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Health plans - design

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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.)
GAO Report on Private Health Insurance: Enrollment Remains Concentrated Among Few Issuers, Including in Exchanges
"Enrollment in private health insurance plans continued to be concentrated among a small number of issuers in 2015 and 2016. In the overall large group market, small group market, and individual market, the three largest issuers held 80 percent of the market or more in at least 37 of 51 states.... For the small group market exchanges, in each year, three or fewer issuers held 80 percent or more of the market in at least 42 of the 46 state exchanges for which GAO had data." [GAO-19-306, Mar. 21, 2019] (U.S. Government Accountability Office [GAO])
Why Employee Benefits Must Be Part of Your Business Strategy (PDF)
"Just as asking customers about your products can yield important information, asking employees how they feel about their benefits can add great value.... Questions to ask should include: [1] What is your overall perception of the benefit plans? ... [2] How are you and your family using the benefits? [3] How satisfied are you with the plan? [4] What would you do to improve the plan's effectiveness?" (CBIZ)
GAO Report: Air Ambulance -- Available Data Show Privately-Insured Patients Are at Financial Risk
"69 percent of about 20,700 transports in the data set were out-of-network in 2017. This is higher than what research shows for ground ambulance transports (51 percent in 2014 according to one study) and other emergency services.... GAO reviewed over 60 consumer complaints received by two of GAO's selected states -- the only states able to provide information on the amount of individual balance bills -- and all but one complaint was for a balance bill over $10,000." [GAO-19-292; Mar 20, 2019] (U.S. Government Accountability Office [GAO])
Five New Massachusetts Bills Propose Telehealth Insurance Coverage, Practice Standards
"[Four of the] bills require certain groups or divisions to provide coverage for telemedicine services under varying conditions.... HB 917 (An Act to Facilitate the Provision of Telehealth Services) ... would not require health insurance plans to cover telehealth services. Instead, it proposes definitions, practice standards, prescribing, and informed consent rules for telehealth services." (Foley & Lardner LLP)
Highlights of 9th Annual Healthcare Industry Pulse Survey
"[F]ully one-third of healthcare executives surveyed ... believe non-healthcare market entrants could upend industry business models.... [N]early 40% of respondents said a market in which the majority of value-based relationships include both upside and downside shared-risk remains three to five years off -- a concerning finding that might indicate payers and providers continue to struggle in their efforts to scale complex, value-based care and reimbursement models from pilot to production." [Free registration required for download of full survey results.] (Change Healthcare)
Reasons to Be Skeptical of the Workplace Wellness Industry
"[T]he workplace wellness industry has more than quadrupled since 2011, drawing in $8 billion in annual revenue and covering almost one in three in American workers.... [A] rigorous study of a comprehensive workplace wellness program concludes that it didn't change employees' behavior or health care costs in the first year. Employees who took part didn't become healthier or more productive, and were not more likely to go to the gym or run in a local race. Total health care costs didn't drop, either." (Scientific American)
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)
[Guidance Overview] Will Grandfathered Plans be Rescued?
"[T]he Departments reiterate that there is no authority for non-grandfathered plans to become grandfathered; put another way, if a plan lost grandfathering status (or never had it), it's unlikely that the Departments will issue rules which allow grandfathered status to be conferred or restored. What is clear, however, is that the Departments are looking for ways to relax the grandfathering requirements and breathe new life into existing grandfathered plans." (Mintz)
[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])
HHS Provides Recommendations to Reform the Health Care System
"[HHS] recommends increasing provider mobility by allowing easier transfer of board licensing across states. The out-of-state issue is particularly relevant for telehealth, since it would preclude physicians from practicing 'out of state' if the patient is calling in across state lines.... HHS also proposes loosening state regulation of network adequacy standards ... this would drive down cost but decrease choice.... HHS argues for more high-deductible health plans (HDHP).... HHS also supports having the government collect quality measures ... [and] recommends pivoting away from provider value-based purchasing system, as they are two burdensome, too crude, and sacrifice unmeasured quality for measured quality[.]" (Healthcare Economist)
ACA Litigation Round-Up: Risk Corridors, CSRs, AHPs, and Short-Term Plans
"Many continue to watch the global challenge to the ACA in Texas (now pending before the Fifth Circuit Court of Appeals with the next round of briefs due in late March), especially after a Maryland's bid to have the ACA declared constitutional was dismissed because the state did not have standing to sue.... This post provides a brief status update on ongoing litigation over the risk corridors program, cost-sharing reductions, the risk adjustment program, association health plans, and short-term plans." (Katie Keith, in Health Affairs)
What Does the Future Hold for Employer-Sponsored Health Plans?
