This Is What Businesses Need To Know About Florida’s COVID-19 Liability Protection Law

Florida’s COVID-19 liability protection law should help businesses avoid baseless coronavirus-related liability claims. After all, COVID-19 taught us that it’s virtually impossible to avoid a highly-contagious virus in the midst of a global pandemic. Virus-free zones are an illusion. The risk of exposure and infection can be reduced with preventative measures, but not eliminated. Nevertheless, a growing number of businesses are being sued by plaintiffs seeking compensation for personal injuries resulting from alleged exposure to COVID-19. In response, the Florida Legislature enacted a law that provides business establishments heightened legal protections against COVID-related liability.

The law seeks to deter unfounded claims against individuals and business while allowing meritorious cases to proceed. It does this by imposing heightened proof and pleading standards on plaintiffs filing COVID-19-related claims. The statute broadly defines a “COVID-19-related claim” to include civil liability claims against a person or business entity for damages, injury or death that arise from or are related to COVID-19, regardless of how the claim is denominated or presented. (A separate statute generally applies to COVID-19 claims against health care providers.)

Under this new law, COVID-19-related claims must be commenced within one year after the cause of action accrues. If the cause of action accrued prior to March 29, 2021, the plaintiff’s deadline to file a complaint is March 29, 2022. The complaint must be pled with particularity. Specific facts and details, as opposed to general statements and conclusory allegations, are required. The plaintiff must also submit a Florida-licensed physician’s affidavit attesting, within a reasonable degree of medical certainty, that the plaintiff’s COVID-19-related damages, injury or death occurred as a result of the defendant’s acts or omissions. If the plaintiff fails to comply with either of these requirements, the case will be dismissed without prejudice, which means they will be given another opportunity to comply.

Once these requirements are satisfied, the court will determine whether the defendant was making a good faith effort to substantially comply with any authoritative or controlling government-issued health standards or guidance at the time of plaintiff’s alleged exposure to COVID-19. This would include guidance issued by the CDC, the Florida Department of Health, counties, cities, etc. If the court finds a good faith effort, the defendant will not be liable for any act or omission associated with the COVID-19-related claim; otherwise, the plaintiff’s case will be allowed to proceed. But to win, the plaintiff must prove by clear and convincing evidence that the defendant’s conduct was grossly negligent, meaning that the likelihood of injury was known by the defendant to be imminent. Otherwise, the plaintiff will lose and the defendant will not be liable.

The broadest protections afforded by this law are reserved for those making a good faith effort to substantially comply with authoritative COVID-19 guidance. This should encourage businesses to implement reasonable and recommended preventative measures to reduce the risk of exposure and infection. Remember, businesses are not immune from COVID-19-related claims. If a plaintiff can satisfy the statute’s heightened pleading requirement (particularity), elevated burden of proof (clear and convincing evidence) and stricter standard or care (gross negligence), your business may be held liable.

Please contact us for more information about risk management measures and insurance to protect your business against COVID-19-related liability claims.

Can Employers Make the COVID-19 Vaccine Mandatory for Employees Under the Americans with Disabilities Act?

Setnor Byer Insurance & Risk

The COVID-19 vaccines provide a glimmer of hope as new cases surge nationwide. It also raises some interesting questions for employers. How, for example, will the vaccine’s increasing availability be viewed in the context of the Americans with Disabilities Act (ADA)? Can employees be required to provide proof of vaccination? Can employers make COVID-19 vaccines mandatory for employees? Fortunately, the Equal Employment Opportunity Commission issued updated guidance to help employers answer some COVID-19 vaccine-related questions that are likely to arise in the near future.

Is asking or requiring an employee to show proof of COVID-19 vaccination a disability-related inquiry under the ADA? According to the EEOC, no. Simply requesting proof of vaccination is not likely to elicit disability-related information, so it’s not a disability-related inquiry. However, the EEOC cautions that subsequent questions (Why didn’t you get vaccinated?) may elicit information about a disability and would need to be job-related and consistent with business necessity. The EEOC recommends warning employees not to provide any medical information as part of the proof in order to avoid implicating the ADA.

