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Health plans - policy

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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)
[Opinion] The Challenge of Selling Health Insurance Across State Lines
"Health insurance premiums largely reflect the underlying costs associated with the delivery of medical care, rather than the degree of insurance market competition.... Yet, health insurance premiums vary substantially between states, and there are often major price disparities in neighboring counties across state borders.... If individuals were allowed to purchase plans from other states, regulators in each state would be forced to put the interests of consumers above those of insurers and the rest of the healthcare industry." (Manhattan Institute for Policy Research)
New York (Again) Seeks to Regulate Pharmacy Benefit Managers
"On January 15, 2019, Governor Cuomo released the 2019-2020 Executive Budget, which ... would require PBMs to be licensed and places limitations on how they can be compensated. This week, the State Senate released its own Budget that, while joining the Governor's efforts to regulate PBMs, purports to create additional safeguards around PBM business activities, including increased financial penalties on PBMs that violate the law." (Mintz)
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])
[Guidance Overview] JCT Overview of Deduction for Qualified Business Income: Section 199A
32 presentation slides. "An individual taxpayer, estate, or trust generally may deduct 20% of qualified business income, and 20% of qualified REIT dividends and qualified PTP income The deduction is limited above a threshold amount of taxable income ($157,500, or $315,000 for joint returns, indexed).... Taxable income means without regard to the section 199A deduction, for this purpose ... Effective for taxable years beginning after 2017 and before 2026." (Joint Committee on Taxation [JCT], U.S. Congress)
Public-Option Proposal Would $774 Billion in Hospital Revenue
"The [KNG Health] analysis projected 40.7 million would enroll in such a public option starting in 2024, and about 90 percent of enrollees would come from those who have coverage in the nongroup market or through employer-sponsored insurance (ESI).... [O]nly 5.5 million of the 29 million people currently uninsured were projected to sign up for the public option. The Medicare-X plan was projected to cut healthcare spending by $1.2 trillion (or 7 percent) over the 10-year period from 2024 to 2033. The bulk of those savings would come from $774 billion in hospital spending reductions stemming from the use of Medicare rates instead of higher commercial insurance rates." (Healthcare Financial Management Association [HFMA])
House Committee Hearing on Lowering the Cost of Prescription Drugs: Reducing Barriers to Market Competition
March 13 hearing. Page includes description and links to text of seven bills directed at controlling prescription drug prices, along with video of hearing, Chairman's briefing memo, and written testimony of invited witnesses. (Energy & Commerce Committee, U.S. House of Representatives)
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)
ACA and Medicaid Expansion Had No Effect on Labor Supply of Older Americans
"[I]nsurance coverage of Americans ages 50 through 64 increased significantly after the ACA, with the uninsured rate dropping from 16 percent in 2013 to 12 percent in 2014 and 10 percent in 2015 and 2016.... [The authors] find no changes in labor supply of older Americans either in response to subsidized marketplace coverage, which became available nationally in 2014, or in response to the expansion of Medicaid eligibility in some states but not others." (Michigan Retirement and Disability Research Center, Univ. of Michigan)
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." (
MIT 401(k) Plan Participants Not Entitled to Jury Trial of ERISA Breach of Fiduciary Duty Claims
"The court followed the 'great weight of authority' in ruling that there is no right to trial by jury in ERISA actions for breach of fiduciary duty.... The MIT decision is notable because it may seal the small crack plaintiffs made in the wall of cases rejecting a jury-trial right in ERISA fiduciary-breach cases." [Tracey v. Mass. Inst. of Tech., No. 16-11620 (D. Mass. Feb. 28, 2019)] (McDermott Will & Emery)
Administration Weighs Publicizing Secret Rates Hospitals and Doctors Negotiate With Insurers
"Mandating public disclosure of the rates would upend a longstanding industry practice and put more decision-making power in the hands of patients. Hospitals and insurers typically treat specific prices for medical services as closely held secrets, with contracts between the insurers and hospital systems generally bound by confidentiality agreements." (The Wall Street Journal; subscription may be required)
As Hospitals Post Price Lists, Consumers Are Asked to Check Up on Them
"Most hospitals appear to be complying with the rule, according to hospital officials and a small sampling of websites. However, the feds acknowledge they are not yet enforcing the rule, industry groups are not monitoring compliance, many hospitals are burying the information on their websites, and debate continues about whether the price lists are creating more confusion than clarity among consumers." (Kaiser Health News)
[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)
2018 in Review: DOL-Issued Guidance under ERISA
