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Health plans - mandated benefits

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Why State Healthcare Individual Mandates are Becoming More Popular
"So far, Massachusetts, New Jersey, the District of Columbia and Vermont have passed individual mandates. Penalties vary and may change yearly, but can be range from a couple hundred dollars to $1500.... Many states that filed an appeal against the ruling that the ACA is unconstitutional are considering adding a healthcare individual mandate. Hawaii, California, Washington, Connecticut, Rhode Island and Minnesota are discussing their own versions of this new law." (Tango Health)
[Opinion] Amicus Brief of ACLJ to Fifth Circuit Addressing Constitutionality of ACA After Repeal of Individual Mandate (PDF)
"The individual mandate no longer functions as a tax and cannot be sustained as a constitutional exercise of Congress's power to tax.... A decision from this Court holding the individual mandate unconstitutional is consistent with the Supreme Court's NFIB decision and does not trench upon the Supreme Court's prerogative to overrule its own decisions." [Texas v. Azar, No. 19-10011 (5th Cir. amicus brief filed May 10, 2019)] (American Center for Law and Justice [ACLJ])
HHS Announces Final Conscience Rule Protecting Health Care Entities and Individuals
"[I]n January 2018, following the launch of its new Conscience and Religious Freedom Division, HHS announced the proposed conscience rule. OCR received over 242,000 public comments, and analyzed and carefully considered all comments submitted from the public on the proposed conscience regulation before finalizing it. This final rule replaces a 2011 rule that has proven inadequate, and ensures that HHS implements the full set of tools appropriate for enforcing the conscience protections passed by Congress. These federal laws protect providers, individuals, and other health care entities from having to provide, participate in, pay for, provide coverage of, or refer for, services such as abortion, sterilization, or assisted suicide. It also includes conscience protections with respect to advance directives. The final rule clarifies what covered entities need to do to comply with applicable conscience provisions and requires applicants for HHS federal financial assistance to provide assurances and certifications of compliance. The rule also specifies compliance obligations for covered entities, including cooperation with OCR, maintenance of records, reporting, and non-retaliation requirements." (U.S. Department of Health and Human Services [HHS])
[Official Guidance] HHS Final Regulations: Protecting Statutory Conscience Rights in Health Care (PDF)
440 pages. "The United States has a long history of providing protections in health care for individuals and entities on the basis of religious beliefs or moral convictions. Congress has passed many such laws applicable to [HHS] and the programs or activities it funds or administers, some of which are the subject of existing HHS regulations ... This final rule revises existing regulations to ensure vigorous enforcement of Federal conscience and anti-discrimination laws applicable to the Department, its programs, and recipients of HHS funds, and to delegate overall enforcement and compliance responsibility to the Department's Office for Civil Rights ('OCR'). In addition, this final rule clarifies OCR's authority to initiate compliance reviews, conduct investigations, supervise and coordinate compliance by the Department and its components, and use enforcement tools otherwise available in existing regulations to address violations and resolve complaints. In order to ensure that recipients of Federal financial assistance and other Department funds comply with their legal obligations, this final rule requires certain recipients to maintain records; cooperate with OCR's investigations, reviews, or other proceedings; and submit written assurances and certifications of compliance to the Department. The final rule also encourages the recipients of HHS funds to provide notice to individuals and entities about their right be free from coercion or discrimination on account of religious beliefs or moral convictions." (U.S. Department of Health and Human Services [HHS])
New State Laws Require More Preventive Services From Insurers
"A bevy of new state laws pertaining to health insurers took effect Jan. 1. It all adds up to a year of potentially higher costs for plans, with some states entering 2019 by protecting various [ACA] provisions by statute -- and even more of them eying how to take advantage of the ACA's state innovation waivers as the year progresses." (AISHealth)
ACA Preventative Services Updates for 2019
"[R]ecommendations that must be integrated into health plans for the 2019 calendar year: [1] Preeclampsia screening through blood pressure tests; [2] Obesity screenings for children and adolescents 6 years and older; [3] Vision screening in children ages 3 to 5 to detect amblyopia or its risk factors; [4] Influenza vaccine for adolescents; [5] Hepatitis B vaccine for adolescents; [6] Human papillomavirus (HPV) vaccine for adolescents." (Findley)
