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47 Matching News Items

1.  Medicare Changes to Make Drug Coverage More Manageable in 2025
Polsinelli PC Link to more items from this source
Mar. 20, 2024
"Beginning in January 2025, Part D sponsors who charge a deductible will be required to allow patients to spread the payment of the deductible ... over 12 months rather than having to pay the full deductible up front.... Other changes taking effect January 1, 2025, include requiring Part D sponsors to ... [1] Cap out-of-pocket costs for a month's supply of each covered insulin product at $35. [2] Limit out-of-pocket drug costs to a maximum of $2,000."
2.  DOL Sues UnitedHealth TPA Over Claim Denials
Polsinelli PC Link to more items from this source
Nov. 20, 2023
"The lawsuit alleges that UMR denied thousands of claims based on diagnosis codes and allegedly failed to comply with the requirements of the [ACA], and the DOL's claims procedures regulation.... [T]he DOL has requested a nationwide injunction against UMR with respect to allegedly improperly denied claims." [Su v. UMR, No. 23-0513 (W.D. Wis. complaint filed Jul. 31, 2023)]
3.  Florida Requires Pharmacy Benefit Managers to Be Licensed Starting January 1
Polsinelli PC Link to more items from this source
Nov. 15, 2023
"The [Office of Insurance Regulation] recently ... published additional information about the application process, including the application forms and instructions ... The Florida Administrator application requirements are some of the most challenging and robust of any state that licenses TPAs."
4.  CMS Halts No Surprises Act IDR Process After Federal Court Sides with Providers on Claim Batching and Increased Fees
Polsinelli PC Link to more items from this source
Aug. 9, 2023
"On Thursday, August 3, 2023, a federal court issued a memorandum and order ... tossing the sharp fee increase to participate in the independent dispute resolution (IDR) process under the No Surprises Act (NSA) and vacating a regulation that significantly limited the ability to batch multiple items and services into a single dispute. This is the third time in approximately 18 months that aspects of the NSA's rules and regulations have been vacated as unlawful." [Texas Medical Association (TMA) v. HHS, No. 23-0059 (E.D. Tex. Aug. 3, 2023)]
5.  Florida Implements PBM Requirements Under the Prescription Drug Reform Act
Polsinelli PC Link to more items from this source
Aug. 7, 2023
"Beginning January 1, 2024, PBMs operating in Florida must continue to be registered with the OIR ... and hold a valid certificate of authority as an Administrator (TPA) in Florida ... [A]ny PBM operating in Florida without a valid certificate of authority as a TPA will be subject to a fine of $10,000 per violation per day. Beginning January 1, 2025, PBMs will be subject to biennial exams to ensure they are in compliance with Florida law."
6.  Practical Considerations for Adding a 401(k) Matching Contribution for Student Loan Payments
Polsinelli PC Link to more items from this source
July 9, 2023
"[N]ext steps for employers ... who are interested in adding a student loan payment matching contribution to their plan: [1] Evaluate potential participation in program ... [2] Model the potential cost ... [3] Review nondiscrimination testing effect ... [4] Assess impact on current programs ... [5] Assess need for system/procedure changes ... [6] Consider privacy protection ... [7] Amend plan document ... [8] Determine communication strategy."
7.  Third Party Administrator and Pharmacy Benefit Manager Licensing and Compliance Developments
Polsinelli PC Link to more items from this source
May 16, 2023
"Florida Governor Ron DeSantis recently signed a new law that significantly increases the regulation of pharmacy benefit managers (PBMs) doing business in Florida. The new law will go into effect on July 1, 2023.... [It] will significantly change how PBMs are regulated in Florida and will dramatically expand the Florida OIR's authority to license and regulate PBMs."
8.  DEA Temporary Rule Extends Telemedicine Flexibilities and Grants Additional Grace Period
Polsinelli PC Link to more items from this source
May 9, 2023
"The temporary rule will take effect on May 11, 2023, and ... [1] Temporarily extends COVID-19 PHE controlled substance prescribing flexibilities through November 11, 2023 ... [2] Grants an additional one-year grace period through November 11, 2024 to patients and practitioners who established a telemedicine relationship on or before November 11, 2023."
9.  New Form 5500 Rules Permit More Plans to Qualify for Audit Exemption
Polsinelli PC Link to more items from this source
Apr. 19, 2023
"The new rules reduce the number of participants in individual account plans that must be counted, which is significant as more plans will qualify for the small plan exemption, allowing them to use the short form for reporting and waive the audit requirement, including the required accountant report. This will result in significant savings for qualifying plans. These rules will primarily impact 401(k) and 403(b) plans[.]"
10.  The Time Is Now for Employers to Prepare for Illinois' Paid Leave for All Workers Act
Polsinelli PC Link to more items from this source
Mar. 29, 2023
"Employers will be prohibited from requiring employees to explain why they are taking leave and to provide supporting documentation. Employees may decide how much of their accrued paid leave to take, but an employer's policy may require that employees take a minimum of two hours of paid leave per occurrence. Employers may develop a notification policy; however, the policy must be reasonable and subject to [specified] limitations[.]"
