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[Official Guidance] IRS Q&As: Information Reporting by Employers on Form 1094-C and Form 1095-C
Updated Mar. 22, 2019. "These Q&As provide additional information about completing Form 1094-C and Form 1095-C for calendar year 2018 that are to be filed in 2019. The Q&As may be used in conjunction with the Instructions for Forms 1094-C and 1095-C, which provide detailed information about completing the forms." (Internal Revenue Service [IRS])
District Court Ruling on Insurer's Mental Health Treatment Guidelines May Become National Template
"[This court's] recognition that 'safe' does not equate to 'effective' demolishes the myth that pushing for lower levels of care is acceptable care. The ruling also precludes insurers from denying claims where treatment is necessary to prevent further medical deterioration even if the patient has plateaued and no further improvement is expected. [This] ruling will dictate the future of all litigation over behavioral health care, which is already evolving away from challenges brought under the [MHPAEA] into arguments relating to the legitimacy of clinical guidelines utilized to determine both coverage and level of care." [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Mar. 5, 2019)] (DeBofsky, Sherman & Casciari, P.C.)
ERISA Plan Controversies: Rising the Stakes for Unprepared Sponsors and Fiduciaries (PDF)
16 presentation slides. Topics include: [1] What's the exposure? [2] How do these lawsuits get filed? [3] Modus operandi of plaintiffs' lawyers. [4] A glimmer of hope: victories in two recent trials. [5] Ways to minimize exposure to lawsuits challenging fees and investment selection. [6] Lawsuits relating to company stock and actuarial equivalence. [7] Lawsuits against health and welfare plans challenging fees. [8] ERISA issues to watch. (McDermott Will and Emery)
[Guidance Overview] DOL Fact Sheet: Adjusting ERISA Civil Monetary Penalties for Inflation (PDF)
"The Federal Civil Monetary Penalties Inflation Adjustment Act Improvements Act of 2015 requires EBSA to adjust ERISA's civil monetary penalties annually for inflation. ERISA monetary penalties assessed by a court (e.g., sections 502(c)(1) and (3)) rather than EBSA are not adjusted for inflation under the 2015 Inflation Act.... The table [in this Fact Sheet] shows the penalty amounts enforceable by EBSA for penalties assessed after January 22, 2019 for violations occurring after November 2, 2015." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
What Can We Learn From 2018's Record-High HIPAA Penalties?
"While most of the penalties were assessed against providers, there are some lessons employers with health plans can learn from these enforcement efforts: [1] It's not the breach; it's the lack of compliance.... [2] We are (still) living in a material world.... [3] BAAs Matter.... [4] Those who know shouldn't speak." (HUB International)
Staying on the Level: Keeping Your Level-Funded Plan Compliant
"Even though insurance caps the employer's financial liability to the pre-set monthly contribution, a level funded plan is fundamentally a self-funded plan. As a result, it has to comply with the federal rules governing self-funded plans. These include: Use of plan assets ... ACA reporting.... HIPAA privacy and security.... 105(h) nondiscrimination rules.... On the other hand, because level funded plans are not insured plans, they are exempt from state regulation." (HUB International)
[Guidance Overview] Changing Cybersecurity Baselines?
