Regulating Managed Care: Theory, Practice, and Future Options

By Stuart H. Altman; Uwe E. Reinhardt et al. | Go to book overview

Chapter Ten
ERISA and the Regulation
of Group Health Plans
Craig Copeland and William L. Pierron

About 73 percent of nonelderly Americans with private health insurance are covered by plans under the aegis of the Employee Retirement Income Security Act of 1974 (ERISA). Still, much confusion and misconception surround the act. Because of ERISA's tremendous impact on Americans' health insurance coverage, policymakers and other concerned individuals need to understand how ERISA regulates group health plans. 1


Why ERISA Was Enacted

The regulation of private-sector employee benefit plans became primarily the responsibility of the federal government with the passage of ERISA. Specifically, ERISA sets forth standards on reporting and information disclosure, claims and appeals procedures, remedies for wrongfully denied benefits, and fiduciary standards: the “backbone” of the act.

Prior to its enactment, employee benefit plans were regulated mainly by the states while receiving preferential tax treatment at the federal level. However, state oversight of employee benefits varied considerably, and because of the lack of consistent legal protections that state regulations afforded pension plans, retirees in some well-publicized cases received fewer benefits than anticipated. 2 Such incidents raised congressional concerns about the solvency and security of employment-based pension plans, which was

-189-

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Regulating Managed Care: Theory, Practice, and Future Options
Table of contents

Table of contents

  • Title Page *
  • Contents vii
  • Foreword ix
  • Acknowledgments xiii
  • The Editors xv
  • The Contributors xvii
  • Introduction - The Philosophy of Regulation xxi
  • Notes xxxii
  • Regulating Managed Care xxxiv
  • Section I - The Role of Regulation in a Market-Oriented Health Care System 1
  • Chapter One - An Overview 5
  • Notes 27
  • Chapter Two - The Current Status of State and Federal Regulation 29
  • References 51
  • Chapter Three - Why Should Managed Care Be Regulated? 53
  • Chapter Four - Macro-Versus Microregulation 75
  • Reference 85
  • Section II - Regulatory Issues 87
  • Chapter Five - Consumer Choice Under “private Health Care Regulation” 91
  • Notes 114
  • Chapter Six - A Model for Health Care Consumers 117
  • Notes 133
  • Reference 133
  • Chapter Seven - Ensuring Equal Access to Care 135
  • Notes 143
  • Chapter Eight - Regulating Quality and Clinical Practice 145
  • Chapter Nine - The Scope of Managed Care Liability 160
  • Notes 185
  • Reference 186
  • Chapter Ten - Erisa and the Regulation of Group Health Plans 189
  • Notes 200
  • References 203
  • Section III - Perspectives on Regulation 205
  • Chapter Eleven - Understanding the Managed Care Backlash 209
  • Notes 224
  • Chapter Twelve - Core Principles for Regulating Health Care Quality 229
  • Notes 237
  • Chapter Thirteen - Balancing Market Forces and Regulation 239
  • Notes 262
  • Chapter Fourteen - Regulation from a Consumer's Perspective 263
  • Notes 274
  • Chapter Fifteen - Regulation from an Insurance Industry Perspective 276
  • Notes 281
  • Chapter Sixteen - Regulation Misses the Big Issue—the Uninsured 282
  • Notes 297
  • Section IV - Managed Care Regulation in Practice 299
  • Chapter Seventeen - A Practical Approach 301
  • Chapter Eighteen - California's Struggle with Regulation 312
  • Notes 329
  • Chapter Nineteen - How the Estimates Vary 331
  • Notes 343
  • Index 345
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