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Benefits in the News > By Subject >Health plan admin - misc |
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[Guidance Overview] Reversing ERISA Subrogation Default Rules By The Stroke Of A Pen Excerpt: "In this recent case, the Sixth Circuit views on necessary plan language are set forth, and the rules applied by the district court should be scrupulously followed by plan administrators and third party administrators in the Sixth Circuit. The case presents the typical health plan reimbursement dispute wherein the plan participant, injured in a car accident, obtains a personal injury settlement and then refuses to reimburse the health plan for related expenditures." (Health Plan Law Blog by attorney Roy F. Harmon III) Automaker Bankruptcies Would Require Taxpayers To Pay $3 Billion Annually for Health Care Excerpt: "[UAW President Ron] Gettelfinger also rejected new concessions by UAW on wages or retiree benefits as some lawmakers have demanded as a condition of emergency assistance for the auto industry." (Kaiser Daily Health Policy Report) [Guidance Overview] Which Family Members Can Have Tax-Free Health Coverage? Excerpt: "Employer-provided family health coverage is tax-free to employees only if family members meet certain rules. Congress and the IRS have recently revised these tax rules, creating uncertainty about which family members can have employer-provided health coverage exempt from federal taxes. This Update reflects IRS guidance issued earlier this year and federal tax law changes enacted in October . . . ." (Mercer) [Guidance Overview] UAW-Type VEBAs Must File New Retiree Drug Subsidy Applications Excerpt: "Faced with the prospect of employers transferring retiree medical liability to union-sponsored voluntary employees' beneficiary association (VEBA) trusts, the Centers for Medicare and Medicaid Services has issued guidance confirming that VEBAs can participate in the Part D retiree drug subsidy (RDS) program but must file their own RDS applications." (Mercer) [Guidance Overview] 2008 Year-End Plan Sponsor 'To Do' Lists (PDF) 22 pages; at pages 1-14; bravo! Excerpt: "Attached are seven 'to do' lists that may require you to take action before the end of 2008 or in early 2009. Many of the action items are a result of the Pension Protection Act of 2006 (the 'PPA'). For your convenience we have broken the 'to do' lists into the following seven categories: All Qualified Plans; Section 401(k) Plans; Defined Contribution Plans (other than Section 401(k) Plans); Defined Benefit Plans; Section 403(b) and Section 457(b) Plans; Health and Welfare Plans; [and] Executive Compensation." (Snell & Wilmer) [Guidance Overview] Fourth Circuit Splits With Sixth Circuit On Procedural Violation Remedy The Fourth Circuit opinion stated, 'The district court's reliance on the Sixth Circuit's decision in Wenner was misplaced, both because it is contrary to the law of this circuit and because that decision's rationale is flawed. In Wenner, a claimant's ERISA benefits were ordered reinstated, a substantive remedy, even though the only ERISA violation was a 29 U.S.C. ? 1133 procedural violation and the merits of the claim had not been decided." (Health Plan Law Blog by attorney Roy F. Harmon III) [Guidance Overview] Overview of Recent Municipal and State Healthcare Reforms Excerpt: "Arizona, Florida, Louisiana, Pennsylvania, and South Carolina all have passed laws requiring insurance companies to provide coverage for treatment associated with autism. In addition, California, New Jersey, New York, Michigan, Ohio, and Virginia are considering such legislation in 2009." (Wolters Kluwer Law & Business) [Guidance Overview] Benefits-Related Provisions in the Final FMLA Regulations Excerpt: "[H]ere are the benefits-related sections of the regulations: 825.209 Maintenance of employee benefits; 825.210 Employee payment of group health benefit premiums; 825.211 Maintenance of benefits under multi-employer health plans; 825.212 Employee failure to pay health plan premium payments; [and] 825.213 Employer recovery of benefit costs. . . . Also, here is what the DOL has to say in the preamble as to what, if any changes, were made to the benefits-related provisions in these final regulations:" (BenefitsBlog by Attorney B. Janell Grenier) [Guidance Overview] Thorny Issues Presented In Grants Of Discretion To Third-Party Benefit Administrators Excerpt: "Employers and TPA's should give careful thought to these case authorities in drafting claims administration agreements. At a minimum, the agreements and the plan language should be coordinated on grants of authority. Obviously, explicit grants of authority are preferred and may in some jurisdictions be required to gain deferential review of claims denials. Administrative practices should conform to the agreement terms with attention to documentation of decisions as responsibility is allocated by plan