I Have Another Insurance Question?

[robs477]

I'm NOT allowed to give it out...she would haunt me with gag gifts if I did and I have enough damned clutter in this house as it is.

Yeah, I know that. I was just expressing my gratitude more symbolically so to speak. That being said, I have become pretty dang proficient in my internet search prowess's over the years and could probably find out if I really wanted to . You ladies spend a lot of time and effort sometimes helping and it is much appreciated, guess that's all I'm trying to say.

 

[DianaCox]

The only compensation necessary is that you Pay it Forward, somehow, some way.

And i learned a few things myself in doing the research - including the general fact that there are phased-in ACA compliance requirements for self-funded plans, which I need to review on my daughter's behalf (we've had a LOT of problems with her self-funded plan covering things that SHOULD be covered).

 

[Spiky Bugger]

Yeah, I know that. I was just expressing my gratitude more symbolically so to speak. That being said, I have become pretty dang proficient in my internet search prowess's over the years and could probably find out if I really wanted to . You ladies spend a lot of time and effort sometimes helping and it is much appreciated, guess that's all I'm trying to say.

Late to the party, but if I told you Diana's address (and, btw, there is another, similarly named attorney in that general area, so don't make assumptions), then she'd give Kirmy my address and I'd start getting Scottish shit in the mail.

Can't risk it.

 

[robs477]

Late to the party, but if I told you Diana's address (and, btw, there is another, similarly named attorney in that general area, so don't make assumptions), then she'd give Kirmy my address and I'd start getting Scottish shit in the mail.

Can't risk it.

Hmmm....With Xmas right around the corner, I could maybe go for one of their single malt Islay scotches if she's gifting

 

[DianaCox]

Robs - I've been thinking about this: "I have until March 1, 2015 to provide "Supporting documentation", and I will wait until the last week in Feb to send it. That will buy us 3+ months to shop the private market as said, for back-up plan "D"."

Why wait? if you can be assured you will (or know you won't) be able to get your granddaughter covered, why not get it all cleared up now and stop stressing about it? Give them the supporting documentation, and the definitions from the IRS statutes, as well as the revised requirements for self funded plans (I assume it's a large company, > 50 full time employees?) for 2015, and ask them to CONFIRM that they will now cover the grand - who is your dependent as defined under 26 U.S.C. § 152(f)(1) and 152(c)(1) and 152(c)(2)(A), as she is as child of your child and living with you, etc., and that per the provisions of the ACA which relate to self-funded plans that go into effect on January 1, 2015, the company is now required to offer coverage to employees and their dependents who are children. Even if they say no, you have the right to appeal the decision.

They may try to assert that she is your foster child though - you might want to consult a lawyer if they assert that. But first, cite this: https://www.dfps.state.tx.us/Adoption_and_Foster_Care/About_Adoption/pmc.asp, which clearly indicates that there are major DIFFERENCES between foster parents (and thus foster child status per the IRS definition that allows [but doesn't REQUIRE, by the way - your company is being bastards] the company to withhold coverage under 4980H of the Internal Revenue Code, enacted by the Affordable Care Act) and permanent managing conservators (who are clearly dependents not excluded by the definition (12): "Dependent. The term dependent means a child (as defined in section 152(f)(1) but excluding a stepson, stepdaughter or an eligible foster child"):

What is Permanent Managing Conservatorship (PMC)?
Permanent Managing Conservatorship (PMC) is a legal term in Texas used in child custody cases. It means that a judge appoints a person to be legally responsible for a child without adopting the child. The court can give PMC to someone other than a parent, including DFPS, a relative, a close family friend, or a foster parent. PMC can only be given by a judge. The judge decides the rights and responsibilities, depending upon the specific situation. When someone other than a parent is named as "permanent managing conservator," he or she is given certain rights and duties about caring for the child such as the right or duty to:​

• • Physically possess the child;
  • Choose moral and religious training;
  • Provide clothing, food, shelter, and education;
  • Provide and consent to medical, psychiatric, psychological, dental, and surgical care;
  • Get the child’s medical records;
  • Receive money that supports the child;
  • Hold or give out money that benefits the child;
  • Consent to get married;
  • Consent to join armed forces;
  • Represent the child in legal issues;
  • Make legal decisions;
  • Decide where the child lives and goes to school; and
  • Make other decisions that the child’s parent would normally make.

For more information, see the Texas Family Code, Section 153.371.

Once the court names you permanent managing conservator, the judge will dismiss DFPS from the case. This means DFPS will no longer be involved with the child or your family.

