BenefitsLink logo
EmployeeBenefitsJobs logo
  
  

Search the News


Featured Jobs
Retirement Plan Administrator
ESOP / Employee Benefits Leader
Distribution Associate - Retirement Plans
New Business Facilitator
Plan / Document Administrator
Search all jobs
 
Get the BenefitsLink app for iPhone and iPad LinkedIn
Twitter
Facebook

Benefits in the News > By Subject >

Health plans - design


View Recent Headlines Now Viewing Excerpts and
Recent Headlines

Self-Insured Health Plans: Recent Trends by Firm Size, 1996-2015 (PDF)
"The percentage of private-sector establishments offering health plans at least one of which is self-insured has increased from 28.5 percent in 1996 to 39 percent in 2015 (a 36.8 percent increase). Between 2013 and 2015, the percentages of establishments offering health plans with at least one self-insured plan has increased for midsized establishments from 25.3 percent to 30.1 percent (a 19 percent increase) ... Similarly, the percentage of health-plan-covered workers enrolled in self-insured health plans has increased from 58.2 percent to 60 percent (a 3 percent increase) from 2013 to 2015." (Employee Benefit Research Institute [EBRI])
Innovations for Controlling Self-Funded Plan Costs
"As employers gain a better understanding of the questionable value of PPO discounts and pricing optics, reference-based pricing and reference-based reimbursement provide possible solutions by addressing the demand for: [1] Price transparency; [2] Claims cost benchmarking; [3] Elimination of inappropriate charges; [4] A plan sponsor fiduciary/co-fiduciary." (Corporate Synergies)
What's Bad for Health Insurers May Be Good for Consumers
"Employees of large companies may have the most to gain from the blocked mergers, explained Gary Claxton, vice president of Kaiser Family Foundation. There are a lot of regional and small insurers that offer employer-sponsored insurance but only the big insurers have large national networks the likes of which giant corporations usually hire. The mergers would mean these employers would have even fewer choices and that would likely translate into fewer plan choices for employees." (CBS MoneyWatch)
HHS Mental Health and Substance Use Disorder Parity Task Force Wants to Hear Your Experiences
"The Task Force wants to hear from patients, families, consumer advocates, health care providers, insurers, and other stakeholders on their experience with mental health and substance use disorder parity requirements.... [including] [1] Suggestions on how to improve understanding of parity among key stakeholders such as consumers, families, health care providers, and insurers. [2] What are some examples of the types of information you commonly see health plans and insurance issuers share with enrollees or providers when coverage for a mental health or substance use disorder benefit is denied? [3] When health plans provide parity compliance-related information, how easy or hard is it for consumers and providers to understand? Do consumers and providers know how to act on this information?" (U.S. Department of Health and Human Services [HHS])
[Opinion] Orszag and Emanuel Do Not Seem to Understand Bundled Payments
"The clinical course of a heart attack is highly variable and could involve only a few or a great many interventions. Under a bundled payment, the physicians and hospital are bearing the risk of the high costs of a potentially complicated, protracted course. Isn't it the role of the insurer, in this case Medicare, to pool risk? Shifting that risk to the health care delivery system creates the potential for either a reduction in important beneficial health care services, or exposing the delivery system to potential monetary losses and the risk of insolvency -- neither of which are desirable." (Physicians for a National Health Program [PNHP])
Health Insurance Coverage in California in 2013 and 2014, After Implementation of the ACA (PDF)
"From 2013 to 2014, health insurance coverage expanded among individuals under age 65 in California, and the uninsured rate fell.... The 2013-2014 reductions in the uninsured rate were primarily due to expanded individual health insurance and Medicaid coverage, as there was very little increase in employment-based coverage.... [W]orkers in small firms had the highest uninsured rate in 2013, but workers in firms with more than 50 employees (particularly those in the 50-99 employee group) experienced the greatest reductions in uninsured rates." (Employee Benefit Research Institute [EBRI])