terms." (Health Plan Law Blog) Employer's Guide to Benefits for Same-Sex Spouses and Domestic Partners (PDF) 38 pages. (Lockton Benefit Group) [Guidance Overview] Final Massachusetts Minimum Creditable Coverage Regulations (PDF) Excerpt: "Although group health plan sponsors are not required to offer coverage that meets the [Minimum Creditable Coverage] requirements, plan participants and beneficiaries need to know whether their group health coverage meets these standards; or whether they should obtain other coverage in order to avoid a tax penalty. Consequently, plan sponsors that offer coverage for Massachusetts residents, whether insured, self-insured or both, should review their plans to determine whether they meet the [Minimum Creditable Coverage] standards." (Segal) [Guidance Overview] 2008 Year-End Checkup for Pension and Welfare Benefit Plans (PDF) 17 pages. Excerpt: "This Alert will help identify general year-end administrative and planning issues that could lead to compliance or employee relations problems if not addressed before, or early in, 2009. In addition, we have highlighted recent legislative or regulatory developments that may require plan design or documentation changes." (Aon) [Guidance Overview] New California Legislation Mandates Security Standards and Breach Notifications for Medical Information Excerpt: "Effective January 1, 2009, California businesses may be held liable for unauthorized access, use, or disclosure of confidential medical information. California Senate Bill No. 541 (S.B. 541) and Assembly Bill No. 211 (A.B. 211), which amend the California Civil Code and the California Health and Safety Code, were signed September 30, 2008, by Governor Arnold Schwarzenegger. The action was motivated in part by recent, notorious incidents of unauthorized access and disclosures of celebrity medical records." (Wilson Sonsini Goodrich & Rosati) [Guidance Overview] ERISA Litigation Chapter - 2007 Annual Review of Developments in Business and Corporate Litigation (PDF) 65 pages. (Jones Day) U.S. News & World Report Releases America's Best Heath Insurance Plans Rankings Excerpt: "U.S. News & World Report on Friday issued its America's Best Heath Insurance Plans rankings and published several articles related to the issue. Headlines and summaries [with links to the articles are on the Kaiser site]." (Kaiser Family Foundation) AMA Wants Physicians to Take Action for Accurate Insurer Payments This Fall Excerpt: "As part of its national campaign to save the health system billions of dollars by improving the accuracy and efficiency of medical claims processing, the American Medical Association (AMA) today announced it has selected November for the first national Heal that Claim Month. Many physician practices often experience an increase in claim denials from health insurers during the last quarter of the year, making November an ideal time to appeal inappropriately underpaid and denied claims." (American Medical Association via Physicians for a National Health Program) [Guidance Overview] Dual-Role Benefit Plan Administrator Conflicts: Proceed with Caution (PDF) 6 pages. Excerpt: "The Supreme Court's ruling in Metropolitan Life Ins. Co. v. Glenn increases the likelihood of the courts overturning certain benefits decisions. Understanding the ruling and what steps to take in its wake can help companies limit that risk." (Thompson Publishing Group via Vedder Price P.C.) S&P Shifts Outlook on U.S. Health Insurers to Negative Excerpt: "The rating agency cites several factors in lowering its outlook, including pressure on earnings, a weaker economic forecast and unfavorable results." (Workforce Management; free registration required) [Guidance Overview] Links to 2008 Q&As Submitted by Benefits Attorneys to Various Benefits-Related Federal Agencies These links are not new, but the documents are interesting and useful enough that we wanted to be sure you know about them. Especially interesting are DOL answers about claims procedures and IRS answers about section 409A. Excerpt: "Each year, the Joint Committee on Employee Benefits (JCEB) of the American Bar Association meets with officials of federal agencies in Washington, D.C., to discuss issues of interest to employee benefits practitioners. This year the JCEB met with the IRS, DOL, SEC, PBGC, EEOC, HHS and CMS. . . . The question and answer transcripts listed below are based on these informal discussions between private sector representatives of the JCEB and agency officials." (Joint Committee on Employee Benefits, American Bar Association) [Official Guidance] HHS Office of Inspector General Publishes 2009 Work Plan The OIG conducts audits relating to the Medicare program and prepares reports to Congress about administration of Medicare. Areas listed in the work plan are those that OIG considers might be subject to abuse, so providers, hospitals, health plans and others might wish to be aware of those areas when developing