This also means you will not receive services such as case management, day care, and post placement services from DFPS.

If you are the child’s foster parent, you will not continue to receive foster care payments after you become permanent managing conservator. (“Foster parent” means that you have completed the process to become a foster parent through a child placing agency.)

If you are permanent managing conservator and decide to adopt later, you will not receive adoption assistance.​

It is CLEAR that PMC's are NOT foster parents, but rather have almost all of the attributes of an adoptive parent. But specifically, PMC's are not foster parents as defined in 4980H of the Internal Revenue Code, enacted by the Affordable Care Act, and thus the child in this arrangement CANNOT be excluded from coverage as a dependent under your plan, including up to age 26.

You should also point out that the terms of your PMC requires that you provide insurance. Tell them you have spoken to an attorney about this.

 

[robs477]

Hi Diana, You are so smart its almost nauseating...LOL, and can "read in between" the lines better than anyone I've seen in quite a while!!....OK...RE: Why wait? if you can be assured you will (or know you won't) be able to get your granddaughter covered, why not get it all cleared up now and stop stressing about it?

That's a good point too, but here are my two underlying reasoning's:

1) My Granddaughter has Thyroid levels that are off the charts and has had for 5 or 6 yrs and she is almost 12. Because she recently started puberty and is growing, she is in a 3-4 month cycle of getting tested every 3 weeks while her thyroid medication is being adjusted. That two months of coverage will buy me enough time to get all her testing and dosage adjustments completed in that time frame and for the most part wont have to go back to the Endo for the next 6-12 months.

2) As discussed, my Company is self funded. I already have pre-approval for my DS which should cost them somewhere around $30K. Within 30-60 days of my post surgery (which will hopefully happen in Jan), my wife wants to start the process going to have her WLS, the VSG, i.e, that's why we're switching to my insurance.....another $20K or so. That's about $50K or so that will be coming out of my Companies fund pretty quickly. I just didn't want to rock the boat so to speak or get more visible on their "Corporate Radar Screen" by getting in a pissing contest over her coverage. Its going to cost me about $100 bucks or so a month to add her on anyway and I figure I can probably get that price or similar on the open market....so....I am trying to choose my battle wisely as I can due to all of that. Those are my main reasons why.

And yes. we are Permanent Managing Conservators and under the law, best as my lay opinion can tell, they were responsible even for allowing coverage for her even before the recent ACA. When I got declined in 2011, I lost an appeal and then I specifically asked via certified return receipt letter if the decision was reviewed by a Corporate Attorney? I got no response and could see the handwriting on the wall. I could have gotten our Attorney involved then, but, where I work, they WILL put you on the "Shit List" if you rock the boat too much not matter how valuable your contribution to the company is. They don't lubricate the "squeaky wheel", they replace it.

Thank you again for your time spent and your expert advise!!! We are all SOO fortunate to have you here, as well as many other Vets too! Rob

 

[DianaCox]

@robs477: Well, I can understand your concerns. I HATE that you feel at risk of an adverse job action based on your utilization of your health care benefit entitlement, due to your company having a self-funded plan - but (sweet lemons?) if they actually DID do something like that, you just might find yourself on the RIGHT side of an employment discrimination law suit that could help fund your retirement.

But I'm pretty sure they were within their rights to NOT cover her before - since the revisions to the rules for 2015 make it clear that NOW, self-funded plans MUST cover dependents (and expressly not including spouse, step or foster children), that confirms that before 1/1/15, it was NOT required that they cover dependents at all.

 

[robs477]

@robs477: Well, I can understand your concerns. I HATE that you feel at risk of an adverse job action based on your utilization of your health care benefit entitlement, due to your company having a self-funded plan - but (sweet lemons?) if they actually DID do something like that, you just might find yourself on the RIGHT side of an employment discrimination law suit that could help fund your retirement.

But I'm pretty sure they were within their rights to NOT cover her before - since the revisions to the rules for 2015 make it clear that NOW, self-funded plans MUST cover dependents (and expressly not including spouse, step or foster children), that confirms that before 1/1/15, it was NOT required that they cover dependents at all.

Yeah, It will be interesting to see what they do given those new laws in place. Also Diana, another factor, dont forget, I live in Texas a "right to work state" which pretty much = "a right to screw U state". The big corporations control the politiicans and they dont even have to have a reason to fire you on the spot, and it happens all the time. Employment discrimination lawsuits are almost non-existant here and very difficult to win and they know it and use their empowerment accordingly. Plus, I am hoping to retire in 3-4 yrs, so, I will just have to suck it up...lol