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Health plans - design

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[Guidance Overview] California Repeals 60-Day Waiting Period Limitation (PDF)
"The confusion between the California 60-day limit and the ACA's 90-day limit was exacerbated by regulations that the Departments of Treasury, Labor, and Health & Human Services recently issued permitting an 'orientation period' of no longer than one calendar month as a permissible condition of substantive eligibility for plan coverage. Sponsors of insured plans that provide benefits to California residents must still follow the California 60-day waiting period limitation through the end of 2014. However, starting in 2015, only the ACA's 90-day limit on eligibility waiting periods will apply." (Buck Consultants at Xerox)
ACA May Benefit More Small Businesses in the Fall
"[I]nsurance companies encouraged business owners to renew their plans before the October 2013 deadline to avoid having to sign up for a new policy during the first year of the controversial ACA rollout.... As a result, not as many businesses needed to look for new policies for their employees as was originally projected. To be successful, SHOP exchanges must attract a large pool of businesses that can exert market pressure on insurance carriers and ultimately bring down prices. Whether that will happen remains to be seen." (Kaiser Health News)
Healthcare Reform in the U.S. Territories; Prepayment of Taxes for Puerto Rico Retirement Plans
"[1] [M]any mandates of the ACA may still apply to issuers and employers [in the U.S. Territories]. The recent letter from HHS has no impact on: [a] the requirements of the ACA that were incorporated into the Internal Revenue Code and [ERISA], or [b] the requirements of ... the ACA that apply to non-federal governmental plans.... [2] As a practical matter, retirement plans that are dual-qualified (i.e., qualified not only under the Puerto Rico Internal Revenue Code but also under the U.S. Internal Revenue Code) cannot permit prepayment of taxes through distribution from the plan because prepayment of Puerto Rican taxes is not a distributable event under the U.S. Code." (Ogletree Deakins)
How SHOP Exchanges Could Be So Much Better This Year
"[T]he biggest barrier to enrollment in this past year, the first for the SHOP, was the fact that many states focused most of their Marketplace resources and volunteer time on coverage for individuals.... Other factors discouraging enrollment for small businesses ... included the limited reach of tax credits, the low number of brokers and agents steering their clients to SHOP plans, and technological problems.... The study also showed a surprising lack of awareness of even the most basic features of the SHOP in the small-employer community." (Wolters Kluwer Law & Business)
[Guidance Overview] Developments Impacting Benefits for Same-Sex Spouses
"Employers should continue to review their benefit plans and policies with respect to benefits extended to employees' same-sex spouses. Year-end amendments may be required for qualified retirement plans to comply with the IRS guidance on Windsor. The recent DOL guidance may require employers to change their policies with respect to FMLA-protected leave to care for a same-sex spouse with a serious medical condition. In addition, employers with self-insured plans may want to consider whether to extend spousal coverage to same-sex spouses in light of [Roe v. Empire Blue Cross Blue Shield] and other challenges that will likely follow." (McDermott Will & Emery)
Post-Hobby Lobby: Changes to Rules for Contraceptive Coverage Issued
"The government is proposing for comment two possible approaches to defining a qualifying closely held for-profit entity, although the comments are invited on other approaches as well. Under the first proposed approach, a qualifying closely held for-profit entity would be an entity where none of the ownership interests in the entity is publicly traded and where the entity has fewer than a specified number of shareholders or owners. Under a second, alternative approach, a qualifying closely held entity would be a for-profit entity in which the ownership interests are not publicly traded, and in which a specified fraction of the ownership interest is concentrated in a limited and specified number of owners." (Wolters Kluwer Law & Business)
Tax Problems Sometimes Arise When Giving Employees Choice of Benefits
"If the employee gives up the right to receive additional 457(b) distributions in the future in exchange for an additional current health insurance subsidy, the IRS views this as an assignment of income and has stated on several occasions that such a choice would result in current taxable income to the employees who elect the additional health insurance subsidy -- even though they are not now receiving any cash and have elected to receive what appears to be a nontaxable benefit." (Focus on Public Benefits)