CMS Proposes Mandatory Cardiac Bundled-Payment Pilot
"A new mandatory program [proposed by CMS] would make hospitals in 98 markets financially accountable for the cost and quality of all care associated with bypass surgery and heart attacks.... n 2014, hospitalizations for heart attacks for more than 200,000 beneficiaries cost Medicare over $6 billion ... Yet for every treatment, the cost could vary by as much as 50%, the agency said.... The CMS also plans to expand its first and mandatory bundled-payment model -- which took effect in January and covers total hip and knee replacements -- to include surgeries repairing hip and femur fractures." (Modern Healthcare Online; free registration required)
[Guidance Overview] Mental Health Parity and Addiction Equity Act Enforcement Is a Priority for Federal Agencies
"The federal government is stepping up its enforcement of the MHPAEA.... The MHPAEA regulations require plan sponsors to follow a complex evidence-based process to support the application of certain medical-management tools to MH/SUD care. Evidence and documentation supporting the application of these tools must be provided to participants and their health care providers." (Segal Consulting)
[Guidance Overview] Final ACA Nondiscrimination Rules Under Section 1557 Now Effective
"For many employer-sponsored plans, Section 1557 will be triggered by receipt of a Medicare Part D subsidy, the HHS subsidy provided to plans covering Medicare-equivalent prescription drug coverage. Because the final rules apply to 'an entity that operates a health program', it is unclear whether the rules allow disaggregation of health plans offered by an employer." (Seyfarth Shaw LLP)
ACA Health Plan Subsidies to Become Easier to Get for 2017
"Additional verification of eligibility will only be required if the difference between stated income and [IRS] or Social Security data is at least 25 percent, or $6,000 ... Currently, additional verification is required if the discrepancy is only 10 percent or greater.... The new data-matching standards 'will allow more consumers to get their household income immediately verified by the Marketplace when they submit an application,' the CMS said." (Bloomberg BNA)
Exploring Single-Payer Alternatives for Health Care Reform
"Single-payer proposals are wide-ranging reform efforts spanning financing and delivery, but vary in the provisions. [The author] modeled two sets of national scenarios -- one labeled comprehensive and the other catastrophic -- and compared insurance coverage and spending relative to the ACA in 2017.... [T]he comprehensive scenario increased national health care expenditures by $435 billion and federal expenditures by $1 trillion relative to the ACA." (RAND Corporation)
What to Consider Before Launching a Provider-Sponsored Health Plan
"Today's New Health Economy demands that providers shoulder greater risk. In response, health systems and physician groups contemplate taking full control of the healthcare dollar by launching their own health plans.... Measure your investment needs.... Take stock of the environment.... Define your purpose, and then execute on it.... Tout your unique advantage -- trusted brand, niche offerings and community presence.... Deepen relationships with other insurers." (PricewaterhouseCoopers)
[Guidance Overview] Nondiscrimination Rule Expands Administrative Practices, Notice/Language Requirements and Coverage for Certain Plans
"Employers and plan sponsors should determine whether they are subject to the regulation. If so, many requirements are already effective. However, they have until October 16, 2016 ... to comply with the notice requirements and until the first plan year beginning on or after January 1, 2017 to make coverage changes to health insurance or group health plan benefit design." (Cheiron)
[Guidance Overview] Opt-Out Payment Arrangements and Employer Impact
"The proposed regulations clarify that if an individual declines to enroll in employer-sponsored coverage for a plan year and does not have the opportunity to enroll in coverage for one or more succeeding plan years, the individual is treated as ineligible for those succeeding years. Subsequently, this ineligibility for the plan could render that employee eligible for premium tax credits. Said another way, if employees are not given an opportunity to enroll at least annually, they are not considered eligible for the plan which could cause ALEs to be liable for Section 4980H penalties." (Compliance Dashboard)
