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Health plans - design


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Employer Groups See Mixed Bag in EEOC Wellness Plan Ruling
"Orion won on the voluntary standard issue, but there should be a concern about the court's application of the safe harbor provision in the Americans with Disabilities Act ... Employers have taken a position that the safe harbor applies and the court essentially ruled that out in this case, she said. The deference the court is giving to the safe harbor provision isn't what employers were hoping for[.] ... Some employer groups see this as a win for their side. The Orion decision is a 'very strong rebuttal' to the EEOC's final regulation that the limited incentives that employers can provide to participants in wellness plans can't go over 30 percent, Mark Wilson, chief economist at the HR Policy Association in Washington, told Bloomberg BNA[.]" (Bloomberg BNA)
[Opinion] American Academy of Actuaries Letter to Congress on Adverse Consequences of Weakening the ACA's Individual Mandate (PDF)
"The individual mandate is an integral component of the law, especially given its provisions that prohibit insurers from denying coverage or charging higher premiums based on pre-existing health conditions. Weakening the mandate, by lowering financial penalties or exempting particular categories of individuals from its requirements, would likely have significant implications for health insurance coverage and costs both to consumers and the federal government." (American Academy of Actuaries)
Supreme Court Pauses Ninth Circuit's Decision in Church Plan Case
"Associate Justice Anthony Kennedy granted Dignity Health a temporary reprieve from complying with [ERISA] until the eight justices decide whether or not to take up their appeal. In July, the Ninth Circuit determined that Dignity Health didn't qualify for a religious exemption from ERISA and its employee pension system couldn't be considered a church plan. Dozens of lawsuits have been filed against faith-based organizations over the issue. The lawsuits target some of the nation's largest health systems." [Dignity Health v. Rollins, No. 16-258 (S.Ct. Sept. 21, 2016)] (Modern Healthcare; registration may be required)
[Opinion] ERIC Comment Letter to CMS: Inappropriate Steering of Individuals to Individual Market Plans (PDF)
"[ERIC believes] that similar practices and problems are adversely affecting those enrolled in, and sponsoring, plans outside of Medicare and Medicaid. As such, we request that HHS considers what policies and strategies might provide relief to those individuals outside of public programs as well.... These comments will detail several examples of situations in which we believe increased oversight and possibly new regulations are needed to protect the rights and care of beneficiaries in both public programs and private health insurance." (The ERISA Industry Committee [ERIC])
The Latest Win for Wellness Programs May Be More of a Win for the EEOC
"[T]his court concluded that it must defer to the EEOC's interpretation of its rulemaking authority, determined that the EEOC's interpretation to be reasonable, and agreed with the EEOC that the new regulation can be applied retroactively as a clarification. Further, the court declined to adopt the holdings of Seff and Flambeau, and concluded the ADA's safe harbor did not apply in any event because wellness programs are 'unrelated to basic underwriting and risk classification.' In addition, Orion's group health plan description did not include the wellness initiative, which the court used as further evidence that the program was independent from the group health plan. As a result, the ADA safe harbor was found not to apply to this wellness program." [EEOC v. Orion Energy Systems, Inc., No. 14-1019 (E.D. Wis. Sept. 19, 2016)] (Kilpatrick Townsend)
ACA Employer Compliance: Changes in 2017 Looming
"In addition to implementation of new regulations, employers entering the second year of compliance with ACA reporting requirements won't have some of the good faith and transitional relief that was available for 2015 reporting." (Bloomberg BNA)
Low Healthcare Literacy Means High Costs for Health Plans
"Insurers are missing the opportunity to educate consumers about the need for preventive care and options that can control costs for them but also the health plan, like going to an urgent care clinic or using telemedicine instead of going to an emergency room, she says. Most people do not know that they can shop around for the best price on prescriptions, for instance, assuming that all pharmacies charge the same amount." (HealthLeaders Media)
[Opinion] How the Administration's Executive Actions Sabotaged Obamacare
"Out of desperation to ensure as many people as possible signed up for health insurance, the Obama administration has arbitrarily suspended onerous mandates, modified coverage requirements and extended enrollment periods. These illegal, ad hoc changes to the ACA ... have unintentionally, but foreseeably, weakened the exchanges during the pivotal first three years." (Josh Blackman in The Washington Post; subscription may be required)