[Guidance Overview] How ERISA, Tax, ACA and Federal Labor Laws Apply to Welfare Benefit Plans (PDF)
69 slides, presented on August 28, 2014. Topics: The Legal Overlay: [1]The Internal Revenue Code; [2] The Employee Retirement Income Security Act; [3] The Patient Protection and Affordable Care Act; and [4] The Labor Laws: USERRA, ADEA, FMLA, and ADA. (Ice Miller, for American Benefits Council)
[Opinion] Insurers Shoving 'Advanced Illness Counselors' on Us
"After an introductory letter that is routinely ignored, the counselors cold-call to try to convince you to accept their end-of-life counseling. Of course, this is 'at no cost to you' since your insurer pays for this service. The services are provided over the phone from offices in New Jersey -- a definition of personal care that only the insurers can understand. The clients of Vital Decisions are the private insurers, not the patients, nor the physicians, nor any other members of the health care team." (Physicians for a National Health Program [PNHP])
Health Plan Service-Provider Calls Terminally Ill Patients to Discuss End-of-Life Issues
"The hope of this program ... is to build a relationship over the phone, so [the individual] might be comfortable discussing his situation and his goals. Then he'll be empowered to communicate those things with others, including his family and his doctors.... It's paid for by insurers and federal privacy rules permit this for business purposes.... And when these conversations do happen, there's can be another byproduct: reduced costs. Research is finding that when patients fully understand aggressive care, many choose less of it." (Kaiser Health News)
EEOC Sick Over Wellness Programs
"The facts of this case are unusual since the employee's termination rather than the employer's wellness plan design, appears to be the likely force behind the EEOC's complaint. Further, the amount of the reward under the employer's program (100% of employee premiums), although arguably permitted under the HIPAA rules, is not typical of the modest incentives offered under most employer's wellness programs. Accordingly, it seems unlikely that this case represents the EEOC's opening salvo in a war against all reasonably designed wellness programs." (Mazursky Constantine, LLC)
How Effective Is Your Health Insurance Exchange Compliance Program? (PDF)
"CMS will likely be an aggressive enforcer on the [Federally Facilitated Marketplace]. Plans will need to understand CMS protocols, processes and data sources related to health insurance exchange compliance.... Medicare and Medicaid compliance programs present an appropriate model and 'starting point' for health insurance exchange compliance.... An effective health insurance exchange compliance program combines a strong infrastructure with a focus on key program areas specified by regulators... Key considerations for health plans implementing a health insurance exchange compliance program." (Deloitte Center for Health Solutions)
Administration's New Contraception Rules Explained
"The regulations unveiled [on August 22] would allow religiously affiliated employers to notify the government -- rather than their insurer -- of their objections to the law's coverage of birth control. The government will then notify the insurer to provide the contraception coverage. A second rule suggests the administration will allow the same mechanism for some businesses that object to contraception on religious grounds but seeks public comment on how to identify businesses to be included." (Kaiser Health News)
[Guidance Overview] Text of Treasury Department Priority Guidance Plan, 2014-2015 (PDF)
Starting on page 4 are 42 items relating to Retirement Benefits, followed by 23 items for Executive Compensation, Health Care and Other Benefits, and Employment Taxes. (Internal Revenue Service [IRS])
[Guidance Overview] Text of Treasury Department Priority Guidance Plan, 2013-2014 4th Quarter Update (PDF)
Starting on page 4 are 45 items relating to Retirement Benefits, followed by 31 items for Executive Compensation, Health Care and Other Benefits, and Employment Taxes. (Internal Revenue Service [IRS])
Pharmacy Benefit Plans and Consumer-Directed Accounts (PDF)
"Pharmacy benefit plan costs typically represent about 18% of employer-sponsored health benefit plan costs, compared with roughly 3% in the 1980s. Innovation in pharmacology and other important medical and technological advances are key drivers of the increase.... Employers must be informed when selecting a pharmacy benefit manager (PBM) and capitalize on today's 'buyer's market' for PBM services, in which virtually all financial and nonfinancial terms are negotiable. Pharmacy plan designs should enable employee cost sharing to keep pace with rising drug costs. The majority of employers have changed their plan designs over the past decade to help achieve this goal." (Benefits Quarterly, published by the International Society of Certified Employee Benefit Specialists [ISCEBS])