Competing Wellness Rules Pose Compliance Challenges
"New workplace wellness regulations that address participation incentive limits under disability and genetic anti-discrimination laws are inconsistent with overlapping federal laws, so employers must scrutinize their programs closely to ensure compliance." (Bloomberg BNA)
1.5M Workers Gained Employer-Sponsored Healthcare Coverage in 2015
"[T]he number of consumers enrolled in employer-sponsored healthcare coverage rose from 55.8 million in 2014 to 57.3 million in 2015. In fact, at large firms, the number of employees covered under employer-sponsored insurance rose by 1.6 million people. However ... at smaller companies with less than 50 employees, the enrollment rate in this type of coverage was reduced from 28.3 percent to 27.1 percent between 2014 and 2015." (HealthPayer Intelligence)
[Guidance Overview] IRS Proposes Additional Regs Clarifying Handling of 'Opt-Out' or 'Cash-In-Lieu' Programs Under ACA
"You must now not only verify that the person has other coverage; but you must verify that it is group (not just individual) coverage. That is not necessarily easy to do. Often times insurers will still assign a 'group' number to an individual card so as to align the insured's internal records with other records the insurer keeps. This effectively turns your HR staff into the 'cash in lieu police' while angering employees who don't understand why they are not getting an award for an individual plan[.]" (Benefit Revolution)
Fight or Run Is Choice for Health Insurers After DOJ Suit
"Within minutes of the Justice Department filing its case in federal court, Aetna Inc. and Humana Inc. issued a joint statement, promising they'd fight in lockstep and 'vigorously defend the companies' pending merger.' ... Cigna Corp. seemed to use a related lawsuit also filed Thursday as a potential escape from Anthem Inc.'s $48 billion takeover of the company.... Anthem declined to comment on Cigna's comments Thursday, other than to say it was ready to challenge the department. If the deal falls apart under antitrust scrutiny, Cigna is owed a breakup fee of $1.85 billion, according to the companies' agreement." (Bloomberg)
Federal Judge Finds ACA Contraception Mandate Violates RFRA
"U.S. District Judge Jean C. Hamilton said Thursday that HHS may not compel Republican state lawmaker Paul Joseph Wieland, his wife Teresa Jane Wieland or their insurer to include contraception coverage in their health plan.... [T]he government had argued that requiring the Wielands to subscribe to a group health plan that covers services, such as contraception, that the family won't use because of religious reasons, isn't a substantial burden on the family. The court, however, disagreed." [Wieland v. HHS, No. 13-1577 (E.D. Mo. July 21, 2016)] (Modern Healthcare Online; free registration required)
[Guidance Overview] Proposed Regs Provide Permanent Relief for Expatriate Health Plans (PDF)
"Under ACA regulations, hours of service worked outside of the 50 U.S. states and the District of Columbia (i.e., where compensation for services constitutes income from sources outside of the U.S.) are not counted, regardless of the individual's residency or citizenship. This means that these employees likely will not have the requisite hours of service to be considered full-time employees and, therefore, would not have to be taken into account in determining whether an employer has offered coverage to substantially all of its full-time employees or in determining the amount of any assessment." (Xerox HR Services)
[Guidance Overview] Agencies Request Input on Potential Contraceptive Coverage Compromises
"The RFI requests a response from entities that object to the current accommodation; it also asks other stakeholders who are not parties to the litigation, such as insurers, third-party administrators, and women who need contraceptives, how possible accommodations would affect them." (Health Affairs)
[Opinion] Medicare Is Not 'Bankrupt'
"Although Medicare faces financing challenges, the program is not on the verge of bankruptcy or ceasing to operate. Such charges represent misunderstanding (or misrepresentation) of Medicare's finances.... Health reform, along with other factors, has significantly improved Medicare's financial outlook, boosting revenues and making the program more efficient." (Center on Budget and Policy Priorities)
[Opinion] Jonathan Gruber: What We Didn't See Coming with the ACA