"DOL continued in 2018 a very limited advance guidance program, with an output roughly comparable to that of 2017.... This trend of limited guidance dates to at least 2013 and thus cannot be wholly attributed to the regulatory proclivities (or lack thereof) of the current Administration. For a variety of reasons, DOL has simply become less engaged in delivering advance guidance to the regulated community." (Eversheds Sutherland)
[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])
[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])
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)
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)
[Opinion] Health Care Spending Is More Than Just the Parts You See
"To really understand how Medicare for All or any other big change in health care financing would affect them, people need to understand how they would impact their overall family health budgets. Few people think about the other health costs they pay: their taxes to support health care, or what their employers are paying towards premiums (which is depressing their wages)." (Drew Altman, via Axios)
'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)
[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])
Senate Finance Committee Hearing: Drug Pricing in America: A Prescription for Change, Part 2
Feb. 26 hearing; page includes video and statements by Committee members Ron Wyden (D-OR) and Chuck Grassley (R-IA), along with written testimony by witnesses: [1] Richard A. Gonzalez, AbbVie Inc.; [2] Pascal Soriot, AstraZeneca; [3] Giovanni Caforio, M.D., Bristol-Myers Squibb Co.; [4] Jennifer Taubert, Johnson & Johnson; [5] Kenneth C. Frazier, Merck & Co., Inc.; [6] Albert Bourla, D.V.M. Ph.D., Pfizer; [7] Olivier Brandicourt, M.D., Sanofi. (Committee on Finance, U.S. Senate)
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)
Key Takeaways from Pharma Testimony at Senate Drug Pricing Hearing
"Pharmaceutical executives were questioned by lawmakers about why they have not effectively reduced list prices for prescription drugs. While acknowledging room for improvement, the executives also blamed PBMs and insurers for the high prices consumers face. Industry watchers said that while substantive change is unlikely in the short-term, the public impression of Tuesday's hearing will linger negatively on drugmakers." (HealthLeaders Media)
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)
In Florida, Drug Re-Importation from Canada Finds New Champions, Old Snags
"Florida is joining the growing ranks of states that, squeezed by climbing drug prices, are eyeing the Canadian fix.... Legislation has been advanced this year in about a dozen states that would advance wholesale drug importation programs ... While statehouses may be abuzz, in Washington, national politics impedes feasibility. And skeptics question how much relief these initiatives could actually provide." (Kaiser Health News)
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.)
Departments Ask for Advice from Health Plan Sponsors: Preserving 'Grandfathered Status' Under the ACA
"The specific questions include: [1] Do any of the requirements for maintaining grandfathered status create particular challenges, and how could these requirements be modified to reduce these challenges? [2] Why do plan sponsors choose to retain grandfathered status? [3] What are the costs and benefits that plan sponsors consider in deciding whether to retain grandfathered status? [4] Is preserving grandfathered status important to plan participants? [5] What changes in benefits typically trigger a loss of grandfathered status?" (Segal Consulting)
State Approaches to Mitigating Surprise Out-of-Network Billing (PDF)
42 pages. "A key first step is removing the patient from the middle of disputes over surprise out-of-network billing and requiring insurers, providers, and/or regulators to resolve problems.... Protections ... should apply comprehensively across settings ... and not merely in emergency situations.... Minimize reliance on notice and consent exceptions ... Include means of enforcement ... [By] focusing regulation on health care providers, the policy approaches detailed in [this paper] are able to largely or entirely protect enrollees in self-insured health plans as well as those in fully-insured plans, while likely surviving any ERISA challenges." (The Brookings Institution)
Premium Subsidies, Incentives and Interconnectivity of ACA Policies
"While the banner of 'pre-existing condition protections' recently has ascended to the perceived status of being the ACA's crown jewel, premium subsidies are the real lifeblood of ACA markets.... While other ACA issues may be interconnected, the impact of premium subsidies (and resulting net premiums) is the primary indication of consumer response to market changes." (The Actuary Magazine)
Feds Want Input on Extending Grandfathered Group Plans
"The agencies are particularly interested in collecting additional data on grandfathered group coverage and understanding whether additional flexibility is needed to allow employers and insurers to maintain grandfathered status. Comments are due within 30 days." (Katie Keith, in Health Affairs)
Employer-Based Coverage Experienced Short-Term Increase, But Trends Downward Long-Term
"Employer-based coverage continues to be the largest source of insurance coverage for Americans (156.3 million), but a recent analysis ... shows that employer-sponsored plans decreased by 9 percent from 1999 to 2017. Lower income employees were less likely to have employer-sponsored coverage, and households with incomes under 400 percent of poverty experienced the most significant decline." (Wolters Kluwer; free registration required)