EEOC Loses Again in Wellness Litigation
"On the question of whether ADA safe harbor immunity applies to medical exams under a wellness program, the EEOC may take some consolation in this court's unwillingness to adopt the holdings of the Seff and Flambeau decisions ... However, the EEOC suffered another litigation defeat regarding its central challenge to this employer's wellness program financial incentives. Addressing the voluntariness of this arrangement, the court had little difficulty concluding that even a strong wellness incentive (100% of monthly premiums in this case) is not enough to render the program involuntary under the ADA." [EEOC v. Orion Energy Systems, Inc., No. 14-1019 (E.D. Wis. Sept. 19, 2016)] (Practical Law Company)
Maintaining an ERISA Exemption for HSAs
"Generally, the [DOL] does not view HSAs as benefit plans subject to ERISA. However, the ERISA exemption is dependent on the employer playing a limited role in the HSA program. Employers should be aware of the following restrictions to avoid compromising the ERISA-exempt status of their HSA arrangements: [1] Allow voluntary participation.... [2] Avoid endorsement of a single HSA provider.... [3] Refuse employer compensation.... [4] Maintain employee control of funds." (Marsh Consulting Group)
New AMA Analyses Support Blocking the Anthem-Cigna and Aetna-Humana Mergers
"Left unopposed, Anthem's acquisition of Cigna and Aetna's takeover of Humana would collectively quash competition in insurance markets across 24 states ... The prospect of reducing five national health insurance carriers to just three should be viewed in the context of the unprecedented lack of competition that already exists in most health insurance markets.... A significant absence of health insurer competition was found in 71 percent of the metropolitan areas studied.... In 40 percent of the metropolitan areas studied, a single health insurer had at least a 50-percent share of the commercial health insurance market. Fourteen states had a single health insurer with at least a 50-percent share of the commercial health insurance market[.]" (American Medical Association [AMA])
Reducing Low-Value Health Care
"[T]here was a profound lack of consensus on how to incorporate clinical nuance, patient preferences and priorities, and cost-benefit tradeoffs into provider and consumer-facing initiatives to reduce low-value care. One employee benefits executive commenting on competing risks stated, 'I think this starts to tread into some really difficult ... ethical territory.... If it's benefit's decision to say somebody in this situation doesn't get access to the service, I don't think we would ever do that.' However, a clinical professional from oncology was in favor of using competing risks in decision making and commented 'A treatment that might be considered as appropriate treatment for [one] patient ... might be considered to be a very poor choice for a patient who's got significant competing risk.' " (Health Affairs)
[Opinion] Just Another Shell Game: Study Falsely Claims Obamacare Premiums Are Lower Than Those of Employer Plans
"[T]axpayers finance a large portion of Exchange-plan premiums through the ACA's 'reinsurance' program. The reinsurance program taxes almost all health plans, including most employer-sponsored plans, and uses the revenue to subsidize Exchange plans.... Exchange-participating carriers have suffered losses, even after accounting for net reinsurance subsidies. So the full premium for Exchange coverage is higher still-and the insurers are paying part of it." (Forbes)
Hitch Keeps Many High-Deductible Plans from Covering Chronic Care Up Front
"[H]igh-deductible plans that are set up to link to health savings accounts can only cover preventive services like vaccines and mammograms until patients buy enough services on their own to pay down their deductible. A bipartisan bill was introduced in Congress in July that would allow high-deductible plans that can link to health savings accounts (HSA) to cover care for chronic conditions like diabetes and heart disease before plan members have met their deductibles." (Kaiser Health News)
Text of Federal District Court Opinion: Wellness Program Was Voluntary But Did Not Satisfy EEOC Safe Harbor; EEOC May Apply Rules Retroactively (PDF)
21 pages. "While Orion sought to develop a wellness program ... to benefit economically by mitigating its health insurance costs, it did not perform any underwriting or risk classification for the purpose of calculating insurance premiums ... Only in the broadest sense is Orion's wellness initiative related to insurance. Adopting Flambeau's expansion of the safe harbor provision to employers providing wellness plans goes well beyond the provision's narrow scope.... [E]ven a strong incentive is still no more than an incentive; it is not compulsion. Orion's wellness initiative is voluntary in the sense that it is optional." [EEOC v. Orion Energy Systems, Inc., No. 14-1019 (E.D. Wis. Sept. 19, 2016)] (U.S. District Court for the Eastern District of Wisconsin)
[Opinion] The Missing Debate Over Rising Healthcare Deductibles