"More people are in Medicaid than anticipated; fewer bought health plans through the exchanges. The reasons why this has happened ... include some surprises, even for those of us who have tracked the law closely and rooted for its success.... CBO projected more than 20 million people would be enrolled in these new online markets by this year. In fact, only about half that many are covered. One big reason is yet another ACA surprise, and a fortunate one: The employer insurance market is much more stable than expected." (Jonathan Gruber, in Politico)
Humana to Significantly Reduce Marketplace Offerings in 2017
"Humana will stop marketing Obamacare exchange plans in several states next year and will exit many off-exchange individual markets as well ... The decision means the company will only offer individual plans in 156 counties in 11 states, down from 1,351 counties across 19 states this year. It had sold plans on [ACA] exchanges in 15 states this year." (Politico)
Justice Department and State Attorneys General Sue to Block Anthem's Acquisition of Cigna, Aetna's Acquisition of Humana
"The U.S. Department of Justice and attorneys general from multiple states and the District of Columbia sued today to block Anthem's proposed acquisition of Cigna and Aetna's proposed acquisition of Humana, alleging that the transactions would increase concentration and harm competition across the country, reducing from five to three the number of large, national health insurers in the nation.... The complaints allege that the two mergers -- valued at $54 billion and $37 billion -- would harm seniors, working families and individuals, employers and doctors and other healthcare providers by limiting price competition, reducing benefits, decreasing incentives to provide innovative wellness programs and lowering the quality of care." (Office of the Solicitor, U.S. Department of Labor)
[Official Guidance] Text of Agency Request for Information: Coverage for Contraceptive Services
19 pages. "This document is a request for information on whether there are alternative ways (other than those offered in current regulations) for eligible organizations that object to providing coverage for contraceptive services on religious grounds to obtain an accommodation, while still ensuring that women enrolled in the organizations' health plans have access to seamless coverage of the full range of Food and Drug Administration-approved contraceptives without cost sharing. This information is being solicited in light of the Supreme Court's opinion in Zubik v. Burwell ... [HHS, DOL] and the Treasury invite public comments via this request for information." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]; U.S. Department of Health and Human Services [HHS]; and Internal Revenue Service [IRS])
[Guidance Overview] Nondiscrimination and Chronic Conditions: The Final Section 1557 Regulation
"The broad disability definition is a positive development for those with serious or chronic conditions, because Section 1557 provides robust enforcement mechanisms, including a private cause of action. In other words, persons with conditions that qualify as a 'disability,' or other protected classes, can challenge discriminatory insurance practices in court." (Health Affairs)
Telemedicine Arrangements: Beware of Inadvertently Dialing Up an Excise Tax
"The preventive services mandate is particularly problematic for telemedicine plans.... if a plan doesn't have an in-network provider that can provide such services, then the plan can't impose any cost sharing for the services to be performed out-of-network. It is difficult to see how any telemedicine arrangement can comply with this mandate on its own.... The fact that the employer is offering to its employees some other fully compliant major medical plan doesn't, in and of itself, negate the telemedicine plan's obligation to meet all the ACA's market reform requirements." (Bloomberg BNA)
Employee Satisfaction with Health and Well-Being Programs Is High, But More Personalization Is Needed
"Most participants (81%) saw a positive impact on their physical well-being and more than 60% agreed or strongly agreed that including family in such programs would likely increase their participation. For those that did not participate, 37% did not find them personally relevant and 20% didn't know they were available, a strong indication that greater personalization and awareness is needed to drive employee engagement." (National Business Group on Health [NBGH])
What's a 'Limited Purpose' FSA?