compliance work plans for the next year. Information OIG gleans from its evaluations also can indicate areas in which OIC might direct future criminal investigations. Increasing emphasis and scrutiny is being placed on Medicare Advantage and Medicare prescription drug programs. (Office of Inspector General, U.S. Department of Health & Human Services) [Guidance Overview] CMS Posts Group Health Plan User Guide on Its MSP Mandatory Reporting Website Excerpt: "EBIA Comment: CMS has indicated that it expects to issue revised versions of the User Guide from time to time. Consequently, it encourages ['responsible reporting entities'] to check the website often for the latest version of the guide and other important information. Note: Although the User Guide incorporates portions of other guidance on the website (e.g., information related to the small employer exception and the statutory language), these items (and other items that have not been incorporated in the User Guide) still appear on the website. Thus, while the User Guide seems to be the best place to start learning about the reporting process, RREs may need to consult other items of guidance as well." (Employee Benefits Institute of America) How Much Is Too Much? An Analysis of Health Plan Profits and Administrative Costs in California Excerpt: "This issue brief examines three main questions: To what extent are health plan administrative costs and profits responsible for the fast rise in premiums? Are California health plans' administrative costs and profits 'reasonable'? What has been the effect of medical loss ratio regulations in other states? The findings suggest that medical spending was the primary driver of recent premium increases. The research does not provide a strong case for or against medical loss ratio regulation in California, but rather raises issues and offers implementation considerations." (California HealthCare Foundation) What Employers Want from Health Insurers – Now Excerpt: "The PricewaterhouseCoopers' report from the Health Research Institute (HRI), What employers want from health insurers – now, examines the needs, wants, and satisfaction levels of employers regarding health insurance and benefits to identify and understand emerging themes from the employer's perspective." (PricewaterhouseCoopers) [Official Guidance] Additional Formats: Text of Final Regs for Group Health Plans and Health Insurance Issuers Under the Newborns' and Mothers' Health Protection Act The linked document is in HTML format, from the U.S. Government Printing Office; it includes a link to the typeset format, which appears in today's printed Federal Register. (Internal Revenue Service; Employee Benefits Security Administration; Centers for Medicare & Medicaid Services) [Guidance Overview] Onsite Health Facilities: Watch Out for Regulatory Pitfalls Excerpt: "By 2009, roughly 30 percent of large employers will have an onsite health care facility, according to research performed jointly by Watson Wyatt and the National Business Group on Health. While these employer-provided onsite facilities serve a useful purpose, many employers and vendors are unaware of the welfare benefit implications they entail." (Watson Wyatt Worldwide) [Official Guidance] Text of Final Regs for Group Health Plans and Health Insurance Issuers Under the Newborns' and Mothers' Health Protection Act (PDF) 46 pages. Excerpt: "This document contains final rules for group health plans and health insurance issuers concerning hospital lengths of stay for mothers and newborns following childbirth pursuant to the Newborns' and Mothers' Health Protection Act of 1996 and the Taxpayer Relief Act of 1997. . . . Applicability Dates: [For Group market rules:] These final regulations for the group market apply to group health plans and group health insurance issuers for plan years beginning on or after January 1, 2009. [For individual market rules:] These final regulations for the individual market apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after January 1, 2009." (Internal Revenue Service; Employee Benefits Security Administration; Centers for Medicare & Medicaid Services) [Guidance Overview] Health Plan Medicare Secondary-Payer Reporting Begins Jan. 1, 2009; Details Announced Excerpt: "Starting in 2009, employers may need to help insurers and third-party administrators report group health plan participant and dependent Social Security numbers to CMS. Employers with self-insured and self-administered group health plans must also comply." (Mercer) [Guidance Overview] End of Year Challenges for Benefit Plans As Statutory and Regulatory Mandates Impact Administration and Design of Compensation, Retirement, and Welfare Arrangements Excerpt: "Although many of the provisions and requirements discussed in this article will not apply to all employers, it is essential that those who are subject to any of those requirements take steps to adopt and implement appropriate