"While the political world focuses on the [ACA], changes have been occurring for the many more Americans who get health insurance through work. The biggest change: rising deductibles, which are transforming the nature of health insurance from more comprehensive coverage to skimpier insurance with higher out-of-pocket costs.... The shift is not a result of Obamacare; the trend began well before the ACA was passed in 2010. The trend is not highly politicized or covered daily by the general news media. All of which contribute to making the changing nature of insurance the most important development in the U.S. health system the public is not debating." (The Wall Street Journal; subscription may be required)
Deriving Risk Adjustment Payment Weights to Maximize Efficiency of Health Insurance Markets
"[The authors] assume that the objective of risk adjustment is to minimize the loss from service-level distortions due to adverse selection incentives, [and] derive expressions for the service-level distortions as a linear function of the risk adjustment payment weights.... [W]hen the number of risk adjustor variables exceeds the number of decisions plans make about service allocations, incentives for service-level distortion can always be eliminated." (Timothy J. Layton, Thomas G. McGuire, Richard C. van Kleef, via National Bureau of Economic Research [NBER])
Hospital Health Plans Growing as Providers Want More Control Over Care
"As health care delivery and payment models continue to evolve, some hospitals have decided to take more control over their private payment options and offer their own health plans. By cutting out the middleman of other insurers, these integrated hospital systems are able to oversee health care spending and ensure that patients receive the services they need." (Wolters Kluwer Law & Business)
EEOC Appeal of Wellness Plan Case May Dead-End Over Lack of Damages
"During oral argument ... a three-judge panel peppered attorneys from the [EEOC] and Flambeau Inc.... with questions about potential damages an employee suffered under a since-ended wellness program. Without a determination that the now-retired employee suffered an economic loss, emotional distress or some other damage, the case likely constituted 'much ado about ancient history,' one of the judges said." [EEOC v. Flambeau Inc., No. 16-1402 (7th Cir. oral argument Sept. 15, 2016)] (Bloomberg BNA)
[Guidance Overview] Nondiscrimination Standards Under ACA Section 1557: Now Is the Time to Act
"A Covered Entity must take appropriate initial and continuing steps to notify beneficiaries, enrollees, applicants, or members of the public of individuals' rights under Section 1557 ... This notice must be posted in significant publications and communications, in conspicuous physical locations, and on the Covered Entity's website by October 16, 2016 ... Covered Entities must also post by October 16, 2016, taglines in at least the top 15 languages spoken by individuals with limited English proficiency in the state or states where the Covered Entity operates." (Epstein Becker Green)
Company Switches to Reference-Based Pricing with Incredible Success (PDF)
"In the first year of the reference-based pricing model, the company promised -- and delivered -- incredible results: Deductibles stayed the same. Coinsurance rates stayed the same. And instead of a 23 percent hike, premiums did not increase at all. Here is the story of how one employer fought back against rising healthcare costs, the status quo, and that law known as health reform . . . and won." (Lockton)
[Guidance Overview] Go All the Way with HSA: Everything HDHP/HSA You Need to Know (PDF)
57 presentation slides. Topics: What are the requirements for a plan to meet HDHP status? Which individuals are eligible to make or receive HSA contributions? What are the forms of disqualifying coverage that prevent HSA eligibility? What are the contribution limit rules for HSA-eligible individuals? How do the rules apply for individuals who gain or lose HSA eligibility mid-year? What tax reporting requirements apply to HSAs? How does HSA eligibility interact with Health FSA and HRA coverage? How and when can employers correct mistaken HSA contributions? (ABD Insurance & Financial Services)
Changes in Coverage by State and in Selected Metropolitan Areas
"Between 2013 and 2014, the percentage of people in the United States without health insurance fell from 16.9 percent to 13.4 percent. Non-Medicaid expansion states reduced their uninsured rate by 2.8 percentage points compared to 4.2 percentage points in Medicaid expansion states. Reductions in the uninsured rate were broad, touching every demographic and socioeconomic group." (Robert Wood Johnson Foundation)
ERIC Works to Create Barrier-Free Access to Telehealth
"ERIC recently submitted testimony to the Michigan House Committee on Health Policy, as well as presented letters to the Missouri State Board of Registration for the Healing Arts, the Louisiana Board of Examiners for Speech-Language Pathology and Audiology, and the Delaware Board of Dietetics/Nutrition." (The ERISA Industry Committee [ERIC])
Why Do Employers Hate the Cadillac Tax?