How should employers respond to employees who are unable to get vaccinated because of a disability? The ADA allows employers to protect against direct threats to workplace health or safety. However, if a COVID-19 vaccination requirement screens out or tends to screen out individuals with disabilities, the employer must show that an unvaccinated employee would pose a direct threat due to a significant risk of substantial harm that cannot be eliminated or reduced to an acceptable level by reasonable accommodation. Managers and supervisors responsible for communicating an employer’s COVID-19 vaccination requirement should know how to recognize and respond to accommodation requests. The EEOC urges employers and employees to engage in a flexible, interactive process to identify accommodations that do not constitute an undue hardship (significant difficulty or expense).

Though employers may rely on CDC recommendations when evaluating reasonable accommodations, the EEOC concedes that an accommodation may not be possible in some situations. If that’s the case, the employer may exclude the employee from physically entering the workplace, but the employee should not be automatically terminated. According to the EEOC, employers must first determine whether the employee is protected under any other provision of the ADA or other any other applicable federal, state or local law before taking any adverse action.

Determining if a direct threat exists and whether it can be eliminated or reduced with a reasonable accommodation generally requires an individualized assessment. Some situations may be black or white, but most will be different shades of gray. Employers may need to consult with counsel throughout the process to avoid unintentional, yet costly mistakes.

Please contact us for additional information about protecting your business during the COVID-19 pandemic.

OSHA Inspections and Penalties for Coronavirus-Related Violations on the Rise

Setnor Byer Insurance & Risk

Did you know that the Occupational Safety and Health Act’s health and safety standards apply to COVID-19? Since the coronavirus pandemic began, the Occupational Safety and Health Administration (OSHA) has received approximately 12,000 complaints and conducted nearly 300 inspections related to COVID-19. These inspections have resulted in proposed penalties against employers totaling more than $3.5 million.

The most common violations cited by OSHA include failures to:

While covered employers are responsible for complying with all applicable health and safety standards, those relating to personal protective equipment (PPE), respiratory protection and sanitation may be especially relevant for preventing the workplace spread of COVID-19. Employers that are not subject to a specific OSHA standard must still comply with the OSH Act’s General Duty Clause, which requires each employer to provide a workplace that is free from recognized hazards that are causing or are likely to cause death or serious physical harm to employees.

OSHA’s emphasis on preventing the spread of COVID-19 in the workplace should provide more than enough motivation for employers to do the same. Employers wanting to protect their business and avoid severe OSHA penalties must do their part to protect workers from COVID-19, including the implementation of appropriate preventative measures as required by applicable law or recommended by relevant public health authorities, like the Centers for Disease Control and Prevention (CDC).

Please contact us for more information about protecting your business and your workers during the COVID-19 pandemic.

CDC Offers Thanksgiving Tips to Keep COVID-19 Away on Turkey Day

Setnor Byer Insurance & Risk

With more than 1 million new COVID-19 cases reported over the last seven days, the Centers for Disease Control and Prevention (CDC) is pleading with Americans to celebrate Thanksgiving at home this year. Unfortunately, travel and gatherings with family and friends who do not live with you can increase the chances of getting or spreading COVID-19. For those who are nevertheless planning to host or attend Thanksgiving celebrations, the CDC urges you to take the following preventative measures.

Travelling

  • Check travel restrictions before you go.
  • Wear a mask with at least two layers over your nose and mouth. Practice social distancing.
  • Wash your hands often with soap and water or hand sanitizer. Avoid touching your mask, eyes, nose and mouth. Bring extra supplies (masks, hand sanitizer, etc.).

Attending a Gathering

  • Bring your own food, drinks, plates, cups and utensils.
  • Wear a mask and stay at least 6 feet apart from anyone who is not in your household.
  • Avoid areas where food is being prepared or handled.
  • Use single-use options (salad dressing, condiments, etc.) and disposable items (containers, plates and utensils).

Hosting a Gathering

  • Encourage guests to eat and socialize outdoors. If celebrating indoors, open windows.
  • Limit the total number of guests and the number of people in food preparation areas.
  • Let guests know what to expect before they arrive.
  • Regularly clean and disinfect frequently touched surfaces and items.
  • Have guests bring their own food and drink.
  • If sharing food, have one person serve food and use single-use options.
  • Politely remind guests to keep practicing everyday preventative measures throughout the event.