"The employment-based health benefits system has a number of advantages over various alternatives.... One of the shortcomings is that it does not guarantee universal coverage, which a Medicare-for-all system could do.... While employment-based coverage is the largest tax expenditure in the U.S. budget, it is also the least per person when compared to other health-coverage-related subsidies.... Capping, reducing, or eliminating the tax preference could generate additional tax revenue to reduce the budget deficit and/or pay down the federal debt." (Employee Benefit Research Institute [EBRI])
The State of Employer-Sponsored Healthcare
"[K]ey areas of employer frustration: ... [1] Consolidated medical and pharmacy benefit manager vendor markets means less competition, resulting in higher prices for employers.... [2] Providers are incented to perform more services rather than improving the quality of care ... [3] Most large employers self-insure their health benefits programs, thereby bearing all of the cost escalation risk.... [4] The current prescription drug supply chain model lacks transparency ... [5] Employers perceive that market players (i.e., doctors, hospitals, pharmaceutical companies, insurers, and even brokers) are mostly vested in the status quo, making change slow and difficult." (Managed Healthcare)
Paying Patients to Switch: Impact of a Rewards Program on Choice of Providers, Prices, and Utilization
"For 131 elective services, patients who received care from a designated lower-price provider received a check ranging from $25 to $500, depending on the provider's price and service. In the first twelve months of the program we found a 2.1 percent reduction in prices paid for services targeted by the rewards program. The reductions in price resulted in savings of $2.3 million, or roughly $8 per person, per year. These effects were primarily seen in magnetic resonance imaging and ultrasounds, with no observed price reduction among surgical procedures." (Health Affairs; purchase required for full article)
Is Your Company a Good Fit for Onsite Wellness?
"[1] Does your organization already have a health strategy in place? ... [2] What are your organization's goals? ... [3] Is there a culture of trust and employee engagement? ... [4] Where do employees work? ... [5] What is the size and demographic of the eligible population? ... [6] What medical services are needed? ... [7] Is your organization self-insured and looking for ways to stabilize the upward trend of medical cost? " (Marathon Health)
Cadillac Tax Repeal on the Horizon?
"Senator Martin Heinrich introduced the Middle Class Health Benefits Tax Repeal Act of 2019 [S.684] in the Senate on March 6, which has already secured 23 co-sponsors (12 Republican, 11 Democrat). Comparable legislation [H.R.748] has been pending in the House since January 2019, with similar bi-partisan support (of the 238 co-sponsors, 110 are Republicans and 128 are Democrats)." (Mayer Brown)
The 'Medicare for All' Continuum: A New Comparison Tool for Congressional Health Bills Illustrates the Range of Reform Ideas
"[A] closer look at recent congressional bills introduced by Democrats reveals a set of far more nuanced approaches to improving the nation's health care system than the term 'Medicare for All' suggests.... [A] new Commonwealth Fund interactive tool ... illustrates the extent to which each of these reform bills would expand the public dimensions of our health insurance system, or those aspects regulated or run by state and federal government." (The Commonwealth Fund)
[Opinion] Reducing Individual Market Premiums to Expand Access to Coverage and Care (PDF)
"The individual market ... should be strengthened to make coverage more affordable while protecting those with pre-existing conditions. To achieve this, BCBSA recommends that policymakers take three critical steps: [1] Revise federal assistance to help more people afford coverage; [2] Enact policies to lower costs and remove financial barriers to accessing care. [3] Improve outreach to encourage people to obtain and maintain insurance Taken together, ... these three actions would reduce the average individual market premium by 33 percent, while enabling an additional 4.2 million people to obtain ACA coverage." (BlueCross BlueShield Association)
[Opinion] The Pros and Cons of Single-Payer Health Plans
"[T]his brief presents both a general picture of the most frequently mentioned single-payer proposal, and [delineates] the advantages and disadvantages of the approach without taking a position on its advisability.... The authors first make five contextual points that are critical to better understanding the debate around single-payer plans, as well as a list of pros and cons." (Urban Institute)
[Guidance Overview] Overview of Section 1332 State Relief and Empowerment Waiver Concepts (PDF)
