Chapter 2 — Further Reading

Tier 1 — Verified canonical sources

Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq., and the Department of Labor's employee benefits guidance. The statutory basis for §2.5. The DOL's claims procedure regulation (29 C.F.R. § 2560.503-1) sets the timelines and content requirements for benefit determinations and appeals under ERISA plans, and it is the document to cite when a self-funded plan is slow. Chapter 30 §30.5 returns to it.

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 — created the health savings account and the statutory definition of a high-deductible health plan. The subject of Case Study 1.

Internal Revenue Service annual guidance on HSA and HDHP limits. The minimum deductible, maximum out-of-pocket, and contribution limits are indexed and published annually by the IRS in a revenue procedure. Look up the current year. Any figure you find in a book, including this one, is stale.

Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and the associated OIG guidance on waiver of cost-sharing amounts. The basis for the ⚖️ Compliance Check in §2.3. The OIG's Special Fraud Alerts and Advisory Opinions on routine waiver of copayments and deductibles are the clearest available statement of the line between a documented individual hardship determination and a routine waiver.

Centers for Medicare & Medicaid Services, coordination of benefits guidance, and the Medicare Secondary Payer provisions at 42 U.S.C. § 1395y(b). Chapter 3 §3.8 develops these; for Chapter 2, the point is that COB order is set by law and not by preference.

National Association of Insurance Commissioners (NAIC) Coordination of Benefits Model Regulation. The source of the birthday rule and the rest of the COB ordering rules, adopted in some form by most states. If you want to read the actual rule rather than a summary of it, this is the document.

No Surprises Act — Consolidated Appropriations Act, 2021, Division BB, Title I. Relevant here for the out-of-network protections described in §2.3. See Chapter 1, Case Study 2, and Chapter 32 §32.4.

TRICARE, tricare.mil, and the TRICARE Manuals published by the Defense Health Agency. The authoritative source for plan options, authorization rules, and allowable charges. Do not reason about TRICARE from Medicare knowledge.

Tier 2 — Attributed, specifics unverified

Kaiser Family Foundation Employer Health Benefits Survey, published annually. The standard reference for enrollment in high-deductible plans, average deductible amounts, premium contributions, and plan-type distribution. Methodology is published; figures change every year. This is the single best free source for the population-level context behind Case Study 1 — and the one place to get current numbers rather than the qualitative descriptions this chapter used deliberately.

Peterson-KFF Health System Tracker. Analysis of cost sharing, medical debt, surprise billing, and price variation. Useful for §2.10's claim that allowed amounts for the same service vary widely between providers in the same market — that variation is documented, and the tracker is where to see it.

State department of insurance publications and consumer guides. Nearly every state publishes plain- language explanations of plan types, network adequacy requirements, prompt-payment rules, and external review rights. Find your state's. It is the fastest way to learn which rules in this chapter are modified where you work — and, critically, which of them do not apply to self-funded plans at all.

State workers' compensation agency fee schedules and provider manuals. §2.9 said workers' compensation varies enormously by state and did not attempt to summarize it. Your state's agency publishes the fee schedule, the required forms, the filing deadlines, and the rules about which provider an injured worker may see. If your practice sees work injuries, this is not optional reading.

Healthcare Financial Management Association (HFMA) materials on contract management and payment model design. The practical literature on §2.6 lives here, along with the standard definitions of the metrics a capitated organization needs.

Managed care history literature. The 1990s capitation expansion and its failures are extensively documented in the health services research literature and in contemporaneous business reporting. Case Study 2's failure modes are drawn from that record; the specific practice is constructed.

Tier 3 — Illustrative and constructed

Figure 2.1, the Northfield Mutual eligibility response — constructed, including the member identifier, the group number, and every accumulator.

The Northfield Mutual fee schedule used in §2.7 and the Encounter: 99214 at \$128.40, 20610 at \$78.60, J1030 at \$6.28, 36415 at \$3.00. Constructed.

Every allowed amount, contract percentage, capitation rate, and Medicare figure in this chapter — constructed for teaching, including the \$96.50 illustrative Medicare allowed amount in §2.6 and the \$29.50 PMPM in §2.6 and Case Study 2.

The twelve-physician group in Case Study 2 — a composite built from documented industry patterns, labeled as such in the case study itself.

If you read only three things after this chapter

1. Your own practice's contract with its largest payer, specifically the reimbursement exhibit, the timely filing clause, and the appeal deadline. Nothing in this chapter is real until you have read one.
2. The current-year KFF Employer Health Benefits Survey summary of findings. Twenty minutes, free, and it will replace every qualitative statement in Case Study 1 with a current number.
3. Your state department of insurance's consumer guide to plan types — and then check which of its protections apply to self-funded plans. The gap is §2.5's whole point, and seeing it in your own state's document makes it permanent.