Finally, the CDC cautions that while the risk of getting or spreading COVID-19 can be reduced, it cannot be eliminated. You should not host or attend in-person Thanksgiving celebrations if you:

  • have been diagnosed with an active COVID-19 infection;
  • have symptoms of COVID-19;
  • are waiting for COVID-19 viral test results;
  • may have been exposed to someone with COVID-19 in the last 14 days; or
  • are at increased risk of severe illness from COVID-19.

Stay safe and Happy Thanksgiving!

An Ounce of Prevention: What Employers Can Do to Keep Workers’ Compensation Costs Down

As a firm specializing in Workers’ Compensation defense, General Liability defense, and Employment and Labor Law defense, we have a bird’s eye view of the successful (and sometimes unsuccessful) practices of our clients. In this article, we offer preventative measures that can be utilized to minimize or mitigate workplace accidents and their associated monetary exposures.

As a general rule, any policy or procedure should be uniformly applied to all Employees, regardless of race, religion, gender, age, or any other protected factor. Failure to apply these provisions uniformly could result in violation of State, Federal, or Local law. As such, if you choose to adopt any of the following suggestions, it is imperative that they be applied without variation.

Perhaps the least expensive and most beneficial practice that a company can utilize is to conduct routine safety workshops. A safety workshop is an inexpensive method aimed at avoiding accidents. We recommend that you conduct safety workshops frequently, perhaps monthly, at which time you can review techniques for safe lifting, ergonomic workplace solutions, and applicable safety rules. To assist your supervisors and HR personnel, Setnor Byer Insurance & Risk, along with Kelley Kronenberg, can facilitate workers’ compensation workshops at your workplace that will specifically address your unique needs and will guide you toward implementing more aggressive and cost-effective practices that can prevent workplace accidents.

Often, injured workers are more apt to stay home if they perceive that the rewards for being out of work are potentially greater than for returning to work. In light of this trend, a useful suggestion for an employer is to establish a safety program. As a company, you may consider offering an incentive to Employees who are accident-free for a specified time period. This practice may also be used for Employees who have a perfect attendance record, thereby reducing frivolous time off for “sick days.” Feel free to contact Setnor Byer Insurance & Risk for additional support. Please note: To avoid disparate treatment or the appearance of impropriety, absences for workers’ compensation purposes, FMLA leave time, or leave provided to an Employee for accommodation of an ADA disability should not count against one’s attendance record in this incentive program.

Obtaining information (post-hiring) about an Employee’s medical history can also be quite useful. The names and contact information for a worker’s physicians can be obtained on your standard employment documents “to be used in the event of a medical emergency.” This information often provides valuable assistance should a workers’ compensation claim later be filed, as it is more likely that a pre-existing condition would have been revealed to a doctor prior to a work accident than after the work accident.

In this regard, we also encourage gathering information from Employees regarding pre-existing medical conditions. This information will be invaluable and may aid in the defense of a workers’ compensation claim, if provided on a timely basis, to the treating physician after an accident. Please be advised that the use of medical questionnaires is strictly governed by the Americans with Disability Act (ADA), and the failure to comply with the requirements of this law could create additional legal exposure for you as an employer.

Under the ADA, the types of questions asked of the Employee depends on the stage of the hiring process.

  • Stage One: Before a Conditional Job Offer is Made. The ADA permits you to show the prospective Employee a job description that describes the physical demands of the job, or to demonstrate the job and inquire whether the prospective Employee is physically able to perform the job function with or without an accommodation.
  • Stage Two: After the Job Offer but Before Employment Begins. The ADA permits the Employer to ask a prospective Employee to respond to a detailed medical questionnaire and to submit to a medical examination, if practical, as long as these are required of all Employees entering the job force within a particular job category.
  • Stage Three: After the Employee Has Begun Working. Among other things, the ADA allows employers to require a fitness-for-duty examination in situations in which the examination is job-related and consistent with business necessity.

The ADA is a complex set of laws-please seek legal advice prior to instituting procedures.

Obtaining information regarding the Employee’s physicians and prior medical care may prove beneficial should the Employee later have an accident. Thus, it is also imperative to know whether the Employee has sustained prior accidents and/or whether a prior workers’ compensation claim or lawsuit has been filed. To answer these questions, we recommend that an index search, background check, or a simple online search be conducted at the post-offer stage.