"On March 5, 2019 the [FTC commissioners] voted 3-2 to issue a proposed amendment to its Standards for Safeguarding Customer Information Rule ... The Proposal ... if finalized, could raise the baseline for plan fiduciaries when developing prudent cybersecurity programs.... [W]hile the steps outlined in the FTC's proposal do not apply to many financial institutions, the Proposal provides insight into changes that the other regulators could make and what plans and participants may expect." (Groom Law Group)
Key Takeaways from Recent ERISA Fiduciary Breach Decision on Behavioral Standards of Care
"The court found that an emphasis on cost-cutting tainted the development of the relevant internal guidelines.... Employers usually would not be closely involved in the development or application of this sort of clinical criteria, and claims administrators may be reluctant to turn over copies of their internal guidelines. Employers, though, may find that [this decision] will prompt them to renew requests for such guidelines and to ask some timely questions of their behavioral health claims administrators." [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Mar. 5, 2019)] (Ogletree Deakins)
[Official Guidance] Text of CMS Final 2020 Actuarial Value Calculator Methodology (PDF)
25 pages. "The AV Calculator [XLSM] represents an empirical estimate of the AV calculated in a manner that provides a close approximation to the actual average spending by a wide range of consumers in a standard population. This document is meant to detail the specific methodologies used in the AV calculation." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Death by a Thousand Clicks: Where Electronic Health Records Went Wrong
"Electronic health records were supposed to do a lot: make medicine safer, bring higher-quality care, empower patients, and yes, even save money.... Rather than an electronic ecosystem of information, the nation's thousands of EHRs largely remain a sprawling, disconnected patchwork. Moreover, the effort has handcuffed health providers to technology they mostly can't stand and has enriched and empowered the $13-billion-a-year industry that sells it." (Kaiser Health News and Fortune Magazine)
Summary Plan Descriptions: You Gotta Provide Them, So Make the Most of Them
"If your participants don't understand the information contained in their SPDs, they may make unsound, and potentially costly, benefits decisions. To determine whether your SPDs have readability issues, you should re-read the SPDs from a participant's viewpoint ... Providing updated SPDs every five or 10 years to former retirement plan participants with vested benefits, retirees receiving benefits, and beneficiaries receiving benefits may seem like an unnecessary cost, given that those individuals won't be affected by most plan changes. To lessen the burden on plan administrators, the ERISA rules include an alternative distribution method for such situations." (Foley & Lardner LLP)
IRS Information Letter Addresses Return of HSA Contributions to an Employer
"If there is clear evidence of an administrative or process error, an employer may request that the contributions it made to an employee's HSA be returned. This correction should put the employer and employee in the same position that they would have been in if the error had not occurred." (United Benefit Advisors)
[Guidance Overview] Completing Form 1094-C: How to Unlock the Section 4980H Affordability Safe Harbors for a Month
"By far the most prevalent error that leads to an employer receiving a Letter 226J is the employer checking the 'No' box or forgetting to check the 'Yes' or 'No' box on line 23 (or, alternatively, on some of the lines from line 24 through line 35). This article explains why making this mistake leaves employers exposed to the section 4980H penalty even for employees whom the employer has coded with a seemingly protective offer code (1A, 1C, 1E, etc.) and an affordability safe harbor (2F, 2G, or 2H)." (Accord)
Time Limit for Appeal Started Upon Notice of Termination of LTD Benefits
"The First Circuit held that a plaintiff failed to timely exhaust her administrative remedies under a long-term disability plan because the plan's 180-day time limit for submitting appeals commenced on the date the plaintiff received notice of the decision that it was going to terminate her long-term disability benefits, not the actual date her benefits were terminated.... [T]he Court rejected plaintiff's argument that the doctrine of substantial compliance and the state's notice-prejudice rule somehow excused her late-filed appeal." [Fortier v. Hartford Life & Accident Ins. Co., No. 18-1752 (1st Cir. Feb. 20, 2019)] (Proskauer's ERISA Practice Center)
[Official Guidance] CMS List of Enhanced Direct Enrollment Approved Partners (PDF)
"Enhanced direct enrollment ... allows CMS to partner with the private sector to provide a more user-friendly and seamless enrollment experience for consumers by allowing them to apply for and enroll in an Exchange plan directly through an approved issuer or web-broker ... The Public List of third-party entities approved to use an enhanced direct enrollment pathway is provided [in this document]. This list is current as of December 13, 2018[.]" [Unnumbered document, Mar. 11, 2019] (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Creative Solutions to Engage Employees in Corporate Wellbeing Programs