"From a business perspective, companies want to continue to take advantage of the full tax exclusion since untaxed dollars make paying workers a little cheaper ... And ultimately, employers have realized it would be a political and reputational nightmare in the short term to stop providing health benefits. It would immediately raise the ire of workers who expect jobs to come with a halfway decent health plan." (Crain's Chicago Business)
Vanguard Enhances Benefits for Its Employees
"[N]ew parents will now be eligible for six weeks of fully paid time off, and mothers giving birth will be eligible for up to 16 weeks paid time off with an increased disability benefit. New parents through adoption and surrogacy will receive assistance with associated costs in addition to being eligible for equal time off." (Pensions & Investments)
[Guidance Overview] Flex Contributions and Opt-Out Payments Under ACA (PDF)
"[E]mployers that offer flex contributions and/or opt-out payments face some unique issues in determining if the health coverage they offer to employees is affordable under the ACA's shared responsibility rules. Depending on how the program is structured, these contributions and payments can adversely affect affordability." (Xerox HR Services)
[Opinion] Postal Service Health Benefits and the FEHBP: The Urgent Case for Getting Reform Right
"The 2016 Postal Service Reform Act proposes shifting postal retirees' primary health care coverage from the Federal Employees Health Benefits Program (FEHBP) to Medicare.... The proposal's impact on both postal retirees and taxpayers could be substantial.... This arrangement drives excessive Medicare use, and thus imposes ever higher costs on both Medicare beneficiaries and taxpayers. Postal annuitants would be forced to enroll in Medicare Part B while continuing premium payments to the FEHBP if they want to maintain any FEHBP benefits or choice among FEHBP plans." (The Heritage Foundation)
[Opinion] Employees Need Congress to Protect Account-Based Health Plans
"Now more than ever, hardworking Americans need to rely on account-based plans such as Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) in order to make healthcare more affordable, manageable, and predictable. They are counting on Congress to recognize this and take action against the looming 'Cadillac' tax." (The Hill)
Premiums and Worker Contributions Among Workers Covered by Employer-Sponsored Coverage, 1999-2016
"Since 1999, the Employer Health Benefits Survey has documented trends in the employer-sponsored health insurance market. Every year, about two thousand private and non-federal public employers with three or more employees have completed the full survey. Among other topics, the survey asks firms for the premium or full per-person cost of their health coverage as well as the share that workers are responsible for. [This graphing tool] allows users to look at changes in premiums and worker contributions for covered workers at different types of firms over time." (Henry J. Kaiser Family Foundation)
Employer-Sponsored Family Health Premium 2016 Costs
"For the first time, half (51 percent) of all covered workers face deductibles of at least $1,000 annually for single coverage. This includes two thirds (65 percent) of workers at small firms (three-199 workers), who typically face higher deductibles than workers at large firms (200 or more workers)." (Health Affairs)
Employer Costs Slow; Consumers Use Less Care, Deductibles Soar
"Average premiums for employer-sponsored family coverage rose 3.4 percent for 2016, down from annual increases of nearly twice that much before 2011 and double digits in the early 2000s ... But 3.4 percent is still faster than recent economic growth, which determines the country's long-run ability to afford health care. And the tame premium increases obscure out-of-pocket costs that are being loaded on employees in the form of higher deductibles and copayments." (Kaiser Health News)
[Opinion] The Time for Telehealth Is Now
"Today, almost all mobile and desktop computing devices are equipped with webcams capable of capturing high-definition video and sound quality. This innovation -- combined with broadband Internet connectivity that now extends across 80 percent of the United States, including the growing population who have online access only through their mobile device -- seems to be overcoming the technology obstacle previously associated to telehealth." (Jeffrey C. Bauer, for HFMA)
Employers to Shift Focus Away from Health Plan Cost-Cutting in 2017
Employers project that per-employee health benefit cost will rise by an average of 4.0% next year after they make planned changes Underlying cost growth has also slowed -- cost would rise 5.5% if employers made no changes.... The difference between the underlying cost growth and the actual cost growth can be an indication of how much or little employers are cutting health plan value by raising deductibles or other cost-sharing provisions. A difference of just 1.5 percentage points for 2017 suggests employers do not plan to do much cost-shifting." (Mercer)
Community Health Options, One of Few Remaining CO-OPs, Backs Out of New Hampshire
"Community Health Options is the latest insurer to withdraw from the exchange market citing financial losses. It drew attention two years ago as the only [ACA] co-op to be making money from its exchange products, reporting a net income of $7.3 million in 2014." (Healthcare Finance News)