District Court Rules ACA Unconstitutional
"Besides determining whether to join one side or the other of this lawsuit (nearly two-thirds of states are now involved) and ongoing questions about the role to play in health insurance exchanges, many states are faced with determining the extent to which they will support association health plans and short-term, limited duration insurance, whether they will expand Medicaid coverage, and whether they will seek waivers of ACA requirements." [Texas v. U.S., No. 18-167 (N.D. Tex. Dec. 14, 2018)] (Ballard Spahr LLP)
[Official Guidance] Statement from the Department of Health and Human Services on Texas v. Azar
"The recent U.S. District Court decision regarding the [ACA] is not an injunction that halts the enforcement of the law and not a final judgment. Therefore, HHS will continue administering and enforcing all aspects of the ACA as it had before the court issued its decision." (U.S. Department of Health and Human Services [HHS])
District Court Declares Entire ACA Unconstitutional: What That Could Mean for Employers and Plan Sponsors
"No employer shared responsibility.... [I]nvalidation of the ACA's prohibition on preexisting condition exclusions would resurrect the HIPAA portability rules in place prior to the ACA.... Plans would be given greater flexibility to apply cost-sharing on participants.... Employers and plan sponsors would no longer be required to extend health coverage to dependent children until age 26.... [P]lans would not need to distribute summaries of benefits and coverage.... [The] tax on high-cost health care (the so-called 'Cadillac Tax') would finally be invalidated[.]" [Texas v. U.S., No. 18-167 (N.D. Tex. Dec. 14, 2018)] (Proskauer's ERISA Practice Center)
[Guidance Overview] Trump Executive Order Expands Opportunities for Healthier People to Exit ACA
"The fact sheet accompanying the order acknowledges that regulations will proceed through notice and comment rulemaking. This will likely take months. Indeed, rulemaking will likely be proceeded by studies by the affected departments, and any proposed and final rules will likely have to be reviewed by the Office of Management and Budget. Therefore, changes are unlikely to affect plans beginning on January 1 of 2018, although some changes may take effect mid-year." (Timothy Jost, in Health Affairs)
[Guidance Overview] HHS Issues Updates to Mandated Preventive Health Care Services for 2018
"[1] Coverage is required for a daily supplement containing 0.4 to 0.8 mg of folic acid for all women planning to becoming pregnant, or who are capable of pregnancy. [2] Screening for hearing loss in newborn infants is no longer required. [3] Screening for obesity in children and adolescents, six years of age and older, is mandated ... [4] Screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy is mandated. [5] A revised immunization schedule for children and adolescents, age 18 or younger ... [is included, along with a] major overhaul of mandated preventive service requirements[.]" (Ogletree Deakins)
HHS Launches Web Page Highlighting Administrative Actions to Empower Patients
"New measures will be announced as soon as is allowable by law. In particular, future actions will: [1] Lower costs and increase choices by providing relief from the burdensome regulations and fostering competition in insurance markets; [2] Work to ensure a stable transition period; [3] Offer states greater flexibility of their Medicaid programs to meet the needs of their most vulnerable populations; and [4] Increase the opportunities for patients to get the care they need when they need it." (U.S. Department of Health and Human Services [HHS])
House GOP Health Care Proposal Relies on Tax Credits and Grants
"[T]he government would no longer penalize Americans for failing to have health insurance but would try to encourage people to maintain coverage by allowing insurers to impose a surcharge of 30 percent for those who have a gap between health plans.... There is no precedent for Congress to reverse a major program of social benefits once it has taken effect and reached millions of Americans." (
States Mull Contraception Coverage as Obamacare Repeal Looms
"Growing numbers of U.S. states are seeking to ensure that women have continued access to free birth control in case the insurance benefit is dropped as part of President-elect Donald Trump's vow to repeal and replace the [ACA].... California, Maryland, Vermont and Illinois since 2014 have enacted statutes codifying the [ACA]'s contraception mandate in state law and expanding on the federal law's requirements. Democratic lawmakers in New York, Minnesota, Colorado and Massachusetts said they are pursuing similar measures this year[.]" (Reuters)
Federal Court Issues Nationwide Injunction Against Enforcement of ACA Rules on Gender Identity and Termination of Pregnancy