An Overview of 60 Contracts That Contributed to the Development and Operation of the Federal Marketplace
"This report is the first in a series that will address the planning, acquisition, management, and performance oversight of Federal Marketplace contracts, as well as various aspects of Federal Marketplace operations. This report provides descriptive and financial data on 60 contracts related to the development of the Federal Marketplace at" (Office of Inspector General [OIG], U.S. Department of Health and Human Services [HHS])
Patient Cost-Sharing Under the Affordable Care Act
"This report summarizes the ACA's provisions that set in place a broader set of required benefits and limit or reduce patients' out-of-pocket costs. These provisions significantly expand the amount of coverage individuals are required to buy when compared to the pre-reform individual market. The report also details requirements in the law that require comprehensive coverage of prescription drugs -- which is broadly similar to the scope of prescription drug coverage offered under similar employer-sponsored plans and Medicare Part D." (America's Health Insurance Plans [AHIP])
Look Beyond ACA Wellness Regs When Designing Your Program: EEOC Sues Employer Under ADA
"[The EEOC] recently sued an employer in Wisconsin claiming the penalty the employer imposed for nonparticipation in its program was too significant, causing the medical inquiries under the program to be involuntary for purposes of the Americans with Disabilities Act (ADA).... Many employers are in the process of reviewing their medical plans ... for 2015. The focus is largely on ACA compliance, in particular the employer shared responsibility penalties. But ... employers need to also be reviewing the ACA wellness program regulations, as well as the other laws that may affect their wellness program design and administration, such as the ADA." (Jackson Lewis)
[Guidance Overview] Agencies Provide Further Accommodations to Organizations Opposing Mandated Contraceptive Coverage
"The proposed regulations acknowledge that an organization organized and operated as a closely held for-profit entity may be an eligible organization under the accommodation regulations but reserve and seek comment on the definition of such an entity ... [and] provide for an alternative written notice to qualify for the accommodation.... Questions remain whether the amended regulations require a church plan offered by an eligible organization to comply with the coverage and funding mechanisms in the regulations." (Ballard Spahr LLP)
California Requires Insurers to Cover Cost of Abortions
"Last fall, Santa Clara University and Loyola Marymount University notified their employees that abortion services would no longer be covered under the universities' health care plans. Employees instead could pay for such procedures through supplemental coverage, provided by a third party.... [California] Department of Managed Health Care director Michelle Rouillard told the insurers that the state had 'erroneously approved' language in the universities' plan that excluded abortion services. She clarified that insurers must comply with California law and respect the coverage of legal abortions." (Sharyl Attkisson, in The Daily Signal)
New Contraceptive Rules Appear to Track Supreme Court Suggestion
"The new rules ... require those with religious objections to providing some or all FDA-approved contraceptives to ... notify the government rather than their insurance carriers that they cannot provide the coverage.... [T]he government would subsequently be responsible for notifying insurers, which would then arrange contraceptive coverage.... Some experts had worried about the government's ability to facilitate the coverage due to the intricacies of ERISA, the federal law that governs pension and health benefits. But the interim rules explicitly give the government the ability to make benefit changes in the absence of the objecting religious organizations." (Kaiser Health News)
[Opinion] Let's Add Some Cash to the Copper (and Other) Plans
"Insurers should be free to offer copper, or lead, or brass or whatever policy they want. However, as long as the federal government is subsidizing insurers billions of dollars in these exchanges, it should offer some of the money for beneficiaries' direct use, via deposits in Health Savings Accounts, Health Reimbursement Arrangements or Flexible Spending Arrangements, instead of handing it over to insurers." (Health Policy Blog of National Center for Policy Analysis)
Will Cost Hikes Force Cuts in Health Benefits for Spouse and Kids?