"[One company] started to think well outside the proverbial box by using three unique tactics to engage employees: [1] Introducing a musical cue and making it fun (with a side of pop culture) ... [2] Make models of your employees -- literally ... [3] Participation at every level." (HealthFitness)
[Guidance Overview] Plans Cannot Prevent Participant from Appointing an Authorized Representative
"[The DOL] has reiterated that an ERISA-covered plan cannot prevent a plan participant from appointing an authorized representative for initial claims and for claims appeals.... The DOL letter only refers to the appointment of an authorized representative and does not discuss the assignment of benefits.... An assignment transfers ownership of a claim to a third party, giving it standing to assert those rights and to sue on its own behalf. The appointment of an authorized representative, on the other hand, does not transfer an ownership interest in the claim." (The Wagner Law Group)
Lockton Spinoff Mylo Aims to Be 'Amazon' of Insurance
"In three years, Mylo ... has sold more than 20,000 policies to more than 14,000 clients.... Mylo is a digital insurance broker that collects client information and then shops the market to find the best combination of coverage and price to meet a client's needs. Technology to do this has been available for a while, but typically it has been deployed internally, by brokers themselves. Mylo created an easy-to-use client-facing system." (The Business Journals)
DOL Explains ERISA Claims Procedure Rules for Patient-Authorized Representatives
"A plan's procedure for authorized representative designations may include requiring a written authorization signed by the claimant on a form specified by the plan.... [B]ecause information disclosed to an authorized representative during the claims process will likely contain PHI, it is advisable for the plan to obtain a HIPAA-compliant authorization from the claimant." (Thomson Reuters / EBIA)
[Official Guidance] Text of IRS Disaster Relief Notice AL-2019-01, for Alabama Victims of Severe Storms, Tornadoes and Straight-Line Winds
"Victims of the severe storms, tornadoes, and straight-line winds that took place on March 3, 2019 in Alabama may qualify for tax relief ... [A]ffected taxpayers in certain areas will receive tax relief. Individuals who reside or have a business in Lee County may qualify for tax relief.... [C]ertain deadlines falling on or after March 3, 2019 and before July 31, 2019, are granted additional time to file through July 31, 2019" (Internal Revenue Service [IRS])
[Official Guidance] Text of 2018 IRS Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans (PDF)
22 pages, Mar. 4, 2019. "Salary reduction contributions to your health FSA for 2018 are limited to $2,650 a year." (Internal Revenue Service [IRS])
Mental Health Treatment Denied to Customers by Giant Insurer's Policies, Judge Rules
"In his 106-page decision, Judge Spero described the company's guidelines as 'unreasonable and an abuse of discretion' and having been 'infected' by financial incentives meant to restrict access to care. 'There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members' underlying conditions,' he said. He dismissed much of the testimony by UnitedHealth's experts as 'evasive -- and even deceptive.' " [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Mar. 5, 2019)] (The New York Times; subscription may be required)
United Loses in Court on Behavioral Health Coverage Guidelines
"A federal judge ruled Tuesday that United Behavioral Health breached its fiduciary duty to patients by using unreasonable and overly restrictive guidelines to make coverage decisions for tens of thousands of mental health and substance abuse patients. The decision, if upheld on appeal, could have wide ramifications of what insurers must cover in the fast-growing behavioral healthcare sector." [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Mar. 5, 2019)] (Modern Healthcare Online; free registration required)
Insurer Skips Doctors, Sends Checks Directly to Patients, Prompting Lawsuit
"The suit by Sovereign Health highlights part of an ongoing war between insurance companies and [health care] providers over payment and billing issues, one that puts the patient right in the middle of the fighting by sending payments straight to patients after they seek out-of-network care. Patients are supposed to send the money on to providers. Many times, they do; other times, they don't." (CNN)
Lessons for Employers from Recent Fiduciary Litigation Involving Health & Welfare Benefit Plans
"These lawsuits should prompt you to question how your ERISA-covered welfare benefit plans are being administered and craft new approaches to limit potential breach of fiduciary duty claims.... [1] Maintain legally compliant plan documents and summary plan descriptions (SPDs) ... [2] Distribute SPDs and other ERISA-required disclosures to employees on a timely basis ... [3] Maintain oversight of plan administrators and regularly assess plan operations for fiduciary compliance." (Fisher Phillips)