11.  Federal Agencies Release Final Rule Implementing the No Surprises Act's Independent Dispute Resolution Process
Polsinelli PC Link to more items from this source
Aug. 25, 2022
"The Final Rule ... [makes] clear that IDR entities should determine the out-of-network rate during the IDR process by selecting the offer 'that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties.' The Final Rule also incorporates new requirements intended to promote transparency, consistency and predictability in the IDR process."
12.  Understanding the Expansion of New Mexico’s Paid Sick Leave Law (PDF)
Polsinelli PC Link to more items from this source
Aug. 10, 2022
"Effective July 1, 2022, the 'Healthy Workplaces Act' now requires all private employers in the State of New Mexico, regardless of the size of their business or total workforce population, to provide eligible employees with up to 60 hours of paid sick leave per year for personal health or injury, to care for a family member, or for reasons related to domestic abuse."
13.  District Court Strikes Additional Portions of Regs Implementing No Surprises Act Addressing Air Ambulance Services
Polsinelli PC Link to more items from this source
July 28, 2022
"The court concluded that the portions of the Rule applicable to air ambulance providers 'rewrite[] clear statutory terms' by 'requiring [IDR entities] to presume the correctness of the QPA and then imposing a heightened burden on the remaining statutory factors to overcome that presumption.' " [LifeNet v. HHS, No. 22-162 (E.D. Tex. Jul. 26, 2022)]
14.  Alabama's New Family Leave Law
Polsinelli PC Link to more items from this source
July 6, 2022
"The State of Alabama's 'Adoption Promotion Act' [went] into effect on July 1, 2022, requiring qualifying employers throughout the state to provide eligible employees with up to 12 weeks of unpaid leave for both the birth or care of a child during the first year after the child's birth or placement of an adopted child with the employee."
15.  New York Enacts Legislation Regulating Pharmacy Benefit Managers
Polsinelli PC Link to more items from this source
Apr. 20, 2022
"PBMs must be licensed by January 1, 2023. PBMs which fail to become licensed in New York by January 1, 2023, may be subject to cease and desist orders and/or monetary penalties ... The new law also requires PBMs to file by July 1, 2022 (and thereafter annually by July 1st) ... a report which provides certain financial information requested by the DFS and the terms and conditions of any contact between the PBM and 'any other party relating to PBM services provided to a health plan or provider."
16.  Maryland Enacts New State Paid Family and Medical Leave Entitlement
Polsinelli PC Link to more items from this source
Apr. 11, 2022
"Maryland recently joined nine other states (and the District of Columbia) in providing employees in the state with a right to paid family and medical leave. Although employer contributions to the paid family and medical leave program will not begin until 2023 and employees may not apply for benefits until 2025, when the law goes into effect it will dramatically expand the leave rights available to Maryland employees because the law applies to employees and employers who are not covered by the federal [FMLA]."
17.  Ninth Circuit Reverses Landmark Wit Case Addressing Behavioral Health Coverage
Polsinelli PC Link to more items from this source
Apr. 5, 2022
"Appeals to the full Ninth Circuit and possibly to the Supreme Court are expected, as plaintiffs are likely to argue the appellate court improperly disregarded the district court's factual findings about the plan administrator's conflicts of interest and unreasonable plan interpretations, contrary to the weight of expert testimony on generally accepted standards of care and other evidence.... It seems clear that Congress will be required, and likely motivated, to address underlying issues with parity and equity for behavioral health coverage." [Wit, et al. v. United Behavioral Health, Nos. 20-17363, 21-15193, 20-17364, 21-15194 (9th Cir. Mar. 22, 2022; unpub.)]
18.  DOL Dips Its Toe Into the World of ERISA Plan Cybersecurity
Polsinelli PC Link to more items from this source
Apr. 25, 2021
"Rather than passively accepting a service providers' cybersecurity policies and procedures, the DOL's guidance states that fiduciaries have an obligation to actively inquire about (and if necessary, request changes to) their service providers' cybersecurity policies. The guidance is clear that it is no longer acceptable to merely accept what is presented by a service provider."
19.  Hitting 500: Updated DOL Rule Clarifies Aggregation of Employees Under the FFCRA
Polsinelli PC Link to more items from this source
May 3, 2020
"Employers should exercise caution in oversimplifying the Integrated Employer and Joint Employer analyses to avoid coverage under the Act. An employer who takes the position that they are an Integrated Employer or Joint Employer for purposes of avoiding coverage under the Act may later find they waived their ability to assert they are separate entities in litigation or other disputes."
20.  Court Requires Successor Employer to Continue Retiree Health Benefits Provided by Prior Collective Bargaining Agreement
Polsinelli PC Link to more items from this source
Apr. 9, 2019
"The court noted that 'unlike pension benefits under ERISA, insurance benefits, such as the benefits at issue in this case, do not automatically vest' and an employer 'may create vested welfare benefits by contract.' The defendants argued that Section 6 of the CBA limited lifetime health benefits because the phrase 'except as the Company and the Union may agree otherwise' incorporated Section 7's language permitting unilateral termination. The court disagreed, noting that Section 7 referred only to termination of the CBA, and did not apply to health benefits under Section 6." [Stone v. Signode Industrial Group, LLC, No. 17-5360 (N.D. Ill. Mar, 13, 2019)]
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