An index search typically will list any known accidents that the Claimant has had, including workers’ compensation claims and automobile/personal injury claims. The reports typically list parties with additional information regarding the claim, i.e. an Insurance Carrier, an Employer, or an insured individual. Often, we are able to subpoena records based upon the index search that greatly assist in limiting exposure. In fact, for some clients, we seek this information once an injured worker has an accident but before litigation has commenced. At an Employer’s request, we can open a “ghost file” and guide our clients from the sidelines in an effort to avoid unnecessary and costly litigation.

Consider the value of many of the public record search options that exist. A person’s name can be looked up on local civil and criminal case dockets, and much information can be garnered by looking at personal web pages such as flickr, myspace, and similar social networking sites. Small and seemingly insignificant details found today could save thousands of dollars should the Employee later file a claim seeking medical or indemnity benefits. In fact, in one case in which we served as defense counsel, the adjuster obtained pictures of a claimant riding and performing stunts on his motorcycle. The pictures were posted on the claimant’s myspace page and were taken after his alleged accident.

It is also useful to institute a daily or a weekly checkout system. You may wish to have Employees sign out on a daily basis and indicate whether they were in an accident, whether they witnessed an accident, or whether they were in need of medical treatment prior to or upon leaving. This is an excellent tool for defending against workers’ compensation claims that are reported late. It must be noted, however, that if an Employee feels coerced or threatened to document an accident, any defenses available will be undermined.

It is important to note that, in conjunction with a checkout system, you must designate an Employee to be responsible for reviewing these reports. If an Employee indicates an accident or injury on the report, such documentation will likely suffice as notice under the requirements of Florida Statute Section 440, even if the document has not been actually reviewed by a supervisor or another Employee of your company. In this regard, upon learning of an accident or injury, you must report this information to your Workers’ Compensation Carrier to avoid penalties for late reporting or exposure related to late provision of benefits.

It is strongly recommended that every employer establish a zero tolerance policy for violence, safety violations, and fraud. To complement this policy, we recommend that each Employee sign a form acknowledging that violence, safety violations, and fraud are grounds for immediate termination. Your safety documents should explain that a safety violation is considered a failure to comply with any company safety rules, established standards of safety for the industry, OSHA rules, or any rules promulgated by an applicable regulatory agency. For your protection, safety rules should also be set forth in your Employee Handbook, which should be adhered to and distributed uniformly.

It is also recommended that the Zero Tolerance Policy be posted in a place frequented by all Employees, such as a lunchroom or near the time clock. The policy may also be reiterated at staff meetings or in Company bulletins and newsletters.

Established in 1980, Kelley Kronenberg is one of the largest Insurance & Employer defense firms in the State of Florida. They have been a leader in Florida law since they began their practice and have maintained a strong presence in the legal profession since then. Kelley Kronenberg believes that their experience and stability serve as the basis for their firm’s success. In addition, they know that their high standards are constantly complemented by their long-standing philosophy that every attorney is trained with an eye toward cost-effectiveness on behalf of their clients, along with exemplary customer service.

® 2008, Kelley Kronenberg. Reprinted with permission.

Understanding Excepted Benefits Under the Affordable Care Act

Many employers offer benefits packages that provide employees with more than just health insurance coverage. Though some of these benefits, like pre-paid legal service plans, are clearly not health-related, others may provide employees with some health-related benefits. Does this mean they are subject to the Affordable Care Act’s health insurance market reforms? Not necessarily.

Certain types of benefits, due to their nature, are not subject to a number of health-related laws, including the Affordable Care Act, the Health Insurance Portability and Accountability Act, the Mental Health Parity Act and the Genetic Information Nondiscrimination Act. These are known as excepted benefits.

There are four categories of excepted benefits.

  1.         Benefits Excepted In All Circumstances

The following benefits, or any combination thereof, are considered excepted benefits in all circumstances:

  • Coverage only for accident (including accidental death and dismemberment)
  • Disability income coverage
  • Liability insurance, including general liability and automobile insurance
  • Coverage issued as a supplement to liability insurance
  • Workers’ compensation or similar coverage
  • Automobile medical payment insurance
  • Credit-only insurance (for example, mortgage insurance)
  • Coverage for on-site medical clinics
  1.         Limited Excepted Benefits

A number of benefits may be considered excepted benefits if they are provided under a separate policy, certificate or contract of insurance. They can also qualify as a limited excepted benefit if they are not an integral part of a group health plan, which means that participants may decline coverage or that claims for benefits are administered under a separate contract than claims for any other benefits under the plan.