19 presentation slides. "CMS released four waiver concepts for states' use to promote more affordable, flexible health insurance coverage options through State Relief and Empowerment Waivers. CMS is providing states with these waiver concepts in an effort to spur innovation, reduce burden for states with potentially limited policy resources or legislative schedules, and to illustrate how states might take advantage of new f lexibilities provided in recently released guidance." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Administration Budget Proposal Includes ACA Repeal, Medicaid Cuts In Budget
"The [ACA] would be replaced with grants that states could use to subsidize private insurance coverage, and Medicaid would be replaced with a block grant instead of the current open-ended federal commitment. Future federal spending increases would be tied to the rate of general inflation, which is lower than health care inflation." (
'Telemental' Health Benefits: Traps for Employers
"The marketplace has [developed] a host of mobile applications that can ... provide users with direct access ... to health coaches and other mental health care professionals, often referred to as telemental health benefits.... If the mobile health app provides access to mental health counseling services and treatment, i.e. medical care, and those services are funded by the employer, the benefit is likely a group health plan subject to ERISA.... If properly designed, [an] EAP/telemental health benefit can be carved out of many of the legal requirements applicable to group health plans under the ACA.... Telemental health benefits also implicate HIPAA and other state privacy laws ... [E]mployers need to address certain legal issues in the licensing and services agreement with telemental health providers[.]" (Winston & Strawn LLP)
CMS Requests Information on Grandfathered Group Health Plans
"[T]he number of group health plans and policies and individual policies that are considered to be grandfathered has declined each year since enactment of the ACA, with only 16% of American workers being enrolled in a grandfathered group health plan in 2018 (down from 56% in 2011) ... Therefore, this initiative to assist plan sponsors and issuers in preserving grandfathered plan status may be arriving too late for the ultimate demise of grandfathered plans." (Cheiron)
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)
Telehealth: Connecting Consumers to Care Everywhere
"Telehealth has emerged as a new platform that improves access by removing traditional barriers to health care such as distance, mobility, and time constraints. For certain conditions, telehealth is as effective as in-person visits with potential for cost savings, and real benefits to provider efficiency, consumer convenience, and better management of chronic conditions." (America's Health Insurance Plans [AHIP])
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)
[Opinion] Partnership for Employer-Sponsored Coverage Comments to Senate HELP Committee on Rising Health Costs
"Eliminating or capping the tax exclusion of employer-sponsored coverage for individuals has been seen as a way to raise federal revenue and/or offset the cost of other federal reforms or programs ... A cap on the exclusion does not address rising health system costs or utilization and will stifle private-sector innovation and delivery designs ... There is no one-size-fits-all employer health plan nor should the federal government enact or implement laws that stifle an employer's ability to develop benefits offerings that meet the needs of their specific workforce[.]" (Partnership for Employer-Sponsored Coverage [P4ESC])
ACA Developments: House Subcommittee Hearing, CMS RFI on Health Care Compacts
"[L]awmakers discussed three bills that would help strengthen the individual market through additional federal funding for reinsurance programs, navigators, and new state-based marketplaces.... [CMS] released its second request for information (RFI) in two weeks on the ACA.... This RFI asks for comment on ways to promote the sale of individual health insurance coverage across states lines, primarily through a 'health care choice compact' under Section 1333 of the ACA. Comments on the RFI are due within 60 days." (Katie Keith, in Health Affairs)
[Guidance Overview] CMS Seeks Recommendations That Allow Americans to Purchase Health Insurance Across State Lines
"CMS is interested in feedback on how states can take advantage of Section 1333 of the [ACA], which provides for the establishment of a regulatory framework that allows two or more states to enter into a Health Care Choice Compact to facilitate the sale of health insurance coverage across state lines. CMS is primarily looking for input on how the agency can expand access to health insurance coverage across state lines, effectively operationalize the sale of health insurance coverage across state lines, and understand the financial impacts of selling health insurance coverage across state lines." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
The Use of Self-Insured Plans as 'Bona Fide' Fringe Benefits Under the Service Contract Act