New Jersey Obamacare CO-OP to Close in 2017
"New Jersey's consumer oriented and operated healthcare plan, Health Republic Insurance, announced [Sept. 12] it would not offer plans in 2017. The departure means that 17 out of the 23 Obamacare co-ops have shut down after spending $1.8 billion in taxpayer funding.... The action means that all 26,000 customers will have to find a new plan at the beginning of the year." (Washington Examiner)
Gap Insurance Takes Sting Out of High-Deductible Health Plans
"Gap plans, used to cover out-of-pocket expenses like high deductibles, are becoming increasingly popular among consumers and businesses.... With monthly premiums on health insurance going up, more people are choosing cheaper, high-deductible options. In 2016, more than 90 percent of people buying insurance under the ACA chose plans with an average deductible of $3,000 or higher." (National Public Radio)
Income, Poverty and Health Insurance Coverage in the U.S. in 2015
"The percentage of people without health insurance coverage for the entire 2015 calendar year was 9.1 percent, down from 10.4 percent in 2014. The number of people without health insurance declined to 29.0 million from 33.0 million over the period." (U.S. Census Bureau)
Consumer-Driven Health Plan Enrollees Spend 1.5 Times More Out-of-Pocket Than Those with Traditional Coverage
"Annual total spending on health care for the CDHP population was, on average, $520 less per capita than the non-CDHP population. In 2014, spending totaled $4,481 per CDHP person and $5,140 per non-CDHP person. Across the study period, people with CDHPs used around 10 percent fewer health care services than the non-CDHP population, and used even fewer brand prescriptions (20 percent fewer filled days than the non-CDHP population). On average, people with CDHPs spent $1,030 per person out of pocket annually on care, compared to $687 for the non-CDHP population." (Health Care Cost Institute)
California Court Finds That Discretionary Clauses in Health Insurance Policies Are Enforceable
"In 2011, the California legislature passed Insurance Code Section 10110.6 which bans the use of discretionary clauses in any ... [contract] that provides or funds life insurance or disability insurance coverage.... Judge Edward M. Chen of the United States District Court for the Northern District of California [recently] applied choice of law principles to find that New York law applied and also found that even if California law were to apply, Section 10110.6 does not apply to health insurance plans." [Bain v. United Healthcare [sic] Inc., 15-03305 (N.D. Cal. Aug. 30, 2016)] (Ogletree Deakins)
[Guidance Overview] Is Your Health Plan Covered Under the New Section 1557 Nondiscrimination Rules?
"If you sponsor a self-funded plan that applies for Retiree Drug Subsidy money under Medicare Part D, then you are a covered entity because you have a health program (i.e., self-funded medical plan) that receives federal financial assistance (i.e., Retiree Drug Subsidy).... If you sponsor a fully-insured health plan, while you may not be a covered entity, your insurer likely is a covered entity which means that there will likely be some plan design changes in your plan." (Graydon Head & Ritchey LLP)
[Opinion] ERIC Amicus Brief in Case Challenging Texas Restrictions on Telemedicine Providers (PDF)
40 pages. "The revised Rule 190.8 that the Texas Medical Board adopted in May 2015 (New Rule 90.8) is a market-protective rule designed to undermine the business model of direct care telemedicine.... New Rule 190.8 is not a 'fair and considered' response to any credible increased 'risks' associated with telemedicine.... What New Rule 190.8 actually does is remove the ability of telemedicine providers to offer basic treatment to patients, thereby making it difficult or impossible for telemedicine providers to compete with traditional office-based providers." [The case is Teledoc, Inc. v. Texas Medical Board, No. 16-50017 (5th Cir., brief filed Sept. 9, 2016). (The ERISA Industry Committee [ERIC])
Obama, Insurers Meet to Discuss ACA Participation
"President Obama and senior administration officials met with leaders from insurance companies participating in [ACA] exchanges on [Sept. 12], underscoring the importance of their participation on the marketplace. The president also wrote a letter to all participating insurers in which he stressed the administration's commitment to working with them and discussed recent actions the White House has taken to improve the marketplace.... [This follows the Sept. 9 announcement by the CMS] that it anticipates that all risk corridor funds collected for 2015 will be used towards the remaining 2014 balance, meaning no funds will be available for 2015 payments." (Morning Consult)
Pressure to Avert Government Shutdown Intensifies as Lawmakers Address Looming Benefits Issues (PDF)
"Congress is focused on fiscal year 2017 funding -- despite the ongoing campaigns and upcoming elections -- and is considering solutions to deal with the multiemployer pension plan crisis and instability of the [ACA] public marketplaces. Meanwhile, there are renewed efforts to block the DOL fiduciary rule, as well as to change certain elements of the retirement savings landscape." (Xerox HR)
Do Transparency Tools Work in Health Care?