One or more of the following benefits may qualify as a limited excepted benefit:

  • Limited-scope dental benefits
  • Limited-scope vision benefits
  • Long-term care benefits
  • Health flexible spending arrangements
  • Employee assistance programs (EAPs)
  1.         Noncoordinated Excepted Benefits

Coverage for only a specified disease or illness, such as a cancer-only policy, may qualify as a noncoordinated excepted benefit. Hospital indemnity or other fixed indemnity insurance may also qualify if it pays a fixed dollar amount per day (or per other period) of hospitalization or illness regardless of the amount of expenses incurred.

To qualify as a noncoordinated excepted benefit:

  • Benefits must be provided under a separate policy, certificate or contract of insurance;
  • There is no coordination between the benefits provided and an exclusion of benefits under any group health plan maintained by the same employer; and
  • Benefits are paid regardless of whether benefits are provided under any group health plan maintained by the same employer.
  1.         Supplemental Excepted Benefits

The following benefits may qualify as supplemental excepted benefits if they are provided under a separate policy, certificate or contract of insurance:

  • Medicare supplemental health insurance (Medigap or MedSupp insurance);
  • Coverage supplemental to the managed health care program established by the Department of Defense (TRICARE); and
  • Similar supplemental coverage specifically designed to fill gaps in primary coverage, such as coinsurance or deductibles, but which does not include coverage that becomes secondary or supplemental only under a coordination-of-benefits provision.

Excepted benefits must satisfy a number of specific requirements set forth in the federal regulations. Employers should consult a knowledgeable and licensed professional before taking action or making changes to their benefits packages.

If you would like more information about excepted benefits or would like to see how Setnor Byer Insurance & Risk can help with your employee benefits package, contact us.

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Steps to Take After a Car Accident

People often say that driving or riding in a car is the most dangerous part of their day. Statistically speaking, many of these people may be right. According to the National Highway Traffic Safety Administration (NHTSA), there were approximately 5.6 million police-reported motor vehicle crashes, 2.1 million injuries and 22,912 fatalities in 2012. Despite these sobering statistics, drivers can take steps after an accident to minimize the damage to people and property.

According to the Insurance Information Institute, drivers should take the following steps immediately after an accident:

Assess the Damage. Immediately after an accident, safely move the vehicle off the road, if possible, and check to see if anyone is injured. When it’s safe to do so, inspect the vehicle to determine the extent of any damage.

Call the Police. If you are in a serious accident, immediately call the police or dial 911. Let them know if anyone is hurt and the extent of their injuries so medical assistance can be dispatched. File a police report even if the police don’t come to the scene of the accident. A report can be important if someone involved in the accident sues for damages or medical injuries, or if there is more damage done to your car than initially thought. If the police do come to the accident scene, get the officers’ names and badge numbers and ask where you can get a copy of their report.

Collect as much information as possible. Get the names and contact information of everyone involved in the crash, including witnesses. Ask all drivers involved in the accident for their license, car registration and insurance ID card. Get the make and model of the cars involved, and make a note of the location, time of day and the weather conditions. A smart phone or other device can be used to record this information. Though emotions may be running high after an accident, focus on the facts and do not discuss who was at fault, or how much insurance you have, with anyone else involved in the accident.

Don’t leave the scene. If you run into an unattended vehicle, try to find the owner. If you can’t, leave a note containing your name, address and phone number.  Record the details of the accident, including the make and model of the car and the address where the accident occurred.

Get the claims process started. Promptly notify your automobile insurance company or agent as soon as possible while the facts are still fresh in your mind. Keep a record of the name, title and contact information for everyone you speak with from your insurance company. Complete any claim forms you receive as soon, and as accurately, as possible. If you have any questions, don’t be afraid to ask the claims adjuster or your insurance agent for assistance.

Keep all documentation. Create a file to keep all of your notes, records and claim forms. This can make the process of resolving your claim quicker and easier.

