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ATLANTA-While all may seem quiet on the legislative front for the Self-Insurance Institute of America Inc., there are some noisy battles to be fought.
The group is busy helping members anticipate changes that will occur as a result of legislation that already has passed, such as the Health Insurance Portability and Accountability Act and Medicare secondary payer provisions that were part of this year's budget bill.
Looming are battles over legislation the SIIA first proposed in 1983 to make it easier for associations to self-fund health plans and another measure that would expose third-party administrators and others to damages for personal injuries or wrongful deaths that arise from plan administration decisions.
It's no time for SIIA members to be complacent, said James A. Kinder, CEO of the SIIA at the annual meeting during the group's National Education Conference & Expo in Atlanta earlier this month.
"While some people might think that the legislative environment is rather quiet," Mr. Kinder warned, and "there's not a lot going on and it's business as usual," in reality, there are a lot of bills and issues to track.
SIIA is attempting to shepherd through Congress S. 729, sponsored by Sen. Tim Hutchinson, R-Ark., which establishes standards that would allow associations to form health plans that would operate under ERISA and not have to comply with state requirements. The SIIA has been a long-time backer of the legislation and earlier versions of it.
The legislation was attached to the House version of this year's budget bill, but due to stiff opposition in the Senate and from the Clinton administration, it later was killed in a congressional conference committee. The measure still is alive, though, as a free-standing bill.
Mr. Kinder said he is optimistic about the bill's future. "It has built up major, major support now."
But, he acknowledges, opposition still is strong from health insurers, state insurance regulators and governors.
Mr. Kinder said he anticipates hearings in October to address the bill, and "perhaps after 14 years of work we might see a bill come through."
Among legislation SIIA hopes to derail is the Patient Access to Responsible Care Act, which has attracted 118 co-sponsors in the House.
The bill, among other things, would subject plans established under ERISA and agents of the plans-including TPAs-to state court suits in personal injuries and wrongful deaths that allegedly occurred because of administrative decisions. Insurers, health maintenance organizations and group health plans could be sued in state court for damages alleged to have been caused by decisions to deny or restrict health care.
The bill, sponsored by Rep. Charles Norwood, R-Ga., and Sen. Alphonse D'Amato, R-N.Y., potentially could expose benefit managers to the suits, according to the SIIA.
The legislation is an attempt to "whittle down the ERISA pre-emption provision under which self-insurance exists," said George J. Pantos, Washington-based counsel for the SIIA.
Speaking at the annual meeting, Mr. Pantos said a key provision in the bill "opens the door for patients to sue the plan for damages if they feel that they were not given certain coverages they think they are entitled to" or experienced a problem because of a coverage decision.
Patients would be able to sue plans "just as they might sue a doctor for medical malpractice," he remarked.
Mr. Kinder said the SIIA is getting more aggressive in its opposition to legislation that would hurt its membership.
"One of our challenges is that for years, we've been an organization that has been on the defense and learned about things as they were introduced," he said. "And we're changing our mode of operation to become a much more aggressive organization, trying to be on the forefront of legislation before it is introduced."
That means a labor-intensive effort is needed by SIIA members, he said. The organization's board of directors will discuss at a November meeting how to restructure its Coalition to Preserve Self-Insurance to make it more proactive in the legislative trenches.
It's too late to thwart some legislative efforts, such as HIPAA, which was the topic at seminars and receptions throughout the conference week.
SIIA members are waiting on final rules that will detail their responsibilities under HIPAA. The law imposes a number of legal requirements on group health plans that will change the way those plans are administered.
HIPAA sets new non-discrimination rules, limitations on exclusions for pre-existing conditions, enrollment requirements, electronic data interchange requirements and confidentiality standards.
TPAs are facing a new liability after changes in Medicare secondary payer rules, which were passed as part of the budget bill.
Under the changes, which the SIIA fought, the federal government can recover from TPAs-in certain situations-and group plans benefit amounts it determines should have been paid for covered workers over 65 before Medicare payments were made. The government has three years from the time the payments should have begun to seek recoveries.
The three-year standard set in the budget law for the government to take action to recover Medicare overpayments from plans and TPAs overturns a 1994 federal appeals court ruling that said the government could not recover funds from TPAs unless the TPA also was a health plan's insurer.