"The government failed to submit much briefing on the issue, presumably expecting RFRA to be inconsequential given the Final Rule's express carve-out for RFRA-protected activities. The court, however, viewed the government's failure to identify a compelling interest as a serious deficit. The court further observed that the government's own health insurance programs -- Medicare and Medicaid -- do not mandate coverage for gender transition surgeries and that the military's TRICARE health insurance program specifically excludes transition coverage." [Franciscan Alliance v. Burwell, No. 16-108 (N.D. Tex. Dec. 31, 2016)] (Stradley Ronon)
[Opinion] Bill Clinton Is Right: Obamacare is Crazy for Workers
"The more you work, the more you earn; and the more you earn, the higher net premium you pay. This is not a characteristic of the employer-based group market in which most of us participate.... The proportion of workers who work part-time because they choose to limit their hours, rather than because employers will not give them more work, has increased from 71 percent of the part-time workforce in December 2013 (the month before Obamacare launched) to 78 percent this September." (National Center for Policy Analysis Health Policy Blog)
The Future of the ACA
"[This article] seeks to identify many elements that are likely to be included in legislation to change the ACA, as well as statutory provisions that are likely to remain unchanged. It also identifies significant changes in policy that the incoming administration may well make, using the authority they will have to change regulations and other guidance and their enforcement discretion. Finally, [it lists] questions individuals, employers, and health care providers are likely to have immediately as they try to plan and budget for the future, and [the authors] provide answers to the extent available." (Jones Day)
[Opinion] Seven Steps to Dismantle Obamacare on Day One of the Trump Administration
"[C]onsider issuing an immediate waiver of all fines and penalties associated with the individual mandate.... [E]mbrace [the House v. Burwell] decision ... [and] determine whether there is a legal basis to recover the roughly $14 billion dollars that insurance companies have already received.... [R]everse or modify the enforceability of the abortion-pill mandate, particularly regarding religious institutions.... [A]dhere to the provisions of the ObamaCare law disallowing health insurance companies from being reimbursed before the United States Treasury receives its funds.... [R]eview all exemptions and waivers with an eye toward dismantling the law.... [H]alt all outreach efforts and eliminate enrollment assistance funds for the ObamaCare market places.... [U]se the bully-pulpit of [the] presidency against insurers." (American Center for Law and Justice [ACLJ])
[Opinion] Donald Trump Is About to Face a Rude Awakening Over Obamacare
"To guarantee that people with pre-existing conditions can get affordable health insurance, you need to have rules requiring guaranteed issue and community rating. To keep insurance companies in business because of guaranteed issue and community rating, you need to have an individual mandate. And because poor people can't afford health insurance, you need subsidies. Combine all three, and what you have, in a nutshell, is ... Obamacare." (The Washington Post; subscription may be required)
House Committee Asks Administration for Obamacare Cost Calculations from Taxpayers Perspective (PDF)
"While the Administration continues to focus on premium 'affordability,' it ignores the undeniable fact that federal taxpayers are subsidizing the premium increases through tax credits.... [T]he Committee requests that CMS provide to the Committee with estimates of the amount of taxpayer dollars that will be spent to subsidize the cost of rising premiums, by November 7, 2016. Specifically, this projection should compare approved 2016 rates and enrollment estimates with 2015 rates and effectuated enrollment." (Energy and Commerce Committee, U.S. House of Representatives)
Access to Quality, Affordable Health Care: Progress and Promise of the Affordable Care Act and Other Administration Efforts
"Eight years ago, candidate Obama promised that he would make quality, affordable health care not a privilege, but a right.... High and rising health care costs placed serious burdens on our businesses, workers and economy ... Thanks in part to the ACA's focus on reducing costs and inefficiencies, health care prices have risen at the slowest rate in 50 years since the law passed, which will benefit all of us for years to come. For example, as a result of low premium growth in employer-sponsored coverage, the average premium for employer-sponsored family coverage in 2016 was nearly $3,600 lower than if premium growth since 2010 had matched the average premium growth rate recorded over the decade preceding the ACA." (Office of the Press Secretary, The White House)
EpiPen Triggers Change In Thinking About Obamacare Requirement
