From the desk of Joe D.
As the summer sun shines and the calendar creeps to August, it’s the perfect time to take a breath and roll up our sleeves.
While the days may be long and the pace a bit lighter, fall’s enrollment and renewal season is now just around the corner. Now is when the real groundwork gets done.
Think of it as preseason training: the preparation now makes the difference between a smooth sprint and a chaotic scramble come September and October.
This is the time to plan what clients need by way of communications, data, compliance, and advocacy.
Thinking ahead and prepping now is essential — because once summer ends, things heat up fast. And no one wants to be caught off guard when clients expect answers, materials, and support at lightning speed.
That includes giving our Intellectual Resources teams the lead time they need to build what’s required— without a barrage of lastminute fire drills.
It all brings to mind the story of the ant and the grasshopper. The ant worked steadily through the sunny months, preparing for the colder days ahead. The grasshopper? Not so much. When winter came, only one of them was ready. Let’s be the ants—strategic, steady, and ready to deliver when it counts. Because while fall may feel far off, we all know it arrives in the blink of an eye.
Enjoy the summer and let’s hit the renewal and open enrollment 1/1 push as prepared as possible.
At the intersection of Medical Coverage and Motor Vehicle Insurance (NJ)
Written by Dennis Hyland
A Plan Sponsor for an group’s SelfFunded Medical Plan (PLAN) in New Jersey is permitted to establish their PLAN as always-secondary payor to an employee’s motor vehicle insurer for a Motor Vehicle Accident (MVA).
Establishing the PLAN as alwayssecondary (for an MVA) can be an effective component of a Plan Sponsor’s comprehensive Cost Containment strategy.
However, as with any administrative determination / undertaking related to Employee Benefits, the Plan Sponsor must be certain to create in its controlling documents the appropriate plan language to competently, clearly and concisely describe how its Self-Funded Medical Plan will work in the unfortunate situation of an MVA involving a PLAN member.
In addition, the Plan Sponsor has the ongoing obligation to fully
Example 1: For a Hospital System in New Jersey
inform its employee population of the PLAN’s secondary payor status for an MVA, and the Plan Sponsor has the ongoing responsibility to make certain the Claims Administrator is correctly administering the PLAN when medical claims for an employee’s MVA are submitted.
Some examples of PLAN language that describe the relationship of a Medical Plan with automobile No-Fault insurance (PIP benefits):
This section applies when expenses are Incurred by a Covered Person due to an Automobile Related Injury. The Medical Plan will be secondary in all cases. Even if the member declines NJ PIP, the plan will pay as if NJ PIP had been in effect and will carve out that assumed benefit.
Example 2: For a Mid-Sized Employer in New Jersey
Exceptions and Exclusions
Except as specifically provided in this booklet, no benefits will be provided for services, supplies or charges: 12. For injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid under a plan or policy of motor vehicle insurance, including a certified self-insured plan, or payable in any manner under the state’s Motor Vehicle Financial Responsibility Law or similar law;
This type of plan language excerpted here, however imperfect, must be in place to establish a PLAN’s always-secondary position for coordinating medical benefits with automobile insurance. However, this can not be just a “set it and forget it” activity, as the Plan Sponsor has the ongoing responsibility to recognize and uncover areas of claims administration that do not comply with the language and intent of the PLAN, and must be certain that all affected parties – specifically the PLAN’s Claims Administrator and the PLAN’s members – understand their responsibilities and obligations in the PLAN’s administration with regard to coordination of the two medical coverages, before the MVA happens.
This is because wobbly medical plan language and inept claims administration – coupled with the lack of clarity given to the Medical Plan’s covered employees with regard to who pays first – will likely undermine the PLAN’s intent to pay MVA claims only as secondary.
Given this likelihood (or possibility), specific Methods & Procedures (M&Ps) should be created to define roles and responsibilities at the intersection of a medical plan and motor vehicle insurance.
Note:
Every automobile owner in New Jersey must have liability coverage and Personal Injury Protection (PIP) included in their automobile insurance policy. PIP is that part of the auto coverage that reimburses for medical expenses, lost wages, and other accident-related costs, regardless of fault.
It is the “no-fault” aspect of auto insurance that makes the automobile insurer responsible for paying PIP benefits for an auto policyholder’s medical treatment arising from a motor vehicle accident (MVA), regardless of fault.
• The required minimum PIP coverage in New Jersey is $15,000 per person, per accident.
• A “Standard Policy” for automobile insurance in New Jersey offers a PIP coverage limit of $250,000. (With higher limits available from some insurers.)
Responsibilities and Obligations of Plan Sponsor for Administering PLAN as Secondary to Automobile No-Fault / PIP Benefits
• Plan Sponsor must declare conspicuously and affirmatively in all Medical Plan Documents that this self-funded New Jersey medical plan is not intended to be a replacement for automobile insurance medical benefits and is not intended to be primary payor for an MVA.
• Plan Sponsor must make certain the SPD and Plan Documents and all employee communications state the PLAN’s intent clearly and completely.
• Plan Sponsor must make certain the Claims Administrator (CA) fully understands their obligations and responsibilities with regard to MVA and COB and the PLAN’s stated intent. | CA must sign off to acknowledge. Plan Sponsor must regularly check in with CA to clarify: What is CA actually doing?
• Plan Sponsor must confirm the ASA describes the obligations and responsibilities of the CA accurately, and must deny the CA any additional admin fees for processing MVA/COB claims correctly or for “recovery.”
• Plan Sponsor must alert PLAN members several times / year, including at Open Enrollment.
• Plan Sponsor must alert new employees at onboarding.
• Plan Sponsor must require PLAN members to sign acknowledgement of Medical Plan as always-secondary coverage for MVA.
• Plan Sponsor must require PLAN members with NJ residence to purchase $250,000 in PIP coverage.
• Plan Sponsor must educate PLAN members on (financial) consequences if they choose Medical Plan as primary in contradiction to PLAN requirements.
• Plan Sponsor must require Claims Administrator to administer coverage for MVA claims as [PLAN = secondary] and in accordance with applicable COB procedures.
• The coordination of benefits with the auto insurer for medical is NOT a “subro” claim.
• The Claims Administrator should not be employing its “Pay&Pursue” methodologies / procedures for COB on MVA claims. “Pursue & Pay” is the correct approach for MVA/COB.
• The Plan Sponsor might consider inviting top automobile insurance providers in New Jersey to present to employee groups, with the possibility of payroll deductions for personal auto insurance (NJMIC; GEICO; P&C relationship?)
EB Celebrations and Milestones
Congrats to our teammates for their impressive achievements!
The following team members have completed the required courses for the REBC program:
• Dania Wade
• Julia Diaz*
• Kyle Kaufmann*
• Matt Cann
• Megan Keane*
• Melissa Wade
• Michelle Santiago
• Mike Hanley
• Rose Rybak
• Shalin Dave*
• Tracy Jadico*
*Also completed the REBC elective courses
Additional Certifications and Achievements:
• Alissa Ellis and Chris Ocampo have completed the required courses for the BAM (Benefits Account Manager) and ABAM (Advanced Benefits Account Manager) Certifications
• Adam Dewitt has received his EBS I Health Plan Navigation Certificate
• Jagger Latimer has received his Group Benefits Associate Designation
Meet EB’s Mewest Team Members!
In what might be the most impawtant life update of the month, Jagger Latimer welcomed not one, but two tiny coworkers — already getting comfortable in their new roles (one has claimed a work laptop as their purr-sonal office).
you do in your role?
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you want to be as a kid?
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famous dinner guests you’d want to have:
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