"A general purpose FSA allows account holders to pay for a long list of IRS-approved expenses, including prescription medications, copays, most dental treatments, and other medical related needs. If a person has an HSA, they are not eligible to also have a general purpose FSA. An LPFSA allows account holders to receive reimbursement for eligible dental and vision expenses. A person with a high deductible health plan with an HSA is eligible for an LPFSA." (DataPath)
Justice Department Will Seek to Block Two Health Insurance Mergers
"Antitrust officials are concerned that Aetna's $37 billion deal with Humana, and Anthem's $48 billion pursuit of Cigna, will harm competition in the health insurance industry ... The deals would have decreased the number of the largest insurers to three, from five.... If the lack of regulatory approval scuttles their deal, Anthem will need to pay a $1.85 billion breakup fee to Cigna, according to the merger agreement. Aetna will be required to give $1 billion to Humana under those same circumstances[.]" (The New York Times; subscription may be required)
Eight Ways Plan Sponsors Can Fight the Opioid Epidemic
"[1] Use data analytics to identify and manage fraudulent drug use. [2] Require prior authorization for opioid prescriptions of more than 15 days for all outpatient pain management prescriptions. [3] Monitor hospital discharges and conduct patient oversight to look for prior drug-abuse events (e.g., overdoses or substance abuse treatment).... [4] Develop plan strategies to cover abuse-deterrent opioids ... [5] Work with the pharmacy benefits manager to establish a fraud tip hotline. [6] Offer alternative treatment for pain management. [7] Train and educate prescribing physicians. [8] Communicate and educate participants about the addiction aspects of opioids." (International Foundation of Employee Benefit Plans [IFEBP])
UnitedHealth's Profit Surges But ACA Sales Drag
"UnitedHealth's second-quarter earnings jumped 11 percent to trump expectations even though the nation's largest health insurer took a bigger hit than expected from coverage linked to the [ACA]. The Minnetonka, Minnesota, company said Tuesday that losses from its ACA-compliant individual business came in $200 million above projections, which means the company now expects to lose around $850 million this year from what is essentially a small slice of its total operation." (ABC News)
[Guidance Overview] Final Nondiscrimination Rules in Health Programs and Activities (PDF)
"If you are not a direct covered entity and your medical plan is fully insured, you may be indirectly subject to these rules because of your health insurance carrier. Many carriers sponsor health plan coverage in the Marketplace. If you are unsure whether your insurance carrier receives some form of federal financial assistance, ask.... If you are not a direct covered entity and your medical plan is self-funded, you may be tangentially subject to these rules because of your third-party administrator (TPA).... Action steps will differ depending on the type of entity." (Marsh & McLennan Agency LLC)
[Guidance Overview] Treatment of Opt-Out Bonuses When Determining Affordability (PDF)
"If your organization maintains a non-conditional opt-out bonus, it must be included in affordability testing for your first plan year beginning on or after January 1, 2017.... Eligible opt-out arrangements need to meet specific requirements (beyond a general conditional opt-out) in order for the opt-out amount to be excluded.... The amount of the opt-out bonus can be excluded from the affordability calculation as long as reasonable evidence is provided for the entire plan year, even if the alternative coverage terminates at some point during the year." (Marsh & McLennan Agency LLC)
Consumer-Driven Plan Enrollment Still Elusive in the Middle Market
"High-deductible plan enrollment continues to grow across the country, but the enrollment is coming from the small group and exchange arena where most other traditional products have all but evaporated.... The middle-market employer is slow to embrace these plans because an overwhelming majority of human resources professionals and employees simply do not like them. While they are an 'efficient' mechanism to procure care, users find them a challenge to understand and they can often lead to substantial out-of-pocket expenses for higher users of care." (Frenkel Benefits)
[Opinion] ERIC Expands Efforts to Increase Access to Telehealth
"ERIC urged both Delaware and Maine to consider the benefits of telehealth and adopt flexible rules that permit the practice of telemedicine without burdensome restrictions, while maintaining a high standard of care.... ERIC agreed with the Delaware Board of Clinical Social Work Examiners that the standards governing in-person visits, that ensure patient safety and a high-standard of care, should also apply, in the same manner, to telehealth visits." (The ERISA Industry Committee [ERIC])
Are Federal Pay and Benefits Too Generous?