"[F]or 2016 and 2017, a third (33%) of employers are considering significantly reducing company subsidies for spouses and dependents; 10% have already implemented such reductions, and nine percent intend to do so in 2015. In addition, 26% said they are considering spouse exclusions or surcharges if coverage is available elsewhere; 30% have that tactic in place now, and another seven percent expect to add it in 2015." (Wolters Kluwer Law & Business)
UnitedHealth's Exchange Presence to Increase Competition
"Competition is about to get stiffer for insurers selling plans on many health insurance exchanges with UnitedHealthcare entering 24 states' online marketplaces with what it says will be affordable plans ... With such a large jump in exchange presence -- from just four state exchanges last year -- other insurers will monitor UnitedHealth's exchange-related moves as they seek to compete against the new exchange entrant." (FierceHealthPayer)
Obama Administration Offers Contraception Compromise for Religious Employers
"Federal officials laid out fresh rules to create a multistep process in which employers opposed to including birth control in workers' insurance would state their objections in writing, and the federal government would take over responsibility for the coverage from there to ensure that employees can still obtain contraception without making copayments, as part of the law.... Catholic bishops, who have led a campaign against the contraception-coverage provision that has included numerous legal challenges since its announcement in August 2011, indicated the new rules make only minor changes and are insufficient." (The Wall Street Journal; subscription may be required)
Large Wellness Penalties Can Trigger Big Problems Under the ADA
"Most employers don't shift the entire cost of coverage to employees who refuse to submit to a health risk assessment. Those that do can continue to argue that the assessment is a 'bona fide benefit plan' under the ADA safe harbor. The more strident the surcharge, however, the easier it might be for a court to conclude the surcharge is a subterfuge to evade the purpose of the ADA." (Lockton)
[Guidance Overview] New Accommodations for Employers on Contraceptive Coverage
"The interim final rule provides another alternative accommodation for non-profit religious organizations.... The proposed rule would, pursuant to the Supreme Court's judgment in Hobby Lobby, allow closely held for-profit organizations to qualify as 'eligible organizations' and thus claim the same accommodation as non-profit religious organizations.... The departments seek comments on how to define a closely held corporation, referring to two different approaches to defining 'closely held' both found in the Internal Revenue Code." (Timothy Jost, for Health Affairs)
Proposing a New Age of Retirement Plan Reconstruction
"The rise of the defined contribution system, which was never meant as a primary retirement pillar, has led to no less than 14 different kinds of defined contribution plans sponsored either by employers or initiated by individuals.... Critics of the nation's defined contribution system say the plethora of retirement strategies are costly, confusing and unwieldy. In many cases, they don't even generate the returns investors think they are getting." (
[Guidance Overview] CMS Explains When Individuals with Medicare May (and May Not) Enroll for Coverage Through Exchanges
"Medicare is complex and nuanced -- and so are these FAQs. Employers should, for instance, be aware that although the FAQs describe the creditable coverage notice requirement as one that will be met by insurers providing plans through a SHOP, group health plan sponsors are ultimately responsible for the notices, and there is no small employer exception." (Thomson Reuters / EBIA)
Mental Health Parity Required Health Plan to Cover Autism Treatments
"When analyzing the plan's arguments, the [federal district] court seemed to suggest that it could have entirely excluded coverage for autism without violating the MHPAEA.... In addition to its MHPAEA holding, the court [also] ruled that the plan's exclusion was invalid under two state insurance statutes -- one requiring mental health parity and the other requiring coverage of minors with 'pervasive developmental disorders.' The bottom line: Plan provisions involving mental health benefits should be carefully scrutinized." [A.F. v. Providence Health Plan, No. 3:13-cv-00776-SI (D. Ore. Aug. 8, 2014)] (Thomson Reuters / EBIA)
[Official Guidance] Text of Proposed Regs: Objections to Mandated Contraception Coverage by Closely Held For-Profit Entities (PDF)
36 pages. "These rules propose and seek comments on potential changes to the definition of 'eligible organization' in the Departments' regulations in light of the Supreme Court's decision in Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751 (2014), to ensure that participants and beneficiaries in group health plans (and enrollees and dependents in student health insurance coverage arranged by institutions of higher education) obtain, without additional cost, coverage of the full range of Food and Drug Administration (FDA) approved contraceptive services, as prescribed by a health care provider, while respecting certain closely held for-profit entities' religion-based objections to contraceptive coverage. These proposed rules also seek comments on any additional steps the government should take to help ensure coverage of the full range of FDA-approved contraceptives, as prescribed by a health care provider, without cost sharing, for participants and beneficiaries in group health plans of such entities (and enrollees and dependents in student health insurance coverage arranged by such entitites that are institutions of higher education)." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services; Employee Benefits Security Administration [EBSA], U.S. Department of Labor; Internal Revenue Service [IRS])