[Official Guidance] Text of EBSA Information Letter: Application of the Authorized Representative Provisions of DOL Benefit Claims Regs (PDF)
"Although a plan may establish reasonable procedures for determining whether an individual has been authorized to act on be half of a claimant, the procedure cannot prevent claimants from choosing for themselves who will act as their representative or preclude them from designating an authorized representative for the initial claim, an appeal of an adverse benefit determination, or both. The plan must include any procedures for designating authorized representatives in the plan's claims procedures and in the plan's summary plan description (SPD) or a separate document that accompanies the SPD." [Feb. 27, 2019 letter to Jonathan Sistare.] (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
[Official Guidance] Text of IRS Q&As on Information Reporting by Health Coverage Providers (Section 6055)
  • Basics of Provider Reporting: Questions 1-3
  • Who is Required to Report: Questions 4-14
  • What Information Must Providers Report: Questions 15-18
  • How and When to Report the Required Information: Questions 19-28
  • Extended Due Dates and Transition Relief: Questions 19-35
[Updated Mar. 2, 2019, replacing prior version of Feb. 9, 2018.] (Internal Revenue Service [IRS])
[Official Guidance] Text of IRS Q&As on Corrected, Incorrect or Voided Forms 1095-A
"The information provided on this page relates to corrected or voided Forms 1095-A for tax years 2014 through 2017. There are differences amongst the years, be sure to refer to the information for the year that affects you." [Updated Mar. 2, 2019, replacing prior version of Feb. 5. 2018.] (Internal Revenue Service [IRS])
[Official Guidance] Text of IRS Q&As on Reporting of Offers of Health Insurance Coverage by Employers (Section 6056)
"Certain employers are required to report to the IRS information about whether they offered health coverage to their employees and if so, information about the coverage offered. This information also must be provided to employees. These FAQs address these reporting requirements."
  • Basics of Employer Reporting: Questions 1-3
  • Who is Required to Report: Questions 4-11
  • Methods of Reporting: Questions 12-16
  • How and When to Report the Required Information: Questions 17-24
  • Designated Government Entity: Questions 25-28
  • Other Third Party Service Providers: Questions 29
  • Extended Due Dates and Transition Relief for 2015 and 2016 Reporting: Questions 30-34
  • Additional Information
[Updated Mar. 2, 2019, replacing prior version of Nov. 3, 2016.] (Internal Revenue Service [IRS])
HSA Compliance Steps for Employers (PDF)
"How do your organization's educational materials assist employees with determining HSA eligibility? ... What changes related to HSA contribution eligibility does your organization track? ... Has your organization established which circumstances permit it to recoup excess HSA contributions? ... How will possible inclusion of HSA contributions for purposes of Cadillac Plan tax calculations impact your employee benefits strategy in the future?" (Gallagher)
DOL Is Rejecting Form 5500 Filings from Professional Employer Organizations
"DOL is rejecting filings from 2016 where [Professional Employer Organizations (PEOs)] have used a coding system to protect the names of their clients. Both retirement plan and health plan Form 5500s have been rejected by DOL." (NAPEO [National Association of Professional Employer Organizations])
What Are the Notice Requirements for a Health Plan That Requires Primary Care Provider Referrals?
"The required notice must be provided to each plan participant describing the plan's primary care physician requirement and the rights explained in the preceding paragraph. It must be provided whenever a summary plan description (SPD) or other similar description of plan benefits is provided to a participant." (Thomson Reuters / EBIA)
[Official Guidance] Text of IRS Publication 598: Tax on Unrelated Business Income of Exempt Organizations (PDF)
23 pages; Feb. 26, 2019. "This publication covers the rules for the tax on unrelated business income of exempt organiizations. It explains: [1] Which organizations are subject to the tax; [2] What the requirements are for filing a tax return; [3] What an unrelated trade or business is; and [4] How to figure unrelated business taxable income." (Internal Revenue Service [IRS])
Navigating Telehealth Benefits Compliance Issues
"[If] telehealth benefits are available to employees not enrolled in the medical plan, the employer will have to ensure that the benefit is either: [1] reflected in the Form 5500 and the plan document ... or [2] that a separate 5500 filing is made and a separate plan document is maintained ... [and] separate COBRA administration will be required.... Because the obligation to comply with MHPAEA falls on group health plans, employers should not assume that a vendor's standard offering includes MH/SUD services ... [D]iffering -- and evolving -- state laws also affect these benefits." (Buck)
Potential Fiduciary Concern: Cross-Plan Offsets