"[Personnel reforms proposed by The Heritage Foundation] included: [1] Requiring new federal hires and employees with between five and 25 years of service to pay more for their retirement benefits by decreasing the government contribution.... [2] Requiring federal workers to shoulder more of their health care costs under the Federal Employees Health Benefits Program [FEHBP].... [3] Eliminating the FEHBP government contribution for retiree health benefits for new hires.... Federal employee unions took issue with the proposals." (Government Executive)
Recommendations from House Republicans Would Affect Employee Benefits
"The proposals would repeal the ACA, cap the employee tax exclusion for employer health benefits, reject the fiduciary advice rule and more. The task force proposed significant reforms to Medicare, including a voucher program that would begin in 2024. Tax exclusions for dependent care assistance, qualified transportation benefits, adoption assistance and other benefits would be eliminated.... While few of the recommendations are expected to see legislative action this year, significant changes for health, retirement and other employee benefits could be on the table in 2017." (Willis Towers Watson)
[Guidance Overview] IRS Proposed Rules on ACA and 2014 Expat Law Address Some But Not All Mysteries
"In order to be considered minimum essential coverage (MEC) ... individual coverage must either be obtained through a state exchange or must receive specific approval from HHS. Coverage provided directly by a foreign government and foreign individual insured coverage must also receive specific HHS approval.... To qualify under EHCAA, the expat plan must have an actuarial value of at least 60 percent (often referred to as minimum value under the ACA).... EHCAA allows the IRS tax forms (1095-B or 1095-C) to be supplied electronically to the enrollee (expat) without consent, unless the enrollee explicitly refuses electronic delivery." (Lockton)
[Guidance Overview] Final Wellness Program Regs Clarify Compliance Requirements (PDF)
42 presentation slides. Topics include: [1] Step-by-step review of the main compliance requirements for wellness programs following the recent final ADA and GINA regulations; [2] Prior HIPAA/ACA requirements that remain unchanged by the ADA/GINA rules; [3] How the structure of the wellness program (e.g., participatory vs. health-contingent) dramatically affects the rules that apply. (ABD Insurance & Financial Services)
Seven Remaining Obamacare CO-OPs Prepare Survival Strategies
"There were 23 in 2014.... Eleven are still in business, but four in Oregon, Ohio, Connecticut and Illinois will disappear by fall due to financial insolvency.... For the rest -- which all posted annual losses in 2015 ... survival is job No. 1. Some are diversifying to serve larger employers, no longer limiting themselves to their ACA mandate to offer health plans to individuals and small businesses. A Maryland CO-OP has sued the federal government to avoid paying millions of dollars to other insurers under the ACA's complex formula to keep premiums stable by balancing risks among insurers and helping ailing ones. Other CO-OPs are trying to renegotiate contracts with hospitals and other providers." (Kaiser Health News)
Another Health Insurance CO-OP Bites the Dust
"Illinois moved Tuesday to take control of Land of Lincoln Health to begin an orderly shutdown of the insurance company, meaning about 49,000 people will lose their health coverage in the coming months.... The Department of Insurance said the decision was based on the startup company's deteriorating financial condition. Land of Lincoln is required to pay $31.8 million to other insurers under a complex formula in the [ACA], which aims to keep premiums stable by balancing risks among insurers." (InsuranceNewsNet.com)
Opportunity Knocking: Education of Human Resources Professionals about Benefits of Private Exchanges
"Forty-four percent of employers would switch to an exchange if it could help control their benefits costs without compromising the quality of plans they offer to employees, according to a new Liazon survey.... When asked to rate their level of familiarity with the private exchange model, nearly half (45 percent) of respondents were not very familiar or not familiar with it at all. Another 36 percent were only somewhat familiar with the exchange model." (Liazon)
Now on Starbucks' Menu: Less Health Coverage