"Three doctors who have led a task force that evaluates preventive medical services say the group's recommendations shouldn't be tied by law to insurance coverage. The former chairmen of the U.S. Preventive Services Task Force [USPSTF] say the link between medical recommendations and insurance coverage leads to financial incentives that can corrupt the process and distort people's health care decisions. Under the [ACA], any preventive service that receives one of the USPSTF's top two ratings must be covered by insurance without any out-of-pocket cost for the patient." (National Public Radio)
Small Biz Health Exchange (SHOP) Still Worth Considering
"[Massachusetts Institute of Technology economics professor Jonathan Gruber] believes the savings rate offered by SHOP-based plans was simply not significant enough to disrupt the existing small group market, which suffered, pre-ACA, from languishing in the worst of all worlds. Selling to small groups was not as lucrative as large groups for insurers and agents, while premiums for customers were high." (Society for Human Resource Management [SHRM])
[Guidance Overview] Text of IRS PMTA 2016-12: Calculation of Premium Tax Credit for Fiscal Year Taxpayers (PDF)
"In determining whether [Individual 'A', a fiscal year taxpayer whose taxable year ends June 30,] is eligible for affordable employer coverage, A uses the uses the required contribution percentage that applies to plan years beginning in 2015, 9.56 percent, to determine if the coverage is affordable for the months July 1, 2015 through December 31, 2015, and uses the required contribution percentage that applies to plan years beginning in 2016, 9.66 percent, to determine if the coverage is affordable for the months January through June 2016.... In determining [the tax liability of Individual 'B', a fiscal year taxpayer whose taxable year also ends June 30,] for excess advance payments for the taxable year ending June 30, 2016, B uses the repayment limitation in effect for taxable years beginning in 2015[.]" [Program Manager Technical Advice, Mar. 17, 2016; published online Aug. 31, 2016] (Internal Revenue Service [IRS])
Administration Officials, Constitutional Experts to Testify on Unlawful Cost Sharing Reduction Payments
"After an 18-month-long investigation, the Ways and Means Oversight Subcommittee and the Energy and Commerce Oversight and Investigations Subcommittee will hold hearings this week on the Obama Administration's unlawful funding of the cost sharing reduction (CSR) program, which was established under the [ACA]." (Committee on Ways and Means, U.S. House of Representatives)
A Compromise, with Real Impact, on Contraceptive Requirements
"There are existing [HHS] regulations ... on ways to implement the birth-control mandate. Those regulations, in their present form, depend upon the government working out with the insurance companies that have created health plans for the religious non-profits to provide access to the actual contraceptive benefits.... [T]he Supreme Court's action ... does clear the way for the government to move ahead to do what it would need to do to assure access as a practical matter. " [Zubik v. Burwell, Nos. 14-1418 et al. (3d Cir. Feb. 11, 2015; cert. pet. granted Nov. 6, 2015; argued Mar. 23, 2016)] (SCOTUSblog)
Seeking Compromise, Supreme Court Remands Contraceptive Coverage Cases to Lower Courts
"[T]he opinion does not resolve the merits of the case -- the substantial burden, compelling governmental interest, and least restrictive alternative issues. The Court's opinion suggests that, at minimum, the least restrictive alternative issue needs a second look.... [T]he Court's order ignores the intractable question of how to provide contraceptive coverage to employees of employers that offer coverage through self-insured plans." (Timothy Jost, in Health Affairs)
Businesses Are Opting for Freelancers to Dodge Health Care Fees
"According to a [recent] study ... [the ACA] is leading companies to hire more freelance workers rather than bring on more in-house staff.... Since 2016, health care fees including the tax penalty for having uninsured employees increased because of the act, causing 74 percent of companies to opt for freelance hires instead, the study says. In fact, 60 percent said they planned to hire more freelancers in place of full timers.... And though most companies agreed benefits were the key to attracting desirable employees, nearly one third of them are eliminating their benefit plans because of fees associated with the new health care policies." (Entrepreneur)
[Guidance Overview] The ACA's Employer Shared Responsibility Determination and the Potential Employer Penalty (PDF)
25 pages. "The [ACA] creates shared responsibilities for both employers and individuals with regard to health insurance coverage.... This report examines the new employer responsibilities. To ensure that employers continue to provide some degree of health coverage, the ACA ... does not require that an employer offer employees health insurance; however, the ACA imposes penalties on a 'large' employer if at least one of its full-time employees obtains a premium credit through the newly established exchange.... The complex calculations and multiple definitions of full-time work have led to confusion among policymakers and employers. This report discusses these definitions and the application to the employer penalty in greater detail." [Report R43981, updated Apr. 16, 2015] (Congressional Research Service)
