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Health Insurance: HMOs (Managed Care Policies)

What Protections Does ERISA Provide To HMO Members?

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Under ERISA:

  • There must be disclosure through a Summary Plan Description of a plan's benefits, limitations and member obligations; identification of the plan administrator and those with authority to decide claims, and directions for obtaining further information and plan documents.
  • Each member must be given a copy of the Summary Plan Description Plan and has a right to see the entire Plan, including the internal criteria that determine rights to benefits.
  • The plan must be operated for the sole benefit of plan beneficiaries. (The people who run the plan have a fiduciary duty to act like prudent people who run the plan for the sole benefit of plan beneficiaries).
  • Employers have no duty to maintain any particular kinds of levels of employee benefits, or to keep a plan in effect at all. If an employer terminates benefits, it must do so in a non-discriminatory manner.
  • Members cannot be discriminated against with respect to benefits.
  • There must be a procedure for full and fair internal review of denied claims. Plans cannot require more than two levels of internal review.

Members have a right to action to sue to enforce their rights, and recover penalties and/or attorneys' fees in certain situations. (Note: to discourage frivolous lawsuits, employers also have a right to receive attorney fees). 

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