measures to ensure their plans' compliance. However modest the requirements may be with respect to a particular plan, the failure to timely implement any required changes could create substantial liability and cost in the event that remedial action is needed at a later date." (Ogletree, Deakins, Nash, Smoak & Stewart, P.C.) [Guidance Overview] Milliman's Monthly Benefit News and Developments, October/November 2008 (PDF) 4 pages. The newsletter provides a summary of the previous month's legislative, regulatory, and judicial information on employee benefits. (Milliman) [Guidance Overview] Legislation Extends Existing Health Coverage for Dependent College Students in Cases of Medically Necessary Leaves of Absence Excerpt: "On October 9, 2008, President Bush signed Michelle's Law, which is intended to allow seriously ill college students, who are covered dependents under health plans, to continue coverage for up to one year while on medically necessary leaves of absence. . . . This law is effective for plan years beginning on or after October 9, 2009 (calendar-year plans must comply beginning January 1, 2010) and to medically necessary leaves of absence beginning during such plan years." (Employee Benefits Institute of America (EBIA)) [Guidance Overview] New Law Expands Mental Health Parity Requirements for Group Health Plans Excerpt: "The legislation amends the mental health parity provisions in ERISA, the PHSA, and the Code, eliminating the sunset provision under which existing requirements would have expired on December 31, 2008, and adding new requirements regarding mental health and substance use disorder benefits that apply for plan years beginning after October 3, 2009 (with a special rule for plans maintained pursuant to a collective bargaining agreement)." (Employee Benefits Institute of America (EBIA)) [Guidance Overview] Adoptions Act Narrows the Definition of Qualifying Child Under Code Section 152 Excerpt: "President Bush has signed into law legislation that includes a provision limiting who can be considered a 'qualifying child' under the definition of dependent in Code Section 152. (Under Code Section 152, a person is considered a dependent only if he or she is either a qualifying relative or a qualifying child.)" (Employee Benefits Institute of America (EBIA)) [Official Guidance] Text of IRS/DOL/HHS Request for Information on Sections 101 - 104 of Genetic Information Nondiscrimination Act of 2008 December 9 deadline for comments. Excerpt: "1. To what extent do group health plans and health insurance issuers currently use genetic information, such as family medical history, and for what purposes? For example, is genetic information currently used for group rating purposes, or for purposes of a wellness program that otherwise complies with HIPAA's nondiscrimination requirements? 2. How do plans and issuers currently obtain genetic information (for example, through health risk assessments, the Medical Information Bureau, or other entities under common control)? 3. Under what circumstances do plans or issuers currently request or require an individual to take a genetic test? 4. Under what circumstances do plans or issuers currently ask for the results of a genetic test in order to make a determination regarding payment of benefits? What is the minimum amount of information necessary for a plan or issuer to make a determination under such circumstances? 5. What types of research do plans or issuers currently conduct or support using genetic tests?" (Internal Revenue Service; Employee Benefits Security Administration; Centers for Medicare & Medicaid Services) [Guidance Overview] Class Action Complaint Sufficient to Meet Twombley Standards Excerpt: "Cady presents a challenge to denial of health plan benefits based upon an 'investigational' classification in a class action context. The lexicographical bent of this case showed itself ahead of the dispute over what treatments are investigational, however, as the principal defendant began with the parsing of terms descriptive of the 'plan administrator.'" (Health Plan Law blog by Attorney Roy F. Harmon III) Ruling Invites More Scrutiny of Denial of Health Benefit Claims Excerpt: "A high court's June decision made it clear that employers and insurers face conflicts of interest in administering health benefit plans because they stand to gain financially by denying a claim. The decision means employers and health insurers would be more vulnerable to lawsuits if they did not adequately address these conflicts." (Workforce Management; free registration required) Employee Benefit Plans – Why Manage Globally? Excerpt: "Multinational companies often struggle to find the time to effectively manage the plethora of insured employee benefit plans that they have around the world. This article argues for taking a more centralized approach to the management of insured employee benefits and better leveraging the network of brokers and