House of Representatives Holds Hearing on Recent ACA Policy Changes
"There have been at least five hearings on the [ACA] in the House.... Last week, the Energy and Commerce Health Subcommittee held a major hearing on efforts to undermine the ACA.... Many Democratic members of Congress focused on the limitations of short-term plans for people with preexisting medical conditions.... Republican members of Congress focused more on the need for choice in the individual market and a belief that short-term plans offer more choice to consumers." (Katie Keith, in Health Affairs)
[Official Guidance] Text of Agency Request for Information: Grandfathered Group Health Plans and Grandfathered Group Health Insurance Coverage
15 pages. "Given the limited information available regarding such coverage, the Department of the Treasury, the [DOL], and [HHS] are issuing this request for information to gather input from the public in order to better understand the challenges that group health plans and group health insurance issuers face in avoiding a loss of grandfathered status, and to determine whether there are opportunities for the Departments to assist such plans and issuers, consistent with the law, in preserving the grandfathered status of group health plans and group health insurance coverage in ways that would benefit employers, employee organizations, plan participants and beneficiaries, and other stakeholders." (U.S. Department of the Treasury, Internal Revenue Service [IRS]; Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]; and U.S. Department of Health and Human Services [HHS])
[Opinion] American Academy of Actuaries Comment Letter to CMS on Proposed Notice of Benefit and Payment Parameters for 2020 (PDF)
"Comments are organized by provisions related to risk sharing, as well as on additional items the Department of Health and Human Services (HHS) specifically requested comments on such as automatic re-enrollment, cost-sharing requirements, the exchanges, silver loading, premium adjustment percentage, and treatment of brand drugs." (American Academy of Actuaries)
Administration Tried to Make It Easier for States to Waive ACA Rules: Will Any Take the Plunge?
"A discussion paper released by the administration highlights states' new waiver options, but doesn't resolve a host of difficult policy choices and operational hurdles that states must address before proceeding with an untested waiver plan. There are also serious legal questions that seem destined for the courts ... Given these issues, this year we may continue to see the type of waiver actions seen in 2018: largely nonideological efforts by states to implement programs shown to be both workable and beneficial for people and health insurance markets." (The Commonwealth Fund)
Feasibility and Reliability of Automated Coding of Occupation in the Health and Retirement Study
"[The NIOSH Industry and Occupation Computerized Coding System (NIOCCS)] does reasonably well compared to coding results from a highly-trained, professional occupation and industry coder, with ... agreement rates on broader codes of around 80 percent. The main weakness of NIOCCS appears to be its failure to produce codes in many cases. Code rates for NIOCCS for the datasets tested ranged from 60 to 72 percent, as compared to a professional coder's ability to code those same datasets that ranged from 95 to 100 percent." (Michigan Retirement and Disability Research Center, Univ. of Michigan)
Another Loss for Retirees: Sixth Circuit Holds No Lifetime Healthcare Coverage
"The Sixth Circuit reversed the district court's (N.D. Ohio) determination that the CBAs at issue vested the Hoover Company retirees with unalterable lifetime healthcare benefits. The majority found that the CBA's general durational clauses that state when the agreements end also control when healthcare benefits end." [Zino v. Whirlpool Corp., No. 17-3851/3860 (6th Cir. Feb. 15, 2019; unpub.)] (Kantor & Kantor)
More Insurers Win Lawsuits Seeking Cost-Sharing Reduction Payments
"On February 14 and 15, two judges at the Court of Federal Claims held that insurers are entitled to unpaid cost-sharing reduction (CSR) payments. One of these lawsuits ... is a class action for unpaid CSRs, meaning the decision applies to the 91 insurers who are part of that class.... In some cases, these insurers are entitled to unpaid CSRs from both 2017 and 2018, even though many insurers opted to use 'silver loading' to make up for unpaid CSRs." (Katie Keith, in Health Affairs)
House, Four New States Allowed to Intervene in Texas v. Azar
"On February 14, 2019, the Fifth Circuit Court of Appeals granted two requests -- one by the U.S. House of Representatives and the other by state attorneys general in Colorado, Iowa, Michigan, and Nevada -- to intervene in the ongoing Texas v. Azar litigation. The Fifth Circuit also denied a request from the intervenor states, led by California, for an expedited briefing schedule. The federal government's brief will be due on March 25, 2019." (Katie Keith, in Health Affairs)
House Officially Intervenes in High-Stakes Case to Defend ACA