"Encouraging workers to reduce unnecessary spending is all about creating the appropriate incentives. Before they will take the time to comparison shop, consumers must benefit from their efforts.... One impediment to comparison shopping for health care is that many consumers are not regular consumers of health care.... Many do not need enough regular services sufficient to learn the process." (National Center for Policy Analysis Health Policy Blog)
How ACA Insurance Expansions Have Affected Out-of-Pocket Cost-Sharing and Spending on Premiums
"The probability of incurring high out-of-pocket costs and premium expenses declined as marketplace enrollment increased. The percentage reductions were greatest among those with incomes between 250 percent and 399 percent of poverty, those who were eligible for premium subsidies, and those who previously were uninsured or had very limited nongroup coverage. These effects appear largely attributable to marketplace enrollment rather than to other ACA provisions or to economic trends." (The Commonwealth Fund)
[Guidance Overview] Employee Benefits and the New Overtime Rules
"Let's pay for this by reducing benefits! ... But it's not that easy to reduce medical benefits.... Changing compensation structures may unintentionally affect eligibility for (and amount of) benefits under existing plans.... Changing compensation in a way that results in the loss of benefits could implicate Section 510 of ERISA.... When modifying benefits, don't overlook legal obligations.... Or the impact on employee morale." (Mintz Levin)
Colorado to Vote on Single-Payer Health System
"A proposed single-payer system for health care in Colorado would fulfill society's moral obligation to cover everyone, supporters say, but opponents of the proposed constitutional amendment say its $25 billion tax increase would nearly double the state's overall budget and drive employers away. The 'ColoradoCare' proposal ... will go before voters in November, making Colorado a battleground on the question of whether a single-payer approach is the best way to achieve universal health care coverage." (Bloomberg BNA)
Medicare Accountable Care Organization Results for 2015: The Journey to Better Quality and Lower Costs Continues
"Overall, 31 percent of the MSSP and Pioneer ACOs received shared savings bonuses for their 2015 performance, an increase over the 27 percent that earned a bonus in 2014. While more ACOs are succeeding under the program, there continues to be substantial variation in financial performance and quality results." (Health Affairs)
Dropout by Dartmouth Raises Questions on Health Law Cost-Savings Effort
"An evaluation for the federal government found that Dartmouth's accountable care organization had reduced Medicare spending on hospital stays, medical procedures, imaging and tests. And it achieved goals for the quality of care. But it was still subject to financial penalties because it did not meet money-saving benchmarks set by federal officials." (The New York Times; subscription may be required)
Recent Rise in Health Coverage Due to Return of Jobs with Benefits
"70.2 percent of residents, age 18 to through 64, had 'private health insurance' ... in the first quarter of this year, which is which is the same rate as persisted until 2006.... What has really happened is a restoration of employer-based benefits as we have slowly clawed our way out of recession: 61.2 million people had non-exchange private insurance in Q1 2010. This included both employer-based benefits and the pre-Obamacare market for individual health insurance. By Q1 2016, this had increased to 66 million. Because most in the pre-Obamacare individual market have shifted into Obamacare exchange coverage, the increase in employer-based coverage will have been close to eight or nine million." (National Center for Policy Analysis Health Policy Blog)
Senators Warren and Sanders Launch Probe Into Insurer That Bailed on Obamacare
"Many Democrats have been suspicious that Aetna's decision came as a direct result of the unfavorable ruling from the White House. That speculation was fueled after a letter surfaced from Aetna's CEO last month that appeared to make a direct threat to Obama administration that the company would leave the exchanges if its merger was not approved." (The Hill)
ACA Round-Up: Insurance Market Concentration, Statutory Reach, and Coverage Gains