"In basic terms, cross-plan offsetting is when a payment from one plan is reduced to 'offset' an overpayment made to the same provider from a different plan.... Employers with self-funded plans should consider taking the following steps: [1] Talk with your third-party administrator (TPAs). Ask if they engage in cross-plan offsetting. [2] If they do, ask if you can opt out. Some TPAs allow plans to opt out of this practice. [3] If they do, and you can't opt out, consider switching TPAs. [4] If you're switching TPAs (or thinking about it), ask the vendors you're considering if they engage in cross-plan offsetting and if you can opt out." [Peterson v. UnitedHealth Group Inc., No. 17-1744 (8th Cir. Jan. 15, 2019)] (HUB International)
How an Employer Can Check Its Service Provider's Work on the Forms 1094-C and 1095-C
"Is the 'Yes' box checked on line 23 (or, alternatively, on lines 24 through 35) of the Form 1094-C? ... Make sure line 14 is completed on all 12 months for each Form 1095-C.... Is line 15 completed properly? ... Are there any months in which line 16 is left blank? ... [If] an employer received a Letter 226J for 2015 or 2016 (the IRS has not started to send out the Letter 226J for 2017 yet), it is likely the service provider has fallen short of its obligation to the employer." (Accord)
[Guidance Overview] New Interoperability Rule Extends to QHP Insurers
"CMS lays out a vision where a patient's health information can move seamlessly between health plans, providers, and post-acute care settings.... The rule applies to payers that offer QHPs through and outside of the federal marketplace, Medicare Advantage plans, Medicaid and CHIP managed care organizations, and state Medicaid and CHIP agencies that offer fee-for-service programs. The rule would not extend to insurers that offer employer-sponsored health insurance or insurers that offer stand-alone dental plans." (Katie Keith, in Health Affairs)
Claims Denials and Appeals in ACA Marketplace Plans
"Together [130] issuers reported 229.8 million in-network claims received, of which 42.9 million were denied, for an average in-network claims denial rate of 19% ... [D]enial rates by issuers were highly variable, ranging from 1% to 45% of in-network claims. Overall for 2017, 40 of the 130 reporting Healthcare.gov major medical issuers had a denial rate for in-network claims of 10% or lower." (Henry J. Kaiser Family Foundation)
ACA Landscape Shifts Again: What's an Employer to Do?
"[E]mployers with 50 or more full-time or full-time equivalent employees must continue to provide minimal essential overage that is affordable and provides minimum value to their full-time employees, or risk penalties under the ACA's 'employer mandate'. (Similarly, the ACA's insurance mandates for coverage of dependents until age 26, no exclusions for pre-existing conditions, etc. also remain in place.) Certain states also have their own individual mandates that remain in effect." (Jackson Lewis P.C.)
First Circuit: Substantial Compliance Doctrine Does Not Save Participant's Untimely ERISA Administrative Appeal
"The First Circuit rejected Plaintiff's argument that the 180-day period should run from the date of the termination of benefits and not from the date of notice.... The court also found that Hartford followed the terms of the Plan, which were consistent with ERISA's requirements, when it provided her notice of the benefit determination and her right to appeal within 180 days. Although the doctrine of 'substantial compliance' has been applied to excuse an insurer's failure to comply with ERISA's notice requirements, it does not apply to late appeals by claimants." [Fortier v. Hartford Life & Accident Ins. Co., No. 18-1752 (1st Cir. Feb. 20, 2019)] (Kantor & Kantor)
CMS Data Match Reporting Suspended
"Although the IRS-SSA-CMS Data Match process has ended, CMS encourages employers to consider entering into an Employer Voluntary Data Sharing Agreement (VDSA) with CMS to exchange GHP and Medicare entitlement data. Some large employers have already entered into VDSAs with CMS to share coverage information." (HUB International)
Sixth Circuit Finds Insurance Agents Properly Classified as Independent Contractors, Dealing Fatal Blow to ERISA Class Action
"[A] divided Sixth Circuit reversed a district court's finding that the agents were 'employees' in an ERISA class action suit brought on behalf of several thousand current and former insurance agents, instead finding that a proper weighing of the Supreme Court's Darden factors established that the insurance giant properly classified them as independent contractors. In particular, in the 'legal context' of ERISA eligibility, 'control and supervision is less important' than the financial structure of the parties' relationship." [Jammal v. American Family Ins. Co., No. 17-4125 (6th Cir. Jan. 29, 2019] (Wolters Kluwer; free registration required)
Hartford Gets Pro-Insurer Ruling on Late-Filed Benefit Appeals
"New Hampshire's 'notice-prejudice' rule -- which makes it harder for insurers to deny late-filed claims -- doesn't apply to benefit claims under [ERISA], the U.S. Court of Appeals for the First Circuit held Feb. 20. The court followed decisions of the Seventh and Ninth circuits, adding that 'no federal court has applied any state's common law notice-prejudice rule' to a late-filed appeal made to an ERISA plan." [Fortier v. Hartford Life & Accident Ins. Co., No. 18-1752 (1st Cir. Feb. 20, 2019)] (Bloomberg BNA)