[Official Guidance] Text of Interim Final Regs: Process for Notice of Objection to Contraceptive Coverage by Religious Non-Profit Organizations (PDF)
38 pages. "These interim final regulations augment current regulations in light of the Supreme Court's interim order in connection with an application for an injunction in Wheaton College v. Burwell, 134 S. Ct. 2806 (2014) ... [and] provide an alternative process that an eligible organization may use to provide notice of its religious objections to providing contraceptive coverage, while preserving participants' and beneficiaries' (and enrollees' and dependents') access to coverage for the full range of Food and Drug Administration (FDA)-approved contraceptives, as prescribed by a health care provider, without cost sharing." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services; Employee Benefits Security Administration [EBSA], U.S. Department of Labor; Internal Revenue Service [IRS])
[Guidance Overview] HHS Fact Sheet: Administration Announces Final Rule for Notice of Objection to Contraceptive Coverage by Religious Non-Profit Organizations, and Proposed Rule for Closely Held For-Profit Entities
"[I]n light of the Supreme Court's recent interim order in a case involving Wheaton College, interim final regulations [are being] published to establish another option for an eligible organization to avail itself of the accommodation. Under the interim final regulations, an eligible organization may notify [HHS] in writing of its religious objection to contraception coverage. HHS will then notify the insurer for an insured health plan, or the Department of Labor will notify the TPA for a self-insured plan, that the organization objects to providing contraception coverage and that the insurer or TPA is responsible for providing enrollees in the health plan separate no-cost payments for contraceptive services for as long as they remain enrolled in the health plan....Also ... in response to the Supreme Court's recent decision, in Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751 (2014), proposed rules [are being] published that solicit comments on expanding the availability of the accommodation to include a closely held for-profit entity that has a religious objection to providing coverage for some or all contraceptive services. The proposed rules describe two alternative approaches for defining such an entity. Under one approach, the entity could not be publicly traded, and ownership of the entity would be limited to a certain number of owners. Under an alternative approach, the entity could not be publicly traded, and a minimum percentage of ownership would be concentrated among a certain number of owners. The number and concentration is not specified in the proposed rules, which solicit public comment on an appropriate number and/or concentration. The rule also solicits comments on other possible approaches and on documentation and disclosure of a closely held for-profit entity's decision not to provide contraceptive coverage. The proposed rules further provide that valid corporate action taken in accordance with the entity's governing structure, in accordance with state law, stating its owners' religious objection can serve to establish that the entity objects to providing contraceptive coverage on religious grounds." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Wear This Device So the Boss Knows You're Losing Weight
"The adoption of wearable devices by companies and insurers is increasing as spending on corporate wellness incentives has doubled to $594 per employee since 2009 ... Technology is creating new forms of wellness programs to measure whether employees are making improvements ... Yet the moves also let employers and insurers gather more data about people's lives, raising questions from privacy advocates." (Bloomberg)
EEOC Files First ADA Suit Against Employer-Sponsored Wellness Program
"The first direct federal challenge to an employee wellness program's legality under the Americans with Disabilities Act was filed Aug. 20 by the [EEOC]. The employer's program did not qualify as 'voluntary' under the ADA because the one employee who refused to participate was forced to bear the entire cost of her health coverage and was ultimately terminated ... The EEOC is seeking injunctions, back pay and compensatory and punitive damages against the company." [EEOC v. Orion Energy Systems, No. 1:14-cv-1019 (E.D. Wis. filed Aug. 20, 2014)] (Thompson SmartHR Manager)
Text of District Court Opinion Exempting Diocese and Affiliated Non-Profit Employers from Contraceptive Mandate and its 'Accommodation' (PDF)