Taking steps before an accident can also make it easier to recover afterward. It’s important to have appropriate insurance coverage with sufficient limits. If you would like more information about obtaining automobile insurance that meets your needs, please contact us.

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Office Holiday Parties: Revel without Regret

Many employers consider a company-wide holiday celebration an excellent opportunity for employees to mingle socially and get to know one another better. It’s also a chance for senior management to interact with employees they rarely see throughout the year. Though holiday parties can create a positive work environment, increase employee morale and promote teamwork, they can also expose employers to a number of potentially significant risks.

Perhaps the most significant risks involve alcohol. What happens if an employee becomes intoxicated and causes damage to something or someone? Though liability is determined on a case-by-case basis, employers may face a greater chance of being held responsible if:

  • Attendance is, or is perceived to be, mandatory (e.g., everybody knows that being seen by the Vice President will enhance one’s chances of a promotion);
  • The employer pays for or provides the alcohol; or
  • The employer conducts business during the holiday party.

Employers can take steps to reduce their potential liability, such as:

  • Collect car keys from all who drink. Toward the close of the party, assign designated drivers or call taxis for anyone who is too impaired to drive. If the party is in a hotel, reserve a block of rooms for the inebriated to spend the night.
  • Appoint someone in a position of authority to monitor alcohol consumption; including making certain that no alcohol is served to minors.
  • Serve a limited amount of alcohol, controlled through “drink coupons.” (i.e., two drinks per person). Close the bar once dinner begins.
  • Send a memo to all employees prior to the party stating clearly that a) employees who arrive inebriated will not be allowed in; b) employees cannot bring their own alcohol; c) excessive drinking will not be tolerated; and d) intoxication and inappropriate behavior at the party will be grounds for discipline.
  • Do not permit supervisors or managers to buy alcoholic beverages for employees.
  • Hold the party at an off-site location and use professional bartenders to serve and monitor alcohol consumption.

There are other risks employers should consider when planning and holding the annual office holiday party, such as:

Discrimination and Harassment: Lines are often blurred during an office party, so they are often crossed. Conduct that is inappropriate at work may be considered appropriate at a party, such as engaging in intimate conversations or acts, giving a racy gift or telling an off-color joke. Employers may be held liable for unlawful harassment or discrimination that takes place during a holiday party, even if it’s off-premises and off-the-clock. Consider redistribution of the sexual harassment policy, and remind employees that a holiday party is no excuse for inappropriate behavior, which will not be tolerated.

Premises Liability: Employees are often allowed to bring spouses and significant others to the office holiday party. Every ‘plus one’ accompanied by an employee is a potential slip-and-fall victim. Employers must make sure the workplace is safe before the party and keep it safe during the party.

Workers’ Compensation: Employees are typically covered by workers’ compensation if they are injured in the course and scope of their employment. Though getting hurt at a holiday party wouldn’t seem to be work-related, an employee may be covered by workers’ compensation if attendance at the party is explicitly or implicitly required (or ‘encouraged’). Tell employees the holiday party is purely a voluntary social event, and mean it.

Employers should review their insurance policies before the party to make sure they are covered in the event something happens during the holiday party. General liability, employment practices liability and workers’ compensation insurance may cover some of the risks created by the office holiday party. However, other risks may require additional insurance coverage, such as a policy that covers one-time events, including alcohol-related liability, which may be available for a small additional premium.

If you would like more information about how Setnor Byer Insurance & Risk can help protect your business during the holidays and year round, please contact us.

Employee Assistance Programs under the Affordable Care Act

Employee Assistance Programs (EAPs) are designed to help employees prevent, identify and resolve various personal issues and matters. Many employers include EAPs in their benefits packages to enhance employee effectiveness and maintain workplace productivity. In addition to providing benefits like pre-paid legal, crisis intervention or professional development services, EAPs commonly provide health-related benefits, such as mental health, substance abuse and wellness services. Does this mean that they must comply with the Affordable Care Act?

According to final regulations issued by the Departments of Labor, Treasury and Health & Human Services on October 1, 2014, the answer is…maybe.

If an EAP qualifies as an excepted benefit, it will generally be exempt from the ACA’s requirements. Otherwise, the EAP must incorporate the market reforms mandated by the ACA, such as no lifetime or annual limits. Under the final regulations, an EAP must satisfy four requirements to qualify as an excepted benefit.

