The Edgewood Independent School District’s recent decision to drop their fully-insured Blue Cross health plan may become a major issue with local teacher unions in coming days as employees adjust to the new health program known in the insurance industry as Cost Plus, True Cost or Reference Based Pricing. Unfamiliar with new benefit protocols, confused employees are questioning the merits of the plan and continued access to local medical caregivers.
Could the Edgewood ISD follow the foot-steps of Mason Independent School District? “After several teachers in the Mason City Schools had trouble getting medical care, the district waffled Tuesday on whether it would abandon the controversial TrueCost (Cost Plus) health care plan.” http://news.cincinnati.com/article/20130219/NEWS0102/302190076/
“We applaud Edgewood for exploring cost effective alternatives to traditional health insurance plans and hope they persevere in holding the line against escalating health care costs” said Oscar “Perro Grande” Meyer, a local South San politiquera. “Perhaps a careful scrutiny of plan contracts to determine liability issues would be important at this early stage before the program matures much further. It’s always in one’s best interest to get a second opinion. Edgewood should engage an independent insurance expert to review the plan, as the City of Lewisville did last year.” http://blog.riskmanagers.us/?p=12968
Editor’s Note: Cost Plus, or Reference Based Pricing can be a viable alternative to traditional managed care plans if properly structured, priced, implemented and conveyed to plan participants. If not, it could end in poor employee moral and unexpected uninsured financial risk. Risk Managers has several Texas school clients utilizing Cost Plus with good results, as well as a number of San Antonio employer groups. www.costplusinsurance.com
From A TPA – Looks like Cost Plus / Reference Based Pricing may take a hit in the San Antonio area if Edgewood terminates the plan and goes back to a PPO. That would be unfortunate.
From Anonymous – Edgewood is screwed if they terminate early. But I like the second opinion comment by Big Dog Meyer
From San Antonio risk manager – Very interesting. Keep us posted.
From a San Antonio physician group – The Edgewood move away from managed care is being watched very carefully here in San Antonio.
From a Lawyer – Our firm represents hospitals. Texas courts have expressly held that ONLY A LICENSED ATTORNEY may lawfully represent third parties in negotiation of their legal rights. Crain v. The Unauthorized Practice of Law Committee of the Supreme Court of Texas, 11 S.W.3d 328 (Tex.App.–Houston [1st Dist.] 2000reh., . den.) Anyone else acting on behalf of a third party is ENGAGING IN THE UNAUTHORIZED PRACTICE OF LAW.
A BUSINESS COMPANY may not circumvent this requirement by having an in-house attorney handle the matter because that is the COMPANY practicing law–which only a PROFESSIONAL CORPORATION is permitted to do. Bar Ass’n of Dallas et al. v. Hexter Title & Abstract Co., 175 S.W.2d 108 (Tex.Civ.App.–Fort Worth, 1943, reh. den.) Nor may the business company hire an outside lawyer and have the lawyer handle the matter, because the law firm’s CLIENT is the COMPANY, *not* the third party. And the company cannot get around this with some sort of “power of attorney” or other “written authorization to represent” ruse either.
Only ATTORNEYS may form a professional corporation and a professional corporation may ONLY practice law.
We have found that some marketers regularly misrepresents to ISD’s (school districts) and various other government units that their plans and activities are protected by ERISA. The fact is that ERISA has a “governmental plan” exception–NO governmental entity comes under ERISA.