53 pages. "[If] there is no compelling governmental interest to apply the contraceptive mandate to the religious employers who operate the 'houses of worship,' then there cannot be any compelling governmental interest to apply (even in an indirect fashion) the contraceptive mandate to the religious employers of the nonprofit, religious affiliated/related entities, like Plaintiffs in this case [including Catholic Charities and St. John's School]." [Brandt, Bishop of the Roman Catholic Diocese of Greensburg et al v. Burwell, No. 14cv0681 (M.D. Penn. Aug. 20, 2014)] (U.S. District Court for the Western District of Pennsylvania)
Wellness Plan Compliance: Test Your Knowledge
"[I]ncentive and penalty-focused health plans carry with them a host of federal and state laws that regulate the extent to which employers can impose wellness programs on employees.... Take the quiz [in this article] to test your knowledge about several other workplace wellness regulations, and whether your organization is in compliance." (William Gallagher Associates)
Resistance Was Futile: California Conforms to ACA Waiting Period Requirement
"Although California employers have mostly adapted to the original 60-day limitation ... the adoption of SB 1034 is welcome news and will allow employers with operations in both California and other states to impose uniform eligibility rules for their health plans if they so choose." (Ogletree Deakins)
Anthem Blue Cross Sued Again Over Narrow-Network Health Plans
"In the latest suit, Anthem members accuse the company of misrepresenting the size of its physician networks and the insurance benefits provided in new plans offered under the [ACA]. In many cases, consumers say, Anthem canceled their more generous PPO, or preferred-provider organization, plan and moved them to a more limited EPO, or exclusive-provider-organization, policy." (Los Angeles Times)
ACA Resources for Frequently Asked Questions, Updated August 15, 2014 (PDF)
19 pages. "The report provides basic consumer sources, including broad overviews of the ACA law. The next sections focus on health coverage: the individual mandate, private health insurance, and exchanges, as well as public health care programs ... The report then lists sources on employer-sponsored coverage, including sources on employer penalties, small businesses, federal workers' health plans, and union health plans. The report also provides sources on ACA's provisions on mental health, public health, workforce, quality, and taxes. Finally, the report lists sources on ACA costs and appropriations, legal issues, the treatment of noncitizens under ACA, and sources for obtaining the law's full-text." (Congressional Research Service [CRS])
Estimated Cost Impact of Creating a New Health Plan Tier ('Copper Plan') with an Actuarial Value Level of 50 Percent (PDF)
6 pages. "[C]reating a new tier with an AV of 50 percent would reduce the federal deficit by $0.3 billion between FY 2015 and FY 2024.... The reduction is due to a net $5.8 billion decrease in subsidies paid by the federal government for individuals in the new health insurance marketplace, primarily due to an increase in the estimated number of employers who will offer affordable coverage to employees.... We also estimate that the premium for the new plan with a 50 percent AV would be nearly 18 percent lower than the premium for an average bronze tier plan in 2016. The lower premium would result in a slight increase in estimated enrollment in the new marketplace." (Avalere Health, for Council for Affordable Health Coverage [CAHC])
Bocce, Baseball, Bowling: A Wellness Program That Covers All the Bases
"Our wellness initiatives were intentional and strategic. Leadership made a healthy workplace culture a priority. The small but dedicated Work 'n' Well Committee was expanded and rebranded the Healthy Workplace Council with a beefed-up budget.... [T]he council focuses on all five aspects of well-being that are measured by the Gallup-Healthways Well-Being Index -- physical, social, community, financial and purpose." (International Foundation of Employee Benefit Plans [IFEBP])
Medical Tourism Gets a Facelift -- and Perhaps a Pacemaker
"[W]ith the globalization of information and the empowerment of the consumer, medical tourism involves individuals acting as a consumer, making their own decisions regarding their health needs, deciphering how they can best be treated, and then finding the most appropriate provider.... [M]any countries across the world are getting more competitive and developing their own health tourism strategy -- competing on quality and price.... Although the exact market size of the medical tourism market is difficult to predict, recent ... research predicts the market at around $50 billion to $65 billion dollars in 2014, growing at approximately 20 percent." (Forbes)
States Opt Out of SHOP Employee Choice in Droves
"Concern is mounting among the 32 states under the FFM umbrella about implementation of employee-choice functionality in the SHOP exchange ... The [National Association of Insurance Commissioners] notes that the employee-choice provision raises considerable challenges for the exchange and carriers, as well as employers and employees." (Employee Benefit Adviser)
Carefully Choosing the Right Benefits Package Pays Off for Employees -- and Employers
"There are a few important tips that can increase the success of employers as they create a balanced and cost-effective benefits package that will appeal to current and future employees. Ask questions-and the important ones.... Choose a customized benefits plan over an off-the-shelf package.... Build it around the workforce.... Start a healthcare literacy program to help employees help themselves." (Healthcare Reform Magazine)
