Can the law limit what heath care providers I see if I have commercial and medicaid? There's a bit of story to this: We had been trying to find a therapist for my son. We wanted one that we felt comfortable with. We didn't care if the provider was out of network or if we'd have to pay for their services out of pocket. We found one that we all really like and have seen them for several sessions now. We have commercial health insurance through my work, and my son also has insurance through the state (Wisconsin) under Medicaid. My commercial insurance has zero out of network coverages. The provider billed my commercial insurance first for the services, knowing that it would likely be declined due to being out of network. After it was declined, the provider then sent the claim to Medicaid, and they declined it too, saying they won't cover any of it since it was out of network to my commercial insurance. I'm fine with that, we just pay for the services out of pocket and that's that. Apparently not. The provider has told us that we can no longer see them because they cannot accept payment from us. The provider said they heard this from a representative at Medicaid and that they read it in some documents. One supporting quote that I was provided with to support their claim that they can no longer see us is this: BadgerCare Plus and Wisconsin Medicaid will not reimburse the provider if the commercial health insurance plan denied or would deny payment because a service otherwise covered under the commercial health insurance plan was performed by a provider outside the plan. In addition, if a member receives a covered service outside their commercial health insurance plan, the provider cannot collect payment from the member. The provider went back to the representative to confirm that they can't bill us even if insurance isn't involved and they were told: No they can’t, that would be considered fraud. Is this legal? How can I not just pay for a service out of pocket? What fraud would I or the provider be committing? I'd understand if we went into this whole thing thinking that it was going to be covered by insurance, but we knew insurance likely wasn't going to cover it. Any help or advice would be really appreciated.
This is &quot;Topic #601&quot; in various ForwardHealth interpretative statements about BadgerCare Plus and Medicaid. The last 3 paragraphs say: When commercial health insurance plans require members to use a designated network of providers, non-network (i.e., providers who do not have a contract with the member's commercial health insurance plan) will be reimbursed by the commercial health insurance plan only if they obtain a referral or provide an emergency service. Except for emergency services and covered services that are not covered under the commercial health insurance plan, members enrolled in both a commercial health insurance plan and BadgerCare Plus or Wisconsin Medicaid (i.e., state-contracted MCO (managed care organization), fee-for-service) are required to receive services from providers affiliated with the commercial health insurance plan. In this situation, providers are required to refer the members to the commercial health insurance plan's network providers. This is necessary because commercial health insurance is always primary to BadgerCare Plus. BadgerCare Plus and Wisconsin Medicaid will not reimburse the provider if the commercial health insurance plan denied or would deny payment because a service otherwise covered under the commercial health insurance plan was performed by a provider outside the plan. In addition, if a member receives a covered service outside their commercial health insurance plan, the provider cannot collect payment from the member. If we take these statements by the Dept. of Health Services as correct interpretations of the law, then it seems that their interpretation is correct: &quot;providers are required to refer the members to the commercial health insurance plan's network providers&quot; (you as a patient have no choice) and &quot;the provider cannot collect payment from the member&quot; (they are encouraged to refer you to a network provider, because they are prohibited by law from taking payment from you). If you had received the services from the provider and not mentioned any insurance, this would have been treated as a normal doctor-patient case, and they would not know that the state would prohibit them from receiving payment from you. By going through the motions with insurance, I regret to say that you exposed them to relevant knowledge which they cannot take back or deny. The fraud would be between the provider and the state, via the provider's relation with this program. That does not endorse the DHS legal interpretation, but since they are the ones who wrote the regulations, it is fairly likely that (by definition) they got it right.