consultants through the consolidation of providers." (Mercer LLC) Connecticut PEO Legislation Requires Licensing Excerpt: "Legislation signed into law by Connecticut Governor Jodi Rell includes a licensing program that provides employer status to the professional employer organizations (PEOs) delivering human resource management, employee benefits, payroll and workers' compensation to thousands of small business owners in Connecticut." (PLANSPONSOR.com; free registration required) [Official Guidance] Text of Golden Gate Restaurant Association Case from Ninth Circuit Upholding San Francisco Mandatory Healthcare Expenditure Law (PDF) 38 pages. Excerpt: "On April 17, 2008, we heard oral argument on the merits of the City's appeal. We now reverse the judgment of the district court and remand with instructions to enter summary judgment in favor of the City . . . . The Ordinance mandates that covered employers make 'required health care expenditures to or on behalf of' certain employees each quarter. . . . The Ordinance does not require any employer to adopt an ERISA plan or other health plan. Nor does it require any employer to provide specific benefits through an existing ERISA plan or other health plan. . . . Because the City-payment option offers San Francisco employers a realistic alternative to creating or altering ERISA plans, the Ordinance does not 'effectively mandate[] that employers structure their employee healthcare plans to provide a certain level of benefits.'" (U.S. Court of Appeals for the Ninth Circuit) [Guidance Overview] Treasury Dept. and IRS 2008-2009 Priority Guidance Plan Includes Guidance for Cafeteria and Health Plans Excerpt: "EBIA Comment: This Priority Guidance Plan covers the twelve-month period ending June 30, 2009, but we are hoping to see final cafeteria plan regulations by the end of 2008. Guidance on GINA will also be welcome as employers, administrators, and insurers begin to familiarize themselves with the requirements of this new law and to consider its impact." (Employee Benefits Institute of America) [Guidance Overview] Eleventh Circuit Eliminates 'Heightened' Standard of Review for Benefit Claim Decisions (PDF) 4 pages. Excerpt: "The Eleventh Circuit has held that the 'heightened' arbitrary and capricious standard of review previously used by the court in cases where a conflicted plan administrator decided a claim for benefits -- and its accompanying burden-shifting analysis -- does not survive the Supreme Court's recent decision in Metropolitan Life Ins. Co. v. Glenn, 128 S. Ct. 2343 (2008). Instead, where a plan grants the fiduciary discretionary authority to determine eligibility for benefits, a decision denying plan benefits should be reviewed under an arbitrary and capricious standard, with the reviewing court considering any conflict as 'a factor' in its decision." (Alston & Bird LLP) [Guidance Overview] Administrative Law Analogies After MetLife v. Glenn Excerpt: "Thus far, . . . administrative law analogies have all been focused on efficiency goals, such as, for example, the exhaustion of adminstrative remedies requirement. After Glenn, one might expect to see other applications where the concern is the integrity of the administrative record." (Health Plan Law blog by Attorney Roy F. Harmon III) 11th Circuit Backtracks on Benefits Denial Review Standard Excerpt: "Falling in line with a U.S. Supreme Court ruling earlier this year, the 11th U.S. Circuit Court of Appeals reversed its earlier decision relating to how employee benefit plan denials should be judged. The appellate court's latest holding deals with instances when the benefits denials were made when plan administrators operate under a conflict of interest and was driven by the Supreme Court's decision in Metropolitan Life Insurance Co. v. Glenn . . . ." (PLANSPONSOR.com; free registration required) Eleventh Circuit Panel Holds That Glenn Overrules Prior Precedent Excerpt: "According to the [Eleventh Circuit opinion in Doyle v. Liberty Life], 'Glenn implicitly overrules and conflicts with our precedent requiring courts to review under the heightened standard . . ' The panel substituted a new opinion for its prior opinion in the case, holding that 'heightened scrutiny' and burdenshifting requirements no longer apply. This note is cross-posted to ERISABoard.com where the opinion is attached." (Health Plan Law blog by Attorney Roy F. Harmon III) [Guidance Overview] Reminder: Deadline for Medicare Part D Creditable Coverage Notices Approaches (PDF) 2 pages. Excerpt: "Medicare Part D notices of creditable coverage must be provided to Medicare-eligible individuals prior to November 15 of each year. Many employers satisfy this requirement by including the notice in enrollment materials or in separate mailings in the fall. In preparing materials for distribution this fall, employers should be aware of revised model notices provided by the Centers for Medicare & Medicaid Services (CMS)." (Buck Consultants) [Guidance Overview] Dependent Eligibility Audits Make Good Business Sense 4 pages. Excerpt: "Employers looking for ways to control health care costs often find dependent eligibility verification or audit programs attractive. Business and compliance concerns make these programs – which attempt to weed out ineligible persons covered by an employer's health plan – a prudent risk management tool that should be seriously considered by any health care plan sponsor." (Mercer) [Guidance Overview] Medicare Secondary Payer Mandatory Reporting Requirements (PDF) 4 pages. Excerpt: "On August 1, 2008, the Centers for Medicare and Medicaid Services (CMS) published a Supporting Statement outlining the Medicare mandatory reporting data elements under the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Act). Effective January 1, 2009, these data elements must be reported to CMS on a quarterly basis. The penalty for failing to report the required data elements is $1,000 per day per person for which the data should have been submitted." (Morgan, Lewis & Bockius LLP) [Guidance Overview] TPA Breached Fiduciary Duties by Paying Itself from Health Plan Assets and Forwarding Remainder to Bankrupt Plan Sponsor Excerpt: "EBIA Comment: Most plan service providers take the position that they are not ERISA fiduciaries, arguing that their function is merely ministerial with no exercise of discretion. While authority or control over plan administration or management must be discretionary before it creates fiduciary status, discretion is not required where (as here) the service provider has authority or control over plan assets. This distinction is found in ERISA's definition of fiduciary, and several other courts have had occasion to find, as this court did, that third-party service providers with no discretionary authority over plan management or administration nevertheless were fiduciaries based on their exercise of authority or control over plan assets." (Employee Benefits Institute of America) [Guidance Overview] In Important 11th Circuit Case After the Glenn Decision, Heightened Arbitrary and Capricious Review Is Questioned Excerpt: "This recent unpublished 11th Circuit opinion presents interesting comment, post-Glenn, on the appropriate standard of review in a benefits denial case. At issue was the plan administrator's reduction of benefits under a long-term-disability plan based on a participant's receipt of Social Security disability benefits." (Attorney Roy F Harmon III in the Health Plan Law blog) [Guidance Overview] District Court Rejects 'Substantial Compliance' Argument As Justification for Failure to Exhaust Administrative Remedies Excerpt: "Failure to exhaust administrative remedies, a venerable and effective ERISA defense, will not be found in the statute. The doctrine is one borrowed from administrative law and imposed by federal courts to trim the docket of cases that might have been resolved by benefit appeals. And so, in [Brown v. J.B. Hunt Transp. Servs.], the plaintiff had a difficult hurdle to overcome when the district court determined that she had failed to appeal the denial of her benefits." (Health Plan Law blog by Attorney Roy F. Harmon III) [Guidance Overview] Failure to Furnish Enrollment Form and Other Documents Does Not Trigger ERISA Penalty Excerpt: "EBIA Comment: This case joins the numerous other reported cases and DOL advisory opinions that attempt to flesh out what documents fall into the catch-all phrase 'other instruments under which the plan is established or operated.' Administrative forms are a particularly gray area because they often contain information relating to claims determinations. Given this ambiguity, plan administrators may be well advised to disclose them to comply with their plan's claims procedures and to help avoid a costly dispute, regardless of the Sixth Circuit's clear rejection of statutory penalties for violations of the claims procedure rules." (Employee Benefits Institute of America) CMS's Summary of Proposed Mandatory Reporting Requirements Under the Medicare Secondary Payer Rule; Comments Requested Excerpt: "Effective January 1, 2009, as required by the MMSEA, an entity serving as an insurer or third party administrator for a group health plan and, in the case of a group health plan that is self-insured and self-administered, a plan administrator or fiduciary must: (1) Secure from the plan sponsor and plan participants such information as the Secretary may specify to identify situations where the group health plan is a primary plan to Medicare; and (2) report such information to the Secretary in the form and manner (including frequency) specified by the Secretary." (International Foundation of Employee Benefit Plans) [Guidance Overview] 'Metlife v. Glenn': The Court Addresses a Conflict Over Conflicts in ERISA Benefit Administration (PDF) 11 pages. Excerpt: "A case concerning disability benefits could have important