"[T]he DOL looks at a number of factors in determining whether an unfunded self-insured plan should be considered 'bona fide' for SCA compliance purposes. The primary factors it considers are: [1] Can the plan be reasonably anticipated to provide the prescribed benefits? [2] Is it a legally enforceable commitment on the part of the employer? [3] Is it carried out under a financially responsible program? [4] Has it been communicated to the employees in writing?" (CBIZ)
Amazon-Backed Healthcare Venture Gets Much-Needed Name
"A new website launched to coincide with the new name outlines in broad terms some of the areas where Haven could make improvements on the current healthcare system.... The name Haven was chosen to reflect the venture's goal of partnering with patients and clinicians alike in pursuit of systemic improvements." (HealthLeaders Media)
[Official Guidance] Text of CMS Request for Information: Sale of Individual Health Insurance Coverage Across State Lines Through Health Care Choice Compacts
15 pages. "This request for information (RFI) solicits comment from interested parties on how to eliminate barriers to and enhance health insurance issuers' ability to sell individual health insurance coverage across state lines, primarily pursuant to Health Care Choice Compacts....Comments are requested in response to [22 specific questions] with respect to individual health insurance coverage.... Providing states with flexibility to address the unique needs of their health insurance markets is a key component of achieving the goals stated in the Executive Order. This RFI is not intended to inform policy which will preempt state law or otherwise impede the role states play as the primary regulators of insurance." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Sixth Circuit Follows Ordinary Principles of Contract Law to Find No Obligation for Lifetime Retiree Healthcare Benefits
"A recent decision [confirms] that a CBA's general durational clause applies to healthcare benefits unless the CBA contains clear, affirmative language indicating the contrary.... The Court found that the CBAs covering the retirees lacked clear, affirmative language that Whirlpool had an obligation to fund their health benefits after the expiration of the agreements' general durational clause. Thus, Whirlpool was under no obligation to continue to offer those benefits past the general durational clause's expiration." [Zino v. Whirlpool Corp., Nos. 17-3851, 17-3860 (6th Cir. Feb. 15, 2019, unpub.)] (Seyfarth Shaw LLP)
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)
Insurance Companies Win Important Ruling on Payment of ACA Cost-Sharing Reductions
"[T]he U.S. Court of Federal Claims held that ACA Section 1402 'sets forth an unambiguous mandate' that the government 'shall make' CSR payments to insurers. The Court further rejected the government's argument that Congress' failure to appropriate money for these payments in any way extinguished the obligation.... The Court likewise found that the statutory obligation created an 'implied-in-fact' contract between the government and insurers, further obligating the government to make the payments." [Community Health Choice v. U.S., No. 18-5C (Ct. Cl. Feb. 15, 2019)] (Faegre Baker Daniels)
Employers Striving to Sustain Competitive, Affordable Health Benefits
"[Employers] have tried and exhausted many tactics to contain healthcare costs, and are looking for other alternatives -- beyond putting their health plan out to bid to optimize network discounts and/or reduce fixed costs, such as Administrative Services Only (ASO) fees and stop loss premiums. [A] diagram shows a range of possibilities an employer can consider[.]" (Findley)
Paying Patients to Use Lower-Price Health Providers Can Result in Savings
"Examining a program that pays patients $25 to $500 for using a lower-price medical provider for each of 135 elective procedures, researchers found the effort led to a 2.1 percent reduction in the average price paid of all eligible services. The decrease in prices paid was greatest for MRIs (4.7 percent), ultrasounds (2.5 percent) and mammograms (1.7 percent)." (RAND Corporation)
Could 2019 Be the Year of MLR Rebates for ACA Issuers in the Individual Market? (PDF)
"For issuers projecting a favorable 2018 loss ratio, now is the time to consider the implications and strategies for 2019 and beyond. [1] Track and optimize QI expenses.... [2] Set 2020 premium rates with a potential MLR rebate in mind.... [3] Consider how the MLR is affected by long-term investments.... [4] Consider offering a 'premium holiday' to reduce member premiums while avoiding some of the tedious logistics of distributing M LR rebate checks.... [5] Ensure an expert is familiar with the details of the federal and state MLR guidelines so that reporting forms are appropriately and accurately filled out.... [6] Revisit risk contracts with the MLR in mind." (Milliman)
Provider-Sponsored Health Plans Can Be At the Forefront of the Changing Health Care Market
"By controlling both the delivery of care and the financing of it, [provider-sponsored plans] have the potential to break some of the constraints that health plans and health systems have traditionally faced." (Deloitte)
Will 'Grandmothered' Plans Terminate This Year?