Responses to Court's Proposal for Zubik v. Burwell Still Show a Gap
"The final round of briefs in reaction to the Court's own idea for a possible compromise have now been filed ... [T]he non-profits said that the government was clinging too much to the idea, objectionable to them, that they must take a specific step to gain a separation from the process of providing contraceptives, and the government said that the degrees of separation that the non-profits demand from the source of contraceptives simply would not work in the real world of health insurance and state laws governing plans." (SCOTUSblog)
Obama Administration Admits It Could Have Respected Nuns' Rights After All
"In a brief filed at the Supreme Court [on April 12] ... the Obama administration told the justices that it could have mandated insurers issue separate contraceptive and abortion-inducing drug coverage to those who want it without hijacking the health plans of religious employers. This could spell big trouble for the government's defense of the mandate." [Zubik v. Burwell, Nos. 14-1418 et al. (3d Cir. Feb. 11, 2015; cert. pet. granted Nov. 6, 2015; argued Mar. 23, 2016)] (The Daily Signal)
Dueling Responses to the Court's ACA Birth Control Idea
"The government brief argued that the Court's alternative would only work for religious non-profits that use an outside insurance company for health coverage for their employees and it warned of serious complications, but the religious non-profits' brief insisted that the suggested approach could be made to work well for all of the institutions, including those who self-insure or use what are called 'self-insured church plans.' Both urged the Court to move ahead to decide the main legal question -- does the current [ACA] birth-control mandate violate the Religious Freedom Restoration Act? Obviously, they called for conflicting results." [Zubik v. Burwell, Nos. 14-1418 et al. (3d Cir. Feb. 11, 2015; cert. pet. granted Nov. 6, 2015; argued Mar. 23, 2016)] (SCOTUSblog)
Obamacare Will Cost $136 Billion More, Cover Fewer People Than We Thought, CBO Says
"Last year, CBO projected that the average subsidy would be $4,040. Turns out, it was $4,240. CBO now thinks subsidies will average $4,550 next year ... a reflection of the fact that premiums leapt upward this year, and are likely to make another big jump for next year. As a result, even though the CBO expects that 4 million fewer people will be getting insurance subsidies in 2024, the total cost of those subsidies paid out that year will stay exactly the same: $99 billion.... CBO [has also hiked] its 10-year Medicaid cost projection by $146 billion.... Instead of 45 million enrolled in Medicaid this year, as the CBO had been predicting, there are 68 million." (Investor's Business Daily)
Blue Cross Blue Shield Association Confirms Obamacare Death Spiral
"These health plans have not done a great job containing costs in employer-based health plans either. Those policies' average monthly health spending increased 8 percent in the first nine months of 2015 versus 2014. However, costs in individual policies increased 12 percent, half again as much. This means the gap in medical spending between the two markets is increasing." (National Center for Policy Analysis Health Policy Blog)
Employers with Self-Funded Health Plans Dispute Administration's Application of ACA Nondiscrimination Provisions
"The latest dispute over the health care law may have to be resolved by the courts. The law's nondiscrimination section applies federal civil rights protections to programs under the health overhaul. The legal text refers to entities 'receiving federal financial assistance,' interpreted to include insurers, state Medicaid agencies, hospitals and other service providers. It doesn't mention major private employers that run their own health plans. A group representing big employers said its members don't have particular qualms about gender transition. But large employers do object to what they see as an overreach by the Obama administration, since their health plans don't get federal financial assistance." (ABC News)
25% Dumped Their Obamacare Plans Last Year, White House Admits
"[E]nrollment in the ObamaCare exchanges fell to 8.8 million by the end of the year, from 11.7 million who'd initially signed up. That's a 25% decline.... There's little reason to think ObamaCare will fare any better this year -- particularly since premiums and deductibles shot up -- which means the 12.7 million signups the White House cheered about last month will probably dwindle to less than 10 million by the end of 2016. When you consider that there were 15 million people who were buying insurance on their own before ObamaCare, that's a paltry number." (Investor's Business Daily)
[Guidance Overview] IRS Health Care Tax Tip 2016-31: Do You Have Minimum Essential Coverage?