Changes Proposed by HHS Will Affect Employer-Sponsored Health Plans
"For 2020, ... the out-of-pocket maximums would be $8,200 for self-only coverage and $16,400 for family coverage (compared to $7,900 and $15,800 for 2019).... HHS is also proposing to allow health plans (both fully-insured and self-funded) to exclude brand name drugs from essential health benefits if a generic equivalent is available. Plans would still need to have an exception process that would allow individuals to access the brand drugs, if necessary." (HUB International)
Common Multiemployer Plan Reporting Pitfalls for Employers
"Understanding common errors in benefit reporting will help you avoid shocking discrepancy letters from payroll auditors about owing unreported benefit contributions to a multiemployer plan.... Hours worked versus hours paid ... Omitted weeks ... Probationary periods and extended coverage ... Report all eligible employees ... Reconcile remittances to employee payroll deductions." (Lindquist CPA)
When May an Employer Recover Mistaken HSA Contributions?
"Generally, if there is clear documentary evidence that an administrative or process error (by the employee or trustee) caused the excessive fund contribution, the employer may request the financial institution return the amounts to the employer, ensuring such correction places the parties in the same position as they would have been if the error had not occurred." (Compliance Dashboard)
[Guidance Overview] The Cost of Non-Compliance: DOL Announces Increased Penalties for 2019
"[T]hese rates are for penalties assessed after January 23, 2019 with respect to violations committed after November 2, 2015, when the inflation adjustment was approved. The cost-of-living adjustment is based on the Consumer Price Index for all Urban Consumers, which resulted in roughly a 2.5% increase." (Winston & Strawn LLP)
[Guidance Overview] Why Your Group Health Plan Should Keep Its Grandfathered Status, and How to Do So
"A grandfathered group health plan is NOT subject to some of the more cumbersome requirements of the ACA.... To maintain grandfathered status, the plan must maintain records documenting the terms of the plan in connection with the coverage in effect on March 23, 2010, and any other documents necessary to verify, explain, or clarify its status as a grandfathered health plan. It must make these records available for examination on request." (ERISA Lawyer Blog)
Lowering Drug Costs: New Proposed Rule Targets Drug Rebates
"Employers with self-funded plans, or who sponsor retiree plans, especially those providing plans in place of Medicare Part D for whom they receive a subsidy, should begin discussions with their PBMs to understand the potential implications to their plan and contracts. Others should monitor communications from their carriers and brokers to determine any cost shifting that may transfer over to the private market." (OneDigital Health and Benefits)
[Official Guidance] Text of CMS Health Insurance Exchange Guidelines: Auditor Operational Readiness Reviews for the Enhanced Direct Enrollment Pathway and Oversight Requirements (PDF)
42 pages. "[CMS] is continuing to implement Enhanced Direct Enrollment (EDE), an optional program allowing EDE Entities (i.e., Qualified Health Plan [QHP] issuers and web-brokers seeking to participate in EDE) registered with the Federally-facilitated Exchange [FFE] and State-based Exchanges on the Federal Platform (SBE-FPs) to host an application for Marketplace coverage on their own websites.... This set of guidelines outlines EDE program and audit requirements for PY 2019 ... and PY 2020.... The primary audit submission window for prospective EDE Entities interested in implementing EDE in calendar year 2019 is from April 1, 2019 to June 30, 2019." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Ohio's New Cybersecurity Requirements on Insurers and Other Licensees Set to Take Effect in March
"Ohio joins South Carolina and Michigan in recent adoptions of the model law.... [Ohio's law] establishes broad data security requirements and imposes standards for investigating and reporting data security incidents. Licensees have one year to comply with most of the new cybersecurity requirements." (Vorys)
Anyone Eligible for Part D Prescription Drug Coverage? CMS Report Required
"This filing requirement applies to all group health plans that cover anyone eligible for the Medicare Part D prescription drug program, whether as an active employee, spouse, dependent or retiree. This disclosure is in addition to the Notice of Creditable (or Non-creditable) Coverage that you provide annually to Medicare-eligible participants in the fall." (Kushner & Company)
[Guidance Overview] Not Offering Health Coverage? Reporting May Still Be Required
"[T]he requirement to report about coverage offered (or not offered) is independent of the ACA employer mandate. This means that any ALE that decides it's less expensive to simply pay the employer mandate penalty for all full-time workers must still file its IRS Forms 1095-C." (HUB International)
FitBit Devices from Your Employer Can Be Used in Workplace Wellness Programs -- But How Much Information Is Too Much?
