIONS

A large number of potential blood donors are excluded from blood donation inappropriately despite changes in eligibility criteria to the contrary. Further public and health education is needed to increase awareness and, thus, increase blood donation by potential donors.

Notification procedures for states implementing "alternative mechanisms" in the individual health insurance market--HCFA. Notice

This notice generally describes the statutory provisions under section 111 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that guarantee availability of individual health insurance coverage to certain individuals with prior group coverage. It also provides procedural guidance for States that intend to implement an alternative mechanism under section 111 of HIPAA. Finally, this notice describes the statutory provisions that will apply in a State that does not implement an acceptable alternative mechanism. This notice does not establish new policy or requirements.

Medicaid program: redeterminations of Medicaid eligibility due to welfare reform--HCFA. Final rule with comment period

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and the Contract with America Advancement Act of 1996 created changes in Federal law affecting the eligibility of large numbers of Medicaid recipients. These changes include revisions to the definition of disability for children and to the eligibility requirements of non-U.S. citizens and individuals receiving disability cash assistance based on a finding of alcoholism and drug addiction. This final rule with comment period protects Federal financial participation (FFP) in State Medicaid expenditures for states with unusual volumes of eligibility redeterminations caused by these recent changes in the law. We are making changes to the regulations to provide for additional time for States to process these redeterminations and provide services pending the redeterminations.

Quality of work incapacity assessment in the Swiss disability insurance system

Quality of medical assessment of work incapacity has been poorly investigated, despite the enormous costs engendered by transient incapacity of work and permanent disability. This study examined some indices of quality from a stratified, random sample (n = 120) of assessments performed by expert assessors of the Swiss disability insurance. The distribution of work incapacity (WI) percentages over a 100% scale showed a clustering around key values significantly associated with financial disability benefits. The precision of WI, expressed as the level of quantitative exactness, was found to be high in 74% (95% CI: 66-82%) of current WI assessments, and in 62% (95% CI: 53-71%) of maximal WI assessments. Disagreement was observed in 17% of cases when comparing two ways of expressing WI by the same physician (95% CI: 10-23%). This exploratory study is limited by the general lack of objective criteria and standards. Further theoretical and empirical developments are needed to determine standardized criteria and clear guidelines for medical assessments of WI, as well as for evaluating their quality.

Community care in South Thames (West) Region: is needs assessment working?

The objective of this study was to review the processes by which individuals' needs are being assessed and related to local eligibility criteria under the new arrangements for community care. An audit of the assessment process, definitions and measurement of need against Department of Health guidance was undertaken across the eight social services departments in South Thames (West) region. The results showed there is no standard approach to assessing needs: all social services have developed different assessment processes and different criteria for identifying needs. None use standardised measures of dependency such as the Barthel Index. Scales for measuring dependency have been developed locally so are not comparable between local authorities. Whilst local authorities have published eligibility criteria, in the main, these are purely descriptive accounts with considerable variation in practice in how local authorities are determining eligibility for services. In many authorities there remains ambiguity as to whether published eligibility criteria relate to eligibility for assessment or eligibility for services. Only one authority had attempted to quantify population needs and service provision in advance of setting its eligibility criteria. In conclusion, information collected on individuals cannot be aggregated for use in population-based planning, nor for monitoring purposes in any of the eight local authorities. National guidance is required on definitions of need and eligibility criteria. There is a need for a standardised core community data set, which embraces both health and social care.

Organ transplantation criteria represent insurer dilemma

In its simplest form, technology assessment, as used for coverage decision making, involves an analysis of published data regarding the safety and effectiveness of a technology, either on its own merits or in comparison with a competing technology. However, while the medical literature, and thus technology assessments, typically focus on a well-defined population, a positive coverage policy almost immediately creates pressure for broadening patient selection criteria. A variant on this phenomenon is the patient selection criteria for organ transplantation. These criteria are based not only on the scientific merits of the procedure but also on frequently ill-defined notions of the most appropriate allocation of a scarce resource, which in turn is determined by supply and demand at individual transplant centers. In these cases, the payer may defer to the patient selection criteria of the individual transplant center. However, the situation arises when a patient, rejected at one transplant center, "shops" and finds another center that has more favorable selection criteria. How, then, can the payer resolve these discrepancies and establish consistent policy guidelines? Should allocation of scarce donor organs be part of a technology assessment and coverage decision? The case of liver transplantation will be used here to illustrate the insurer's dilemma.

A contingency-based approach for assessing policies on aging

This article assesses the demographic and ideological shifts reshaping aging policy and proposes an approach to rethinking the bases of aging-based and aging-related policy. This approach takes into account new and multiple patterns of need and well-being among the old and, as such, holds the promise of providing both a defense of and a rationale for a range of age-related benefits. As well, it opens the possibility of shifting responsibilities for well-being in old age among government, the private sector, and individuals themselves.

Verifying the future of electronic eligibility verification

Many vendors and potential users of eligibility verification systems know the obstacles that deter the widespread acceptance and implementation of the technology. On the following pages, executives of firms representing the payor, provider and clearinghouse communities express their perceptions regarding the status and need for online eligibility verification and its cost advantages.

Oregon's experiment

Oregon's systematic design for universal access to health care, known as the Oregon Basic Health Services Act, has provoked heated debate over its rationale, plan and process. It is a novel attempt to address inequities in the distribution of health care for those below the federal poverty level. Its controversial nature compels more informed discussion to guide further analysis. Accordingly, this report is primarily descriptive, aiming to provide a clear synopsis of the Oregon project's history, complex methodology, and strengths and weaknesses.

Evaluating the predictive validity of nursing home pre-admission screens

This article demonstrates a method for evaluating the predictive validity of nursing home pre-admission screens (PAS) by using measures of predictive validity adapted from the field of epidemiology. Our approach estimates how well as PAS performs in identifying the "who but for" population of the Medicaid home and community-based services waiver programs for the frail elderly. The methodology's usefulness in screen revision is also illustrated.

Eligibility for publicly financed home care

OBJECTIVES

Proposals for publicly financed home care for the elderly now tend to include cognitive impairment criteria as well as activities of daily living (ADL) criteria. The numbers of elderly deemed eligible for services will depend on the definitions of ADL and cognitive impairment used.

METHODS

Data from the 1984 National Long-Term Care Survey were used to generate a series of estimates of the community-dwelling elderly with ADL disabilities and cognitive impairment.

RESULTS

When only ADL criteria are used, estimates of disability range from 472,000 to over 3 million (1.6% to 12.5% of the community-dwelling elderly). These estimates increase to approximately 1 million to 4.2 million (3.5% to 14.0% of the community-dwelling elderly) when cognitive impairment criteria are added.

CONCLUSIONS

The use of more stringent or more liberal eligibility criteria will have dramatic effects on the number of elders who qualify for services. The nature of the eligibility criteria employed in any expansion of federally financed home care benefits will be a major factor in determining the costs of such a program.