"[S]ome examples of coverage that qualify as minimum essential coverage: [1] Employer-sponsored coverage; [2] Group health insurance coverage for employees under a governmental plan such as the Federal Employees Health Benefit program; [3] a plan or coverage offered in the small or large group market within a state; [4] a grandfathered health plan offered in a group market[ [5] Self-insured group health plan for employees; [6] COBRA coverage; [7] Retiree coverage." (Internal Revenue Service [IRS])
[Guidance Overview] CRS Report: Resources for Frequently Asked Questions about the Affordable Care Act (PDF)
28 pages. "The report provides basic consumer sources, including a glossary of health coverage terms, followed by sources on ACA's tax provisions. The next sections focus on health coverage: the individual mandate, private health insurance, and exchanges, as well as public health care programs, such as Medicaid and the State Children's Health Insurance Program (CHIP), Medicare, Indian health care, and veterans' and military health care. It then lists sources on employer-sponsored coverage, including sources on employer penalties, small businesses, and federal workers' health plans. It also provides sources on the ACA's provisions on mental health, women's health, public health, workforce, and quality. Finally, the report lists sources on ACA agency audits and investigations, costs and appropriations, insurance coverage statistics, legal issues, the treatment of noncitizens under the ACA, and sources for obtaining the law's full text." [Report R43215, updated Mar. 3, 2016] (Congressional Research Service [CRS])
[Guidance Overview] The 2017 Benefit and Payment Parameters Final Rule: Drilling Down (Part 1)
"The final rule, therefore, generally defines the geographic rating area of a small business as the rating area where the greatest number of employees work or reside. The SHOP marketplace will use the place of business address used to qualify the employer for SHOP coverage for rating purposes.... The final rule makes a number of changes in the '3R' premium stabilization programs: risk adjustment, reinsurance, and risk corridors.... Under the final rule, HHS will spend all remaining reinsurance program funds in 2016.... HHS has concluded that it needs all rate filings to reasonably evaluate rate increases. Insurers seeking rate increases must also file an actuarial memorandum, and insurers seeking increases above the threshold must additionally file a written justification." (Health Affairs)
Text of Comments on IRS Notice 2015-87: Further Guidance on the Group Health Plan Market Reform Provisions of the ACA to Employer-Provided Health Coverage and on Certain Other ACA Provisions
BenefitsLink has obtained the 60 comments to the IRS that were filed by the February 18 deadline, about IRS Notice 2015-87, which addressed "among other health care arrangements: [1] health reimbursement arrangements (HRAs), including HRAs integrated with a group health plan ... and [2] group health plans under which an employer reimburses an employee for some or all of the premium expenses incurred for an individual health insurance policy." It also "clarifies certain aspects of the employer shared responsibility provisions of Section 4980H, including the identification of employee contributions when employers offer HRAs, flex credits, opt-out payments, or fringe benefit payments required under the McNamara-O'Hara Service Contract Act or other similar laws, the application of the adjusted 9.5 percent affordability threshold ... to the safe harbor provisions under Section 4980H, and the employer status of certain entities for Section 4980H purposes." (BenefitsLink)
Testimony of IRS Commissioner Koskinen Before the Senate Homeland Security and Governmental Affairs Committee on Implementation of the ACA
"While the operation of these Marketplaces is overseen by the Department of Health and Human Services (HHS), the IRS has the limited role of providing Marketplaces with data and computational services for use in their determinations about eligibility for financial assistance.... The IRS, through this computational service, provides the Marketplace with a single figure: the maximum advance premium tax credit for which the applicant may be eligible based on those data inputs.... During the 2015 open enrollment period, the IRS processed more than 25 million requests for federal tax return data and more than 17 million computational requests, with an average IRS response time of less than five seconds." (Internal Revenue Service [IRS])
Text of Response Brief by HHS in Supreme Court Case on ACA Contraceptive Coverage (PDF)
"Petitioners object to providing contraceptive coverage on religious grounds but are eligible for a regulatory accommodation that would allow them to opt out of the contraceptive-coverage requirement. Petitioners contend, however, that the accommodation itself violates the Religious Freedom Restoration Act of 1993 (RFRA) ... because the government will require or encourage third parties to provide petitioners' employees and students with separate contraceptive coverage if petitioners opt out. The question presented is: Whether RFRA entitles petitioners not only to opt out of providing contraceptive coverage themselves, but also to prevent the government from arranging for third parties to provide separate coverage to the affected women." [Zubik v. Burwell, Nos. 14-1418 et al. (3d Cir. Feb. 11, 2015; cert. pet. granted Nov. 6, 2015)] (Solicitor General of the United States; via American Bar Association)