"On his 21st day back at work after a heart attack and triple bypass surgery, Chris Zubko received a call from the main office. Through an app on his phone, his boss was literally monitoring every step of Zubko's recovery.... Welcome to a rapidly growing phenomenon in the workplace: constant health surveillance." (The Washington Post; subscription may be required)
Is a Health Insurance Captive Right for You?
"What is a group captive and how does it work? ... What provider network is used in a captive arrangement? ... What is the cost to the employer? What about the employee? ... What are the protections for the employer from severe high claimants? ... Is the Captive Premium expensive? ... How do I go about joining a captive and is there a capital contribution? ... How are wellbeing programs worked into this type of insurance? ... What are the benefits to participating in a captive as opposed to traditional health insurance?" (CBIZ)
Court Rejects Claims for Improper Denial of Wilderness Therapy Program Benefits
"Plan exclusions of residential mental health treatment in a wilderness setting continue to generate litigation.... Although plan participants have met with varying degrees of success, the attention generated by these cases -- along with the DOL's focus on mental health parity enforcement -- suggests that more cases will follow." [H.H. v. Aetna Ins. Co., No. 18-80773 (S.D. Fla. Dec. 13, 2018)] (Thomson Reuters / EBIA)
[Guidance Overview] DOL Reaffirms ERISA Preemption of State Wage Withholding Laws
"This information letter, dated December 4, 2018, responds to a question from an insurers' association about whether ERISA would preempt a state law that prohibits an employer from implementing automatic enrollment arrangements under which the employer automatically enrolls an employee in the employer's disability plan, and contributes part of the employee's wages as plan contributions (unless the employee affirmatively opts out of the arrangement)." (Winston & Strawn LLP)
Remote Prescribing Trends in Telehealth
"On the federal level, we should expect to see promulgation of regulations by the U.S. Drug Enforcement Administration outlining the special registration exception as mandated by the SUPPORT Act passed in 2018, allowing a pathway for health care providers to prescribe controlled substances through telemedicine ... On the state level, as telehealth becomes a mainstream mode of health care delivery, we are seeing states attempt to legislate telehealth services in more targeted, and potentially contentious, areas of health care." (Epstein Becker Green)
[Guidance Overview] IRS Provides Additional Examples Where Employers May Recover HSA Contributions
"[Information Letter 2018-0033] confirms that where there is clear documentary evidence demonstrating that there was an administrative or process error, the employer may request the return of the contributed amounts, with any correction placing the parties in the same position as if the error had never occurred." (The Wagner Law Group)
2019 ACA Compliance Overview: Cost-Sharing Limits
"Review your plan's out-of-pocket maximum to make sure it complies with the ACA's limits for the 2019 plan year ($7,900 for self-only coverage and $15,800 for family coverage).... For 2019, the out-of-pocket maximum limit for HDHPs is $6,750 for self-only coverage and $13,500 for family coverage.... [C]onfirm that the plan will coordinate all claims for EHBs across the plan's service providers or will divide the out-of-pocket maximum across the categories of benefits, with a combined limit that does not exceed the maximum for 2019." (Strategic Benefit Services)
 
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