Just at the offset this does not constitute legal advice, just some opinions I have on this point. Technically, you would not be prohibited to generate speech and use it however you like. Under normal circumstances any output generated by the system that does not contravene the service agreement would be your intellectual property. This would include the text and speech generated. Once you go about the request limit you would naturally be required to pay, but until that time you can use the service as a paying customer. Just to clarify this point I would like to make reference to the service license agreement, clause 3, which make reference to the following prohibitions: (a) copy, modify, create a derivative work of, reverse engineer, decompile, translate, disassemble, or otherwise attempt to extract any or all of the source code of the Services (subject to Section 3.4 below and except to the extent such restriction is expressly prohibited by applicable law); (b) use the Services for High Risk Activities; (c) sublicense, resell, or distribute any or all of the Services separate from any integrated Application; (d) create multiple Applications, Accounts, or Projects to simulate or act as a single Application, Account, or Project (respectively) or otherwise access the Services in a manner intended to avoid incurring Fees or exceed usage limits or quotas; (e) unless otherwise set forth in the Service Specific Terms, use the Services to operate or enable any telecommunications service or in connection with any Application that allows Customer End Users to place calls or to receive calls from any public switched telephone network; or (f) process or store any Customer Data that is subject to the International Traffic in Arms Regulations maintained by the Department of State. Unless otherwise specified in writing by Google, Google does not intend uses of the Services to create obligations under HIPAA, and makes no representations that the Services satisfy HIPAA requirements. If Customer is (or becomes) a Covered Entity or Business Associate, as defined in HIPAA, Customer will not use the Services for any purpose or in any manner involving Protected Health Information (as defined in HIPAA) unless Customer has received prior written consent to such use from Google. Similarly, as specified here: Customer will not, and will not allow third parties to: (i) use these Services to create, train, or improve (directly or indirectly) a similar or competing product or service or (ii) integrate these Services with any applications for any embedded devices such as cars, TVs, appliances, or speakers​ without Google's prior written permission. These Services can only be integrated with applications for the following personal computing devices: smartphones, tablets, laptops, and desktops. In addition to any other available remedies, Google may immediately suspend or terminate Customer's use of these Services based on any suspected violation of these terms, and violation of these terms is deemed violation of Google's Intellectual Property Rights. Customer will provide Google with any assistance Google requests to reasonably confirm compliance with these terms (including interviews with Customer employees and inspection of Customer source code, model training data, and engineering documentation). These terms will survive termination or expiration of the Agreement. You should also take a look at this and this. However, as per the terms of the agreement the speech generated would be your intellectual property, unless otherwise specified. Good luck!
Parents have a legal obligation to care for their minor children: it is illegal to harm a child through action or inaction. State law and associated welfare programs are complex: you can start here. If surgery is medically necessary, her insurance should cover it. If her parent do not have medical insurance, they still have the obligation of care; though various governmental programs may alleviate the problem, such as the state medical assistance program. The parents may therefore be in violation of the law, and anyone may report this to DSHS (specifically through Child Protective Services). This obligation terminates when the child turns 18 (assuming that someone does not petition for adult guardianship). Legislation is not crystal clear as far as what constitutes "injury of a child ...under circumstances which cause harm to the child's health". CPS has no authority to compel parents to pay for a medical treatment, but they can go to the courts on behalf of the child. At that point, it's hard to say what the court would order. For example, if the parents are capable of providing medical insurance and just willfully chose to not cover their child, the court could order them to get insurance. It is virtually guaranteed that the courts would not order the immediate amputation of the child's feet, and there would be no legal basis for ordering the parents to pay for the procedure in a decade, after the child is an adult. However, if you are suggesting that there is an immediate treatment (which the parents have opted to not provide, hence the prospects of later amputation), then it is reasonably likely that the courts would order the parents to provide for the treatment (if it would be possible for them; otherwise, the state may intervene and provide for the treatment).
Insurance is regulated at the state rather than the federal level in the United States, and the terms of individual insurance contracts also matter. Most states prohibit insurance of intentional unlawful acts as a matter of public policy, either under common law doctrines or under express statutes or regulations. The public policy is that no one should be insulated from liability for their own intentional acts. And, in insurance policies for individuals who are not employers, this is typically accomplished with an intentional acts exclusion in the language of the policy. (Negligent acts are almost always insurable. The status of acts that constitute gross negligence, willful and wanton conduct, reckless conduct, or bad faith conduct, varies somewhat from state to state.) But, the situation is muddier when the insured is an employer or an entity. It frequently is possible for an employer or entity to insure itself against unauthorized misconduct by employees or officers or directors who are breaching their duties to the employer or company, rather than carrying out the official policies of the company. Factories don't knowingly do anything. People in or connected to factories do things and know things. And, if a factory employee is cutting corners in violation of his job responsibilities and that hurts the company, that could be an insurable risk. But, if a factory employee is acting in accordance with the directions of the CEO and Board of Directors in causing the factory to emit waste violating the law, and if the people giving him orders known that this violates the law, then this is probably not an insurable loss of the company as a matter of public policy. Another complication involves the question of who is insured. The Town of Greenfield may be able to legally buy insurance that compensates it for the costs of having to deal with intentional environmental law violations by factories undertaken as a matter of corporate policy in the town, even though the corporation couldn't buy this insurance. Indeed, the Town could even impose a tax on the corporation that requires it to pay the premium on the Town's insurance policy. But, this wouldn't relieve the corporation of liability or violate public policy because the insurance company would have a right of "subrogation" to sue to owner of the factory to reimburse it for the full amount of any claims that it had to pay to the Town. This is true even if the corporation and the responsible individuals in the corporation are, in fact, judgment proof or bankrupt, so that the subrogation right is actually meaningless in fact. It is also probably legal for a company to "self-insure", i.e. to set aside reserves of its own money to pay for it violations of the law in the future without regard to intent, and to have administrators employed to process payment in those situations, because then it is not actually insulated from harm for its own wrongdoing. But, this is risky because a policy of condoning illegal conduct could subject the company to punitive damages and sanctions in addition to compensatory damages. It also matters what kind of harm the insurance policy pays for. It would not be illegal, in almost any state, to issue an insurance policy that pays for a criminal defense lawyer for someone who is accused of a crime. But, it would be illegal in almost every state to issue an insurance policy that pays for fines and court costs and restitution imposed as punishment for committing a crime. Paying for a criminal defense lawyer, or a bail bond, at a time when you are presumed innocent, is not a form of punishment and hence is an insurable expense.