"Grandmothered plans, also known as transitional plans, were purchased after the passing of the PPACA but before October 1, 2013. These plans usually offered coverage at a lower premium than PPACA-compliant plans because they were medically-underwritten and/or did not include all of the PPACA required services. Transitional plans were meant to have a short shelf-life and were required to terminate at their first renewal after the implementation of the PPACA in 2014. However, the final decision on when the plans would have to be terminated was left to individual states and insurance carriers offering such plans." (Hill, Chesson & Woody)
Expanding Access to Public Insurance Plans (PDF)
32 pages. "[T]his issue paper examines four general approaches for incorporating or expanding public plan availability in the health insurance system -- including a government-facilitated plan in the ACA marketplaces, allowing individuals to buy into Medicaid, allowing individuals to buy into Medicare, and expanding Medicare to more or to all." (American Academy of Actuaries)
Tech's Costly Health Benefits Pay Dividends
"Tech companies that don't yet turn a profit are doling out benefit packages worth over $100,000 per employee.... Costly benefits may seem a net negative for investors who typically focus on traditional measures like earnings and cash flow. But a growing number of investors are substituting net present value for social value, including nonfundamental attributes like employee satisfaction in their analyses." (The Wall Street Journal; subscription may be required)
Assessing the Impact of Mental Health Parity Rules in the Large Group Employer-Sponsored Insurance Market
"The impact of MHPAEA on mental health (MH) and substance use disorder (SUD) utilization and spending outcomes was assessed ... focusing on outpatient services.... MHPAEA had significant and positive effects on any use of SUD services and the frequency of SUD services used." (Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
Surprise Billing Legislation: What Employers Need to Know
"Congress [is] beginning to take action to address the issue of surprise medical billing via the introduction of three bills. [1] Protecting Patients from Surprise Medical Bills Act ... [2] No More Surprise Medical Bills Act of 2018 ... [3] Reducing costs for out-of-network services act of 2018 ... All of [these] bills could affect the services offered by employers under their group health plans.... [T]he legislation could also impact the costs borne by the employer for certain services provided to employees." (Thompson Coburn)
Vermont Individuals Stay on Health Exchange as Some Employers Exit
"The state's small group insurance market, for businesses with 100 employees or less, saw a decline of more than 10 percent compared with this time last year. Officials attributed that mainly to employers migrating to newly expanded association health plans. But state officials also noted that enrollment in individual health plans grew by 0.7 percent." (VTDigger)
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)
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)
Comprehensive Guide to Creating a Long-Term Benefits Strategy
"[R]evisit and adapt areas of your program as the workforce continues to change based on economic, personal and geographical needs.... Having a financial plan for your benefits package can be a great starting point ... [E]mployers need to monitor the effects of their benefit offerings to determine if the benefits package aligns with the cost expectations for both the employee and employer.... Never underestimate the power of evaluating different funding mechanisms." (OneDigital Health and Benefits)
Mapping Out a Blueprint for the Health Plan of the Future
"While more than 50% of employers plan to make changes in how health care is delivered to employees within the next two years, only about 30% say they will tailor health plan solutions by local market ... This number needs to double or triple.... A number of emerging health care delivery solutions are based on a smaller, high-performing network of providers coordinating care more effectively within a local market." (Willis Towers Watson)
'Medicare-For-All' Bill Introduced in the House -- Why Does It Matter?
"[T]he transition to the new Medicare-for-all system would take place over two years ... This House vision of Medicare-for-all would also cover long-term care.... The House bill also would take a swipe at high prices for prescription drugs by empowering the government to negotiate prices directly with manufacturers and to take away and reissue drug patents if such efforts faltered." (Kaiser Health News)
[Opinion] Facts About Association Health Plans
"Association Health Plans (AHPs) [1] are not cheaper than individual or small group plans.... [2] are NOT always safe to join.... [3] DO NOT always provide comprehensive coverage.... [4] WILL have an impact on the individual or small group market in a state." (Families USA)
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)
[Official Guidance] ERISA Advisory Council to Meet April 10
"[T]he 195th open meeting of the Advisory Council on Employee Welfare and Pension Benefit Plans (also known as the ERISA Advisory Council) will be held on April 10, 2019. The meeting will take place ... from 9:00 a .m. to noon and from 1:00 p.m. to approximately 3:30 p.m. The purpose of the open meeting is to set the topics to be addressed by the Council in 2019. Also, the Council members will receive an update from leadership of [EBSA]." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
Agencies Request Information on Grandfathered Health Plans
"According to research cited in the request for information (RFI) ... in 2018, 20 percent of employers offered at least one grandfathered health plan.... If that figure is accurate, quick action on the part of the departments might stabilize the number of employer plans that retain grandfathered status.... Employers that would like to retain grandfathered status have an opportunity to provide feedback to the departments." (Lockton)
States Eyeing Health Insurance 'Options'
"[F]rom state single-payer initiatives, to Medicaid buy-in, or opening up state plans to private individuals, each [proposal] demonstrates a desire on the part of state politicians to try and find a solution to rising health care costs.... [If] these programs (or some form of them) are enacted, enrollment in them may reduce the amount of uncompensated care from health care providers, which may result in a decrease in the cost of private insurance." (HUB International)
House Democrats Introduce Sweeping 'Medicare for All' Bill
"The bill ... would transition the U.S. healthcare system to a single-payer 'Medicare for All' program funded by the government in two years. The legislation is the party's most high-profile and ambitious single-payer proposal in the new Congress and has more than 100 co-sponsors ... [It] remains unclear whether Democratic House Speaker Nancy Pelosi will bring the legislation up for a vote." (Reuters)
[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 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.)
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