Dave and Busted? Reductions in Employee Work Schedules May Not Negate Employer's ACA Health Coverage Mandate
"The court found that the complaint 'sufficiently and plausibly' alleged enough facts to support a possible finding that Dave & Buster's intentionally interfered with the plaintiffs' rights to receive benefits under the company's health plan. The court noted that the complaint referenced specific e-mails and other communications that the plaintiffs allegedly received when their work schedules were reduced, as well as public statements by senior executives and disclosures in the company's securities filings, which overtly explained that the workforce management protocols were instituted to thwart the potential impact of the ACA on the company's bottom line." [Marin v. Dave & Buster's, Inc., No. 15-3608 (S.D.N.Y. Feb. 9, 2016)] (National Law Review)
The Ongoing Saga of the ACA Contraceptive Mandate: Where Are We Now? (PDF)
"This very public debate that has involved federal authorities, the Supreme Court, interest groups and individuals has left many confused about where the mandate comes from, what it says and how it applies to different groups. In this white paper, [the authors] attempt to combine and summarize the complex and many times disjointed answers federal authorities have provided to these important questions." (Lockton)
[Opinion] 'Risk Adjustment' Threatens Obamacare
"Risk adjustment is intended to smooth out the unpredictability of the health insurance marketplace ... While well-intended, the implementation of this safeguard has had the unintended consequence of ... taking money from predominantly new, small, innovative plans ... and giving it to the big, established insurance carriers.... The simplest option is a percentage limit on risk adjustment payments assessed to insurance carriers." (Peter Beilenson, in The Baltimore Sun)
San Diego Church Challenges California Abortion Coverage Mandate
"California's mandate does not include an exemption for group health insurance plans purchased by churches or other employers that have religious beliefs against abortion. Skyline claims the mandate is at odds with the way the Knox-Keene Act treats religious employers, citing an exemption that allows religious employers to opt out of providing contraceptive coverage. Religious employers are also exempt from providing health insurance coverage for infertility treatments, according to the complaint." (Courthouse News Service)
[Guidance Overview] Text of DOL Report to Congress: Improving Health Coverage for Mental Health and Substance Use Disorder Patients Including Compliance with the Federal Mental Health and Substance Use Disorder Parity Provisions (PDF)
337 pages. "Since the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA), the Departments of Labor, Treasury and Health and Human Services have enforced the law, assisted consumers, and continuously clarified the responsibility of plan sponsors and insurance companies providing mental health and substance use disorder coverage.... Through investigations of employment-based plans, regulations and guidance, and outreach, the Departments strive to ensure that coverage for mental health and substance use disorder treatment is provided comparably with that offered for other medical care.... This report includes examples of situations where EBSA was able to intervene on behalf of participants and ensure that participants received coverage for the healthcare they needed." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
Amicus Briefs Posted Online in Supreme Court Case Challenging Application of Contraceptive Coverage Mandate to Little Sisters of the Poor and Other Religious Organizations
The briefs are towards the bottom of the target web page. Excerpt: "Issue: Whether the HHS contraceptive-coverage mandate and its 'accommodation' violate the Religious Freedom Restoration Act by forcing religious nonprofits to act in violation of their sincerely held religious beliefs, when the government has not proven that this compulsion is the least restrictive means of advancing any compelling interest." (SCOTUSblog)
Critics Say ACA 'Risk' Strategies Are Having Reverse Robin Hood Effect
"In early summer, a small, nonprofit HMO in Birmingham, Ala., got a surprise from the federal government: a bill for $1.7 million. The charge, which amounted to a startling two-fifths of the premium money that Viva Health had collected from 1,100 customers, stemmed from an obscure part of the [ACA] designed to support health plans with lots of sick, expensive customers by giving them money from plans with healthier customers.... Blue Cross and Blue Shield of Alabama, which dominates the market in which Viva sells, is getting more than $2.5 million." (The Washington Post; subscription may be required)
[Opinion] American Academy of Actuaries Comments to HHS on Notice of Benefit and Payment Parameters for 2017 (PDF)
10 pages. The Academy offers comments related to the risk adjustment, reinsurance, and risk corridor components of the proposed rule for the 2017 benefit and payment parameters, as well as comments on a number of other provisions in the proposed rule, including fair health insurance premiums, student health insurance coverage, the three-month grace period for enrollees, hardship exemptions, and small group considerations. (American Academy of Actuaries)
[Opinion] Suspend. Delay. Postpone. Repeat.