Late to the party, but I'll answer anyways. In general, providers have a lot of wiggle room when sharing information with parents, on condition that the patient hasn't explicitly objected despite having opportunity to do so. HIPAA allows the provider to make a judgment call on whether such information can be shared without explicit consent: Quoting Title 45 § 164.510 : (i) Obtains the individual's agreement; (ii) Provides the individual with the opportunity to object to the disclosure, and the individual does not express an objection; or (iii) Reasonably infers from the circumstances, based the exercise of professional judgment, that the individual does not object to the disclosure. HHS does discuss disclosure to family members in their FAQ : A covered entity is permitted to share information with a family member or other person involved in an individual’s care or payment for care as long as the individual does not object. A parent of a child who has just turned 18 is likely still somewhat involved in the child's care, so, absent either an objection or a reason to believe the child would object if asked, sharing is probably not a violation.
It's probably not unlawful to ask, but an answer cannot be required immediately. Per the Department of Labor, Susan has 60 days to elect COBRA coverage (the qualifying event here being the termination of Susan's employment): Your plan must give you at least 60 days to choose whether or not to elect COBRA coverage, beginning from the date the election notice is provided or the date you would otherwise lose coverage under your group health plan due to the qualifying event, whichever is later. It would be unlikely for an employer to discourage an employee from electing COBRA coverage due to costs to the employer, as you suggest: Susan is still employed and thus could be treated differently in her last two weeks depending on how she responds because the company is struggling financially and is looking for every opportunity to save money. Susan electing to use COBRA coverage is unlikely to cost the company money, because the employer is permitted to charge her the entire cost of the coverage, plus 2 percent to cover the cost of administering it (additional DoL source). As far as privacy goes, I don't think anything illegal has occurred here. The most prevalent law regarding privacy of health information, HIPAA, generally does not apply to employers. Susan could, of course, request a private discussion, and any response from Emily could not rise to the level of illegal harassment or create a hostile work environment.
As discussed in this investopedia article contributions may be limited for Highly Compensated Employees (HCE). This article discusses the Actual Deferral &amp; Actual Contribution Percentage Tests (ADP/ACP) which are used to determine limits for HCEs. However, in a unionized company, there can be other considerations . Union Bargaining agreements can override the plan terms, and cause a reduction in the contribution limits. The article &quot;Challenges of Retirement Plans with Union Members&quot; says: Retirement plans at organizations where the workforce is largely unionized have the unique challenge of being obligated to negotiate plan terms with the union. It’s a process that can be very burdensome, experts say, but also very rewarding. When a retirement plan is run at an organization with a union, the collective bargaining agreements trump the retirement plan document, as specified by the National Labor Relations Act, according to David Kern, partner with the labor and employment practice and chair of the National Labor Relations Act team at Quarles and Brady LLP, in Milwaukee. “Any changes to the plan need to be bargained with the union,” Kern says. Retirement plans at non-union organizations typically have a provision that the employer has the right to modify the plan at any time, says Amy Ciepluch, chair of the employee benefits and executive compensation team at Quarles &amp; Brady. At a union shop, however, “that type of language would not trump what a collective bargaining agreement guarantees. The collective bargaining agreement would govern.” However, the federal limit on total retirement contributions is unchanged. So an employee limited in 401K contributions can increase contributions to an IRA or other retirement account.
IANAL, and I don't live in America, but some of this depends on their intent. If they gave the drugs away by mistake, they probably have not broken any laws. If they were given away deliberately (and you would need to prove this &ndash; which might be hard) then yes, he has broken laws. Either way, I expect you have a right to compensation (i.e. $900) from the physician to "make you whole again." If required necessary you could file for that in your local small claims court: The physician will either come to the party pretty quickly and sort it out, or the court will award you the money you need to buy the replacement meds. (But you will need to evidence the replacement cost, for a start....)