ramifications for how health benefits are administered as well. . . . This paper analyzes the history of the conflict in the courts over this issue; the Supreme Court's resolution of it in MetLife; and the implications of this decision for plans, beneficiaries, and health policy." (Health Affairs) [Guidance Overview] The Supreme Court Strikes Twice (but Misses the Mark) (PDF) 4 pages. Excerpt: "In its recently completed term, the Supreme Court issued two ERISA-related opinions that address questions left unanswered by earlier Supreme Court decisions and that are of critical importance for plan administration (and litigation that may result from fiduciary missteps). . . . If the Court's intention was to entertain us with a series of interesting (but not that interesting) and thought-provoking essays . . ., then it hit the target both times. If, on the other hand, the Court's goal was to supply clear and sensible guidance in an area that is generating more (not less) litigation, its aim was not true." (Adams and Reese LLP) [Guidance Overview] TPA-Provided EOBs That Failed to Inform Former Employee of Claim Denial Did Not Comply with Claims Regulations Excerpt: "EBIA Comment: To the extent it denies payment of submitted expenses, an EOB is an 'adverse benefit determination' triggering the plan's appeal procedures and requiring a detailed notification of adverse benefit determination. When an EOB fails to contain all of the required bells and whistles under ERISA's claims procedure regulations, a claimant may be allowed to go to court without completing a plan's claims procedures." (Employee Benefits Institute of America) [Guidance Overview] Employee Benefits Update, August 2008 (PDF) 6 pages. The newsletter covers select compliance deadlines, retirement plan developments, and health and welfare plan developments. (Reinhart Boerner Van Deuren s.c.) [Guidance Overview] CMS Taking Steps to Implement New Medicare Secondary Payer Reporting Requirements Excerpt: "The Centers for Medicare and Medicaid Services (CMS) has set up a Web site to facilitate implementation of new mandatory reporting requirements relating to the Medicare Secondary Payer (MSP) rules for group health plans. The CMS Web site can be accessed at www.cms.hhs.gov/MandatoryInsRep. The new reporting requirements will be implemented on January 1, 2009, and the CMS's Web site will be a 'one-stop shop' for all relevant implementation and compliance materials." (Deloitte) [Guidance Overview] Employer's State Law Claims Against Stop Loss Carrier Dismissed Excerpt: "[Bank of Louisiana v. Aetna US Healthcare Inc., the] Fifth Circuit case on remand, highlights an area of particular interest to those of us that work with self-funded group health plans - the relationship between the employer and the stop loss carrier. In this case, the Fifth Circuit gave the employer an opportunity to pursue several state law claims against Aetna, the stop loss carrier, but these claims failed to reach the conduct that was the gravamen of the employer's complaint." (Health Plan Law blog by Attorney Roy F. Harmon III) [Opinion] On Estoppel and Equitable Remedies Under ERISA: It Should Be a Two-Way Street Excerpt: "I've complained at times in the past that too many federal Circuit and District courts view ERISA's equitable remedies as a one way street. Plan fiduciaries chasing subrogation or overpayment claims have free rein to recover money from plan participants under the guise of 'appropriate equitable relief.' Yet those some courts often deny the participants any monetary recovery for violations of ERISA because recovery of money supposedly falls outside the scope of 'appropriate equitable relief.'" (Brian S. King's ERISA Law Blog) [Guidance Overview] CMS Publishes Summary of Proposed Mandatory Insurer Reporting Requirements Excerpt: "The MMSEA . . . created new Medicare Secondary Payer (MSP) data–reporting requirements. Starting January 1, 2009, the new MSP data–reporting requirements will require insurers, TPAs and a plan administrator or fiduciary of a self–insured/self–administered group health plan to: [i] Collect from the plan sponsor and plan participants information to identify situations where the group health plan is primary to Medicare, and [ii] Submit such information to the Department of Health and Human Services (HHS) in a form and manner specified by HHS." (Sibson) [Guidance Overview] New Hampshire Mandates Obesity Coverage and Bariatric Surgery Excerpt: "New Hampshire health insurers and HMOs must soon cover medically necessary treatments and services related to morbid obesity, including bariatric surgery, if the insured is age 18 or older and meets [certain] standards . . . . Other related services to be covered include pre-operative psychological screening and counseling, behavior modification, weight loss and exercise regimens, and post-operative follow-up." (Mercer) |
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