  1. The EAP cannot provide significant benefits in the nature of medical care.

The amount, scope and duration of services are considered when determining whether an EAP meets this requirement. For example, an EAP that provides only limited, short-term outpatient counseling to substance abusers without requiring prior authorization or review for medical necessity, will not be considered an EAP that provides significant benefits in the nature of medical care. Alternatively, EAPs providing disease management services (lab testing, counseling, prescription drugs, etc.) for chronic conditions, such as diabetes, do provide significant benefits in the nature of medical care.

The Departments may provide additional clarification in the future regarding when a program provides significant benefits in the nature of medical care.

  1. Benefits provided by the EAP cannot be coordinated with benefits under another group health plan.

This requirement has two elements:

  • Participants in the other group health plan must not be required to use and exhaust benefits under the EAP (making the EAP a “gatekeeper”) before becoming eligible for benefits under the other group health plan.
  • Eligibility for EAP benefits must not be dependent on participation in another group health plan.
  1. Employee premiums or contributions cannot be made a condition of participation in the EAP.
  2. The EAP cannot impose any cost-sharing requirements (co-pay, etc.).

These final regulations apply to group health plans with plan years beginning on or after January 1, 2015. Until then, the Departments will consider EAP benefits meeting the conditions of the 2013 proposed regulations or these final regulations to qualify as excepted benefits.

At Setnor Byer Insurance & Risk, we are committed to guiding you through the ACA’s market reforms. Check back with us periodically for future informational updates about the Affordable Care Act.

If you have specific questions about the ACA or if you are ready to take action and would like to see how Setnor Byer Insurance & Risk can help, contact us.

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How Can Safety Reduce Workers’ Compensation Insurance Premiums?

Workers’ compensation insurance provides indemnity and medical benefits to employees injured on the job. Many states, including Florida, set the premiums for workers’ compensation insurance, so shopping around isn’t the way to save money. However, employers can reduce their workers’ compensation insurance premiums by maintaining a safe workplace

Insurance companies prefer safe workplaces because there are presumably fewer claims to pay. They encourage employers to maintain a safe workplace by using experience modification ratings to adjust premiums. Employers with fewer claims are rewarded with premium credits, and employers with more claims may face increased premiums.

The experience modification rating, or experience mod, is designed to tailor the final premium to an employer’s actual claims experience. An employer’s actual workers’ compensation claims experience, typically over a three year period, is compared to other employers operating in the same type of business with a similar number of employees.

If an employer’s claims experience is consistent with the industry average, the experience mod is 1.0, which when multiplied by the base premium, will not increase or decrease the premium. If the claims experience is 25% better than the industry average, the experience mod will be .75, which when multiplied by the base premium, will decrease the premium by 25%. Alternatively, if the claims experience is 25% worse, the experience mod will be 1.25, which will increase the premium by 25%.

The experience mod gives more weight to accident frequency than to accident severity. In other words, an employer with one loss totaling $100,000 will have a better experience mod than an employer with 10 losses totaling $100,000. Since any single injury could have astronomical costs, an employer with a higher frequency of small claims is considered a greater risk than an employer with a single, expensive claim.

Medical-only claims do impact the experience modification as much as indemnity claims, so employers are not necessarily penalized when they occur. However, the existence of open or unresolved claims can negatively impact the experience mod, so employers benefit from getting claims resolved and closed.

Insurers may offer dividend payments to employers with few or no claims. Dividends, which are generally reserved for the most attractive risks, are usually based on a sliding scale wherein the amount of the dividend decreases as the number of claims increases. Rather than focus on the most generous dividend percentage, employers should compare dividend percentages that comport with their specific claims history.

Employers can reduce their workers’ compensation insurance premiums by taking advantage of the experience modification rating system. Though it requires a commitment to workplace safety and loss control, the savings could be significant. Given the complexity, employers should work with an insurance agent who knows about the experience modification rating system and available dividend plans, and who can ensure claims are treated appropriately and resolved quickly.

If you would like more information about workers’ compensation insurance or how Setnor Byer Insurance & Risk can help control your workers’ compensation insurance costs, please contact us.