Medical Second Opinions and ERISA: What employers need to know

At WorldCare, we are sometimes asked if medical second opinion (MSO) services as part of an employee benefit plan are subject to ERISA. MSOs may or may not fall within ERISA’s reach – this is complicated stuff and the rules are not all that clear in different contexts.

So let’s share a few key points:

• MSOs are a leading weapon in the war to control healthcare and related costs and to improve patient outcomes. As such, having a serious illness MSO embedded in your employee medical and/or disability program is a highly-valued service, with a proven ROI, that is increasingly in demand.

• There are ERISA implications for wellness programs that provide medical care and MSOs sometimes fall under the design and communicating of contemporary wellness programs. So employers should be alert – since the Labor Department has been aggressive in policing them for compliance with other than the HIPAA rules.

• Where it is a self-insured benefits program, or a plan that covers fewer than 50 participants, not all ERISA provisions apply. However, many rules still need to be followed. As a practical matter most employers would prudently consider the same issues even if it views the MSO separate from its medical plan.

• HIPAA non-discrimination rules do not apply to fully-insured supplemental plans (that are designed to reimburse deductibles and co-payments). MSOs embedded here are typically outside the reach of ERISA as well.

For more details, WorldCare encourages you to consult your lawyer. If you would like to talk to one of our medical second opinion experts, email info@worldcare.com and we’ll set-up a time for you talk.