Health Plans Experiment with New Benefit Designs to Give Value
"Health insurers offering plans in the [ACA] marketplaces are experimenting with new types of benefit designs aimed at giving consumers some value before subjecting them to deductibles or other cost-sharing requirements. But the benefit designs may confuse many consumers.... Some plans, dubbed 'doughnut hole' plans, require copayments before deductibles are met and coinsurance payments afterward ... Some plans require separate deductibles for drugs, or separate copayments for hospitalizations, which can be significant, ... [T]wo plans side by side [may] look like they have the same deductible. But one plan covers primary care services pre-deductible and the other plan, it's more of a traditional type where you have to pay everything out of pocket until the deductible is met." (Bloomberg BNA)
ERISA at 40: Federal Preemption and the ACA (PDF)
5 pages. "A sweeping preemption provision that constricted the ability of states and localities to regulate employer-sponsored benefit plans was a major feature of ERISA as enacted, designed to create administrative uniformity for employers who sponsor benefit plans covering employees nationwide.... This article discusses the reach of ERISA preemption as it concerns pre-ACA health care reform laws designed to expand employer-provided health coverage, the status of those laws in the wake of the ACA, and the role and motivation of states and localities in regulating employer-sponsored coverage in a post-ACA world." (Buck Consultants at Xerox)
Employers Expect Health Care Costs to Rise 5.2% in 2015 But Hope to Whittle Down to 4%
"U.S. employers expect a 4% increase in 2015 health care costs for active employees after plan design changes, according to [Towers Watson]. If no adjustments are made, employers project a 5.2% growth rate, putting absolute cost per person for health care benefits at an all-time high.... Of particular concern on the cost front is the [ACA's] excise tax, which goes into effect in 2018. Nearly three-quarters (73%) of employers said they are somewhat or very concerned they will trigger the tax based on their current plans and cost trajectory. More than four in 10 (43%) said avoiding the tax is the top priority for their health care strategies in 2015." (Towers Watson)
Why More, Not Fewer, People Might Start Getting Health Insurance Through Work
"It's early yet to be sure of a strong trend, but the Walmart experience mirrors evidence from early polls and the historical experience of Massachusetts, which enacted a law similar to the [ACA] in 2006. More people may be signing up for employer-based coverage than did before.... What Walmart's experience reminds us is that there were also uninsured people who simply chose not to buy coverage before there was a law requiring them to do so. Now they may be changing their minds." (The New York Times; subscription may be required)
Survey by New York Federal Reserve: Higher Health Costs, More Part-Time Workers Due to Obamacare
"More than 73% of manufacturers and 58% of service firms said the health care law has increased costs this year. Companies are also more pessimistic about Obamacare next year. Over 80% of manufacturers and 74% of service firms expect health plan costs to increase in 2015." (U.S. Chamber of Commerce)
ERISA at 40: The Evolution of Employee Benefits
"This article explores ERISA's history, focusing on the major developments that have emerged over the years. It also includes thoughts from leading practitioners on the future of employee benefits law and practice." [Contributors include: Alvin H. Brown, Alan D. Lebowitz, Andrew L. Oringer, Prof. Kathryn J. Kennedy, and David N. Levine.] (Practical Law Company)
[Guidance Overview] California Repeals 60-Day Limit on Eligibility Waiting Periods, Now Conforms to ACA's 90-Day Rule
"[T]he text of the new statute itself is confusing because it consistently states: 'A health benefit plan for group or individual coverage shall not impose any waiting or affiliation period.' ... In reading the [California Health and Safety Codes], however, it is important to remember that the relevant code sections only apply to California's insurers. Therefore ... the law has been amended to tell California's HMOs and PPOs that they can't apply waiting periods. This frees up employers to set their waiting periods at whatever they deem appropriate as long as it complies with PPACA's 90-day (or maybe 90-days plus a month ... ) limit." (Benefit Revolution)
Pittsburgh Health Care Giants Take Fight to Each Other's Turf
"For decades, Highmark BlueCross/Blue Shield and University of Pittsburgh Medical Center worked together. But as the line between insurance companies and health care providers across the country blurs, these longtime allies are venturing into each other's business and becoming competitors.... There's another reason an insurance company would decide to become a healthcare provider: the Affordable Care Act. It tells insurance companies what basic services to offer; who they must insure and even what percent of premiums can go to administrative expenses and profits. That takes away a lot of what insurance companies used to do, so they're looking for new reasons to exist." (National Public Radio)
HMO, PPO, EPO: How's a Consumer to Know Which Health Plan Is Best?