"By postponing the Cadillac Tax from 2018 to 2020, pausing the Medical Device Tax for 2017 and 2018, and also pausing the Health Insurance Tax for 2017 the federal government is reducing revenues to fund Obamacare by $32.1 Billion.... The total cost over ten years of eliminating these three taxes will decrease Obamacare revenues by $331,900,000,000. This makes up more than half of the revenues Obamacare is supposed to generate over that same time period." (InsureBlog)
CMS Proposed Insurance Reforms Incite Industry Backlash
"CMS faces a daunting task in finalizing its rule for the 2017 health insurance market. The agency received more than 500 comments this week, many of which demand the rollback of provisions intended to help consumers.... Insurance companies and business groups slammed the CMS' proposals to regulate provider networks and standardize plan options, saying it would choke their ability to keep healthcare premiums low." (Modern Healthcare Online; free registration required)
2014 Plan Year Issuer Compliance Review Summary Report (PDF)
35 pages. "This report summarizes the results and recommendations from two key compliance activities related to plans certified for plan years beginning between January 1, 2014, and December 31, 2014: [1] compliance reviews and [2] renewal and discontinuation notice reviews ... By sharing this report, CMS can provide insights on identified areas of non-compliance in 2014 and help issuers ensure their policies, procedures, and consumer notices comply with CMS regulations and guidance." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Federal District Court Rejects Secular Entity's Challenge to ACA Contraceptive Coverage Requirement
"Unlike the dozens of challenges to the Affordable Care Act contraceptive coverage rule, including the challenge currently before the Supreme Court, this case was brought by a secular organization. Real Alternatives Inc. challenged the contraceptive requirement not under the Religious Freedom Restoration Act (RFRA), as have the other plaintiffs, but as a violation of the Constitution's Equal Protection requirement, and also as arbitrary and capricious and thus impermissible under the Administrative Procedures Act." [Real Alternatives, Inc. v. Burwell, No. 1:15-cv-0105 (M.D. Penn. Dec. 10, 2015)] (Health Affairs)
[Opinion] Contraceptive Mandate Cases: Why the Supreme Court Will Instruct Lower Federal Courts to Stop Second-Guessing Religious Beliefs
"So what's the big deal about signing a form? None, according to the majority of federal courts of appeals that have decided the question. These courts have assessed the moral implication of the issue for themselves and decided that submitting a form does not actually require religious non-profits to facilitate access to contraceptive coverage. The problem is that the affected religious non-profits have reached the exact opposite conclusion, and it is not the role of the federal courts to second-guess the religious organizations' analysis." (SCOTUSblog)
Crunch Time Again for ACA Enrollment
"Rising premiums and shaken faith among insurers have cast a cloud over sign-up season for President Barack Obama's health care law ... 'Medical costs of enrollees have been higher than expected and total enrollment remains low,' said Caroline Pearson [of] Avalere Health. 'If participation is leveling off, then plans may be stuck with a risk pool that is not particularly balanced.' ... The fines for people who remain uninsured in 2016 have gone up substantially[.]" (
Welfare Benefit Plans: More Than Just the ACA
"ERISA generally allows the plan sponsor to decide whether to offer a plan and allows flexibility in the plan's benefit design. But if an employer does decide to sponsor a plan, there are mandated benefits. Here is [a] list of those mandated benefits complete with initials and acronyms." (The Retirement Plan Blog)
The Cost of the Individual Mandate Penalty for the Remaining Uninsured
"[The authors] estimate that 78% of people who are uninsured and marketplace eligible would be subject to the individual mandate penalty if they remain uninsured in 2016 ... Those who are eligible for premium subsidies will face an average household penalty of $738 in 2016, while the average household penalty totals $1,450 for uninsured individuals not eligible for any financial assistance." (Henry J. Kaiser Family Foundation)
Improving Health and Health Care: An Agenda for Reform
"The plan [presented by the authors] is not confined to replacing the ACA. [They] propose major reforms to the tax treatment of employer-sponsored health care, Medicaid, Medicare, Health Savings Accounts, and other areas of existing policy. The cumulative effect of this comprehensive plan would be to decisively reorient health care policy away from bureaucratic regulation and toward the preferences of patients and consumers." (Health Affairs)
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