"Starbucks announced [July 11] that it will give its U.S. workers a raise that will boost compensation by 5% to 15%.... The coffee giant also said it will offer employees more affordable health insurance that will cut costs by being less comprehensive.... Champions of free markets will argue that Starbucks is simply giving workers more choices, and that's true. Why should younger, healthier people pay higher premiums for more extensive health coverage?" (Los Angeles Times)
CMS Data Brief: 2016 Median Marketplace Deductible, Seven Health Services Covered Before the Deductible
"The median individual deductible for HealthCare.gov Marketplace policies in 2016 is $850, down from $900 in 2015. Importantly, these figures account for the fact that many consumers qualify for financial assistance that lowers their deductibles based on their income.... On average, Healthcare.gov Marketplace policies cover seven common health care services (most often generic drugs and primary care visits), in addition to preventive services, with no or low cost-sharing before consumers meet their deductibles." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
The Use and Impact of Health Care Price Transparency: Where Are We, and Where Do We Go from Here? (PDF)
"[1] Consumer demand for and availability of price information is growing, but many consumers do not use price comparison tools when they are available, and use of transparency tools did not significantly reduce consumer health spending or total health expenditures. [2] Although previous research has suggested that clinicians reduce their ordering rates when they are given information on prices, the current RWJF studies found no overall change in ordering rates when pricing information was displayed on physicians' ordering screens at the point of care. [3] The consolidation of health care markets appears to have significant effects on health prices, and market power is associated with higher prices." (Robert Wood Johnson Foundation)
[Guidance Overview] IRS Releases Proposed Regs Regarding ACA Calculation of Coverage Affordability for Employers Offering Opt-Out Payments
"The most notable employer impact created by these proposed regulations is a new requirement that an employer who offers cash-in-lieu must maintain an 'eligible opt-out arrangement' to avoid increasing an employee's premium contribution by the cash amount when it calculates affordability for the employer mandate. The requirements for an 'eligible opt-out arrangement' are more stringent than the conditional opt-out arrangement contemplated by IRS Notice 2015-87." (Liebert Cassidy Whitmore)
Cigna Ordered to Pay More Than $13 Million in Out-of-Network Healthcare Provider Billing Dispute
"The court's decision relied primarily on two findings. First, the court determined that Cigna improperly applied the 'exclusionary language' contained in the plans it administered. Second, the court determined that Cigna failed to establish that the relevant language in the plan documents created a constructive trust or equitable lien." [Connecticut General Life Ins. Co. v. Humble Surgical Hospital, No. 4:13-cv-3291 (S.D. Tex. June 1, 2016)] (Baker Botts LLP)
[Guidance Overview] Navigating the Wellness Program Maze
"[T]he first step in reviewing your wellness program is to identify the laws and the provisions of the laws that apply.... [An accompanying Wellness Program Review Chart] provides a description of basic wellness program characteristics and identifies applicable laws and includes consideration of the application of the Internal Revenue Code for taxation of rewards.... The next step is to identify the most restrictive limitation of the applicable laws." (Calfee, Halter & Griswold LLP)
Risk Adjustment and CO-OP Financial Status
"While many carriers have lost money in the ACA marketplace, most are able to draw from profitable lines of business to cover losses. The co-ops lack such options, and primarily respond by resorting to federal credit in the form of surplus notes. Yet, the supply of this credit is rapidly dwindling, and co-ops face many limitations in their ability to raise additional capital. There is no sustainable path forward that does not involve profitability, and for many, this seems far from being achieved." (Robert Wood Johnson Foundation)
[Opinion] U.S. Health Care Reform: Progress to Date and Next Steps
"Policy makers should build on progress made by the [ACA] by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the [ACA] demonstrates that positive change is achievable on some of the nation's most complex challenges." (Barack Obama, JD, in JAMA)
Top Ten Compliance Issues for 2017 Health Benefit Planning