"Ideally, plan type provides a shorthand way to determine what sort of access members have to providers outside a plan's network, including cost-sharing for such treatment, among other things. But since there are no industry-wide definitions of plan types and state standards vary, individual insurers often have leeway to market similar plans under different names." (Kaiser Health News)
[Guidance Overview] ACA Compliance: Changes in Employment Status Under the Look-Back Measurement Method
"While these rules appear simple and straightforward, this is not always the case in practice.... [W]hat happens if a newly hired employee changes his or her status during his or her initial measurement period or the corresponding stability period? The final regulations provide the following rules: Full-time employee... New variable hour, seasonal, and part-time employees... Ongoing employees." (Mintz Levin)
Prescription Drug Benefits: An Important Part of a Compensation Plan
"[P]rescription drugs can substitute for a more expensive medical service, reduce absenteeism and improve on-the-job worker productivity. If not managed, prescription drugs represent a constant financial drain on company resources that undermines the return on investment of the entire health care benefits program." (Idaho Business Review)
[Guidance Overview] Individual Medical Policy Arrangements May Result in Significant Excise Tax Liability (PDF)
31 pages. "[ECFC agrees] that the payment of [individual market (IM)] policy premiums is a permissible cafeteria plan qualified benefit and that the provision of such coverage through the cafeteria plan continues to be exempt from income and employment tax under the Internal Revenue Code. We also agree that a cafeteria plan, in and of itself, is not a group health plan subject to the ACA. However, the Agency Guidance clearly states that any arrangement, which pays or reimburses an employee's IM policy premiums on a pre-tax basis would be an 'employer payment plan', which the Agency Guidance clearly indicates is a 'group health plan' subject to the ACA. The Agency Guidance is also clear that an employer payment plan violates the ACA and employers who sponsor such arrangements would be subject to a potential excise tax of $100 per employee per day." (Employers Council on Flexible Compensation [ECFC])
Patient Advocacy Groups Claim Insurance Discrimination in New Forms
"Ending insurance discrimination against the sick was a central goal of the nation's health care overhaul, but leading patient groups say that promise is being undermined by new barriers from insurers. The insurance industry responds that critics are confusing legitimate cost-control with bias. Some state regulators, however, say there's reason to be concerned about policies that shift costs to patients and narrow their choices of hospitals and doctors." (ABC News)
[Opinion] How We Can Transcend Obamacare
"If we were to spend all our capital 'repealing and replacing' Obamacare, we might not have enough left to tackle the real drivers of unsustainable single-payer health care in America: Medicare and Medicaid.... Exchange-based plans would give those below the poverty line access to high-quality, private insurance and phase out single-payer public-option health insurance. Over the long run, only private insurers will have the competence and the incentive to come up with innovative, cost-efficient ways to improve health outcomes for the poor.... [M]igrating future retirees and low-income Americans onto exchanges could yield substantial benefits to the quality and cost of subsidized health coverage. But there's no reason we should accept the Obamacare exchanges as they are." (Avik Roy, in National Review)

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