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AGENDA ITEM REVIEW FORM |
3.E.
Special Employee Benefit Trust Board Meeting
- Meeting Date:
- 04/13/2022
- Department Head:
- Kay Macuil
- Submitted By:
- Kay Macuil, City Attorney, Attorney's Office
ITEM:
Discussion and possible action on any and all matters regarding establishing a waiver policy of pre-clearance penalty and specific request by employee for waiver of a pre-clearance penalty. (Glenn J. Gimbut, Assistant City Attorney)
SUMMARY:
Background
The City of San Luis’s benefits plan provides that if hospital services are to be used for preventative screening procedures, the services need to be pre-cleared through the third-party administrator.
Without pre-clearance, the city’s employee suffers a $500 penalty regarding coverage.
Specific Situation
Only three (3) applications of penalty over the past five (5) years have come to HR’s attention. A recent situation is one of the three.
The situation arose when the procedure was to be performed in the outpatient clinic, and this procedure was 100% covered by the plan. But the clinic’s facilities were undergoing remodeling, so the doctor changed the location to the hospital. The use of the hospital instead of the clinic was not pre-cleared.
The employee is asking for a waiver of the $500 penalty. The Board has the power to do so under the Trust.
The policy question is: does the Board wish to consider requests for waiver? If it does, then the above request is pending, and the employee asks that the Board consider their request. As this does not appear to be a common occurrence (only the third time in 5 years), staff would ask that the Board consider hearing such requests. In the present situation, pre-clearance would not have made a difference since the third-party administrator would have granted it if the doctor had made the simple pre-clearance call. The employee thought the doctor and the clinic were making all appropriate arrangements in the current situation. In addition, the employee had actually checked directly with the third-party.
The City of San Luis’s benefits plan provides that if hospital services are to be used for preventative screening procedures, the services need to be pre-cleared through the third-party administrator.
Without pre-clearance, the city’s employee suffers a $500 penalty regarding coverage.
Specific Situation
Only three (3) applications of penalty over the past five (5) years have come to HR’s attention. A recent situation is one of the three.
The situation arose when the procedure was to be performed in the outpatient clinic, and this procedure was 100% covered by the plan. But the clinic’s facilities were undergoing remodeling, so the doctor changed the location to the hospital. The use of the hospital instead of the clinic was not pre-cleared.
The employee is asking for a waiver of the $500 penalty. The Board has the power to do so under the Trust.
The policy question is: does the Board wish to consider requests for waiver? If it does, then the above request is pending, and the employee asks that the Board consider their request. As this does not appear to be a common occurrence (only the third time in 5 years), staff would ask that the Board consider hearing such requests. In the present situation, pre-clearance would not have made a difference since the third-party administrator would have granted it if the doctor had made the simple pre-clearance call. The employee thought the doctor and the clinic were making all appropriate arrangements in the current situation. In addition, the employee had actually checked directly with the third-party.
RECOMMENDATION / SUGGESTED MOTION:
I MOVE TO WAIVE THE $500.00 PRE-CLEARANCE PENALTY AND FIND THE WAIVER JUSTIFIED UNDER THE CIRCUMSTANCES PRESENTED.
Fiscal Impact
Fiscal Impact:
If the waiver is granted, there would be a $500 cost to the trust, which the trust would have paid if the physician had made the call.