"[1] Wellness.... [2] Essential health benefits and ACA nondiscrimination rules.... [3] Mental health parity.... [4] Employer shared-responsibility (ESR) strategy and reporting ... [5] Preventive care.... [6] SBC model documents.... [7] FLSA final overtime rules' impact on employee benefit plans.... [8] Expatriate group health plans.... [9] HIPAA privacy, security, and electronic transactions.... [10] DOL fiduciary rule." (Mercer)
Benefits Interference Claims Against Allstate Move Forward
"Sixteen years-worth of litigation against the insurance company has been consolidated into one complaint. After Allstate terminated employment contracts of approximately 6,200 employee-agents and offered four alternative post-Allstate futures in 1999, 499 individual lawsuits have been filed." (planadviser)
Another CIGNA-Administered ERISA Health Plan, DHL Express, Sued for Embezzlement
"This latest case seems to be another brick in the wall of ongoing cases, alleging similar violations, against CIGNA-administered health plans across multiple sectors of the economy. Among top companies ensnared in litigation by CIGNA's practices ... [are] Macys, JP Morgan Chase and Chevron. These practices may be endemic to the industry as a whole as evidenced by other large UnitedHealth administered health plans, such as GAP and AT&T that have also faced lawsuits alleging similar violations." (AVYM Healthcare Revenue Consultants)
[Guidance Overview] Takeaways from the ACA Nondiscrimination Final Regs
"If the employer (non-health care provider) sponsors a self-insured health plan, the regulations do not apply directly to the group health plan. If the self-insured employer uses a third-party administrator (TPA) or administrative-services-only (ASO) provider that is also an insurance company, the TPA/ASO is subject to the regulations and must administer the employer's plan in a nondiscriminatory manner or risk enforcement action by OCR." (Hill, Chesson & Woody)
Surprise Medical Bills Fuel Fight Between Providers, Insurers
"The growth of insurance plans built around small networks of health-care providers is fueling new fights over surprise medical bills, when patients inadvertently get care from out-of-network doctors. Providers and insurers are blaming each other for sticking patients with higher bills in such cases, and nearly two dozen states have passed or are considering legislation to protect consumers." (The Wall Street Journal; subscription may be required)
Access to Providers and Network Accuracy Lacking for Those in Marketplace and Commercial Plans
"[O]btaining access to primary care providers was generally equally challenging both inside and outside insurance Marketplaces. In less than 30 percent of cases were consumers able to schedule an appointment with an initially selected physician provider. Information about provider networks was often inaccurate. Problems accessing services for patients with acute conditions were particularly troubling." (Health Affairs)
[Guidance Overview] Overview of Health Insurance Exchanges (PDF)
15 pages. "The report includes summary information about how exchanges are structured, the intended consumers for health insurance exchange plans, and consumer assistance available in the exchanges, as specified in the ACA. The report also describes the availability of financial assistance for certain exchange consumers and small businesses and outlines the range of plans offered through exchanges. Moreover, the report provides a brief summary of the implementation and operation of exchanges since 2014." [Report No. R44065, dated July 1, 2016.] (Congressional Research Service [CRS])
[Opinion] Millennials: Are You Not Entertained?
"The main complaint among Millennials is the lack of convenience. The age of technology is upon us and with so much information available in an instant there is always somewhere to go, something to do, and more to learn. We don't have time for lunch, let alone an hour phone call with a receptionist, followed by 2 hours in a waiting room filling out forms, before a 3-minute meeting at which time the doctor tells us we're fine, which is then followed by the inevitable $150 bill. Our mind set is simple -- If I'm not sick, I don't need to waste my time and money to see the doctor. I can just go on WebMD and diagnose myself. The problem with this mind set is also simple -- it's wrong." (Xerox HR Insights)

Important word about authorship:
BenefitsLink® (BenefitsLink.com) provides this page for you, containing selected hypertext links to pages on the web that our editors think will be useful or interesting to you. But BenefitsLink is not the author or publisher of those linked pages (except as expressly indicated). You should contact directly the author of any such linked pages for copyright or other information about their contents.
 
Webmaster:
© 2016 BenefitsLink.com, Inc.
Privacy Policy