"In 2011, the three largest insurers had 80 percent or more of the individual and small group markets in 33 states each. By 2014 the number of such states increased to 41 for the individual market and 40 for the small group market.... Although concentration of insurance markets was continuous throughout the period, the ACA has in fact changed health insurance markets." (Health Affairs)
[Guidance Overview] HHS Proposes 2018 OOP Maximums and Marketplace Guidance (PDF)
"In 2017, the OOP limits will be $7,150 for self-only coverage and $14,300 for other than self-only coverage. HHS has proposed 2018 OOP maximums of $7,350 for self-only coverage and $14,700 for other than self-only coverage.... [A table] summarizes the ACA indexed dollars limits for 2018 and prior years." (Xerox HR Services)
Court Affirms Health Plan's Exclusion of Services Provided in an Educational Setting
"The court concluded that the participant failed to show that the treatment provided at the facility, which had a comprehensive and accredited educational program, fell outside the plan's exclusion for services provided in an educational setting.... This case, which involved expenses incurred at a mental health residential treatment facility in 2011, would likely have a different outcome under the final mental health parity regulations applicable to group health plans for plan years beginning on or after July 1, 2014." [Stephanie C. v. Blue Cross Blue Shield of Mass., No. 13-13250 (D. Mass. June 30, 2016)] (Thomson Reuters / EBIA)
Debit Cards: A No-Brainer for Employer-Sponsored Benefits
"In addition to incentivizing plan enrollment for employers, benefits debit cards can also streamline the process by reducing the need for extensive account administration and claims filing.... With an FSA, employees can use the card in store and online to pay for IRS-approved medical-related expenses.... A debit card for an HSA can be particularly useful for account holders enjoying rollover at years' end, which can result in significant account growth." (DataPath)
Federal District Court Enforces Forum Selection Clause Contained in ERISA Plan
"[The court] observed that forum selection clauses further ERISA's goal of promoting a uniform administrative scheme by having the same court decide all cases relating to a single plan, and also found [the participant's] claim of physical and financial limitations irrelevant to its analysis.... In rejecting [contrary rulings by other courts], the court concluded that ERISA's policy that litigants have 'ready access to the Federal courts' was not intended to supersede the general enforceability of forum selection clauses. Thus, a plan may contractually limit the number of locations where an action 'may be brought.' " [Mathias v. Caterpillar, Inc., No. 16-1846 (E.D. Pa. Aug. 29, 2016)] (Proskauer's ERISA Practice Center)
[Opinion] Don't Get Too Excited, Pinal County
"News broke of Blue Cross Blue Shield of Arizona remaining in the marketplace in Pinal County, Arizona late on Wednesday. Obamacare supporters will rejoice with a thunderous round of applause to the insurance company and positive vibes about how tax credits will keep costs low. But the folks in Pinal County have little to get excited about.... In their announcement to remain in the marketplace, their Senior VP of sales, strategy and marketing, Jeff Stelnik, said premiums will increase by 51%." (InsureBlog)
Arizona's Pinal County Will Have an ACA Insurer After All
"Blue Cross Blue Shield of Arizona will offer plans on the [ACA] exchange in Arizona's Pinal County next year, resolving a situation that drew a national spotlight ... [It] will be the sole exchange insurer in 13 of Arizona's 15 counties in 2017.... Insurance officials in other states remain nervous about the possibility that other counties might lose all their exchange insurers if other companies decide in coming weeks to reduce their footprints." (The Wall Street Journal; subscription may be required)
[Guidance Overview] Spotlight on Transgender Health Coverage (PDF)
"In the case of an insured plan, the insurer -- not the employer -- may be a covered entity obligated to comply with Section 1557 requirements for all of its operations, including its policy terms. Carriers may (or may not) reach out to plan sponsors to alert them of changes to coverage in light of the final Section 1557 rules. It is not clear if the Section 1557 rules would allow an insurer to offer policies that would let an employer opt out of coverage for transgender healthcare services." (Xerox HR Services)

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