"The U.S. House of Representatives officially intervened Thursday to defend the [ACA] at the Fifth Circuit Court of Appeals, where 38 state attorneys general and the U.S. Department of Justice are arguing over whether any or all of the sprawling legislation remains constitutional.... Circuit Judge Leslie H. Southwick ruled that she didn't have to determine whether the House has such a right. 'In the absence of any other federal governmental party in the case presenting a complete defense to the Congressional enactment at issue, this court may benefit from the participation by the House,' Southwick wrote, granting the request." [Texas v. Azar, No. 19-10011 (5th Cir. ruling on motion to intervene, Feb. 14, 2019)] (HealthLeaders Media)
Democrats Roll Out Bill to Let Americans Buy Into Medicare at 50
"Under [S. 470], consumers aged 50 to 64 could shop for Medicare coverage on the [ACA]'s insurance exchanges, allowing them to compare the program's offerings to plans already available to them ... Consumers would buy the plans at full cost, so the legislation is scored as budget-neutral instead of increasing deficits -- although customers eligible for Obamacare subsidies may use them to defray their Medicare buy-in premium." (
[Opinion] Premium Subsidies, Incentives and Interconnectivity of ACA Policies
"At the end of 2018, we were left with a working ACA model -- but one that would not have been designed from a blank slate. Undoubtedly, more changes will occur as 'government intervention drives marketplace changes, which, in turn, creates a recurring need for more government intervention.' As these changes occur, it is important that we consider the holistic impact." (The Actuary Magazine)
Hospital Price Transparency: Making It Useful for Patients
"Crude versions of price transparency like the release of hospital chargemaster lists are unlikely to help patients get more value for their health care dollars.... Here are core elements of effective price transparency that Congress, the Trump administration, and private payers could consider in crafting policies that will effectively empower patients to be better purchasers." (The Commonwealth Fund)
[Opinion] 368 Members of Congress Support Medicare Privatization
"The next time you hear a politician claim to support Medicare for All, it might be wise to ask if that includes supporting the private Medicare Advantage plans.... America's Health Insurance Plans (AHIP), has collected the signatures of 368 members of Congress for letters to encourage [CMS] to further nurture the private Medicare Advantage plans that are already displacing the traditional Medicare program -- now about 40 percent." (Physicians for a National Health Program [PNHP])
House Ways & Means Committee Hearing: The Cost of Rising Prescription Drug Prices
Feb. 12, 2019, hearing; includes link to video along with statement by Chairman Richard Neal, (D-MA) and witness testimony from: [1] Mark E. Miller, Ph.D., Arnold Ventures; [2] Rachel Sachs, Washington University in St. Louis, MO; [3] Alan Reuther, UAW Retiree Medical Benefits Trust; [4] Ola Ojewumi, Patient; [5] Joseph R. Antos, Ph.D., American Enterprise Institute. (Committee on Ways and Means, U.S. House of Representatives)
Ninth Circuit Revives Employers' State Law Claims Against Health Insurance Companies for Hidden Surcharges and Kickbacks
"First, the court held that when Defendants collected and concealed allegedly excessive insurance premium surcharges from the employers, they were not exercising discretionary authority over plan management, and thus, were not acting as ERISA fiduciaries. Second, the allegedly excessive insurance premium surcharges paid by the employers for coverage under fully-insured health plans were not 'plan assets' ... [and thus] Defendants were not acting as fiduciaries when collecting, concealing, or spending the surcharges." [The Depot, Inc. v. Caring for Montanans, Inc., No. 17-35597 (9th Cir. Feb. 6, 2019)] (Kantor & Kantor)
Court Overturns Arizona Law Which Prohibited Municipal Employee Benefits Ordinances
"The ruling reinstates a portion of a 2006 law that permits Arizona municipalities to pass local ordinances requiring employers to provide employment benefits more favorable than those provided under statewide laws. However, federal law, such as [ERISA], still imposes limits on how much these local ordinances may compel employers to do." [Meyer v. Arizona, No. 18-0031 (Ariz. Ct. App. Feb. 5, 2019)] (Ogletree Deakins)
Senate Committee Hearing: How Primary Care Affects Health Care Costs and Outcomes
Feb. 5, 2019. Includes video and written testimony by: [1] Joshua J. Umbehr, M.D., Atlas MD; [2] Sapna Kripalani, M.D., Vanderbilt University Medical Center; [3] Katherine Bennett, M.D., University of Washington School of Medicine; [4] Tracy Watts, Mercer. (Committee on Health, Education, Labor and Pensions, U.S. Senate)
North Carolina: The New Frontier For Health Care Transformation
"Thanks to a convergence of public and private-sector health care leadership, ... North Carolina is now on the verge of ... a set of reforms that would create an unprecedented, accelerated shift in how health care is paid for in the state, and the way social risk factors are incorporated in health care payment and delivery systems. Over the next five years, the state is poised to make an estimated 70 percent or more of health care payments through alternative payment models." (Health Affairs)
Health Insurance Coverage Eight Years After the ACA
"Compared to 2010, many fewer adults are uninsured today, and the duration of coverage gaps people experience has shortened significantly.... [T]he adult uninsured rate was 12.4 percent in 2018 in this survey ... More people who have coverage are underinsured now than in 2010, with the greatest increase occurring among those in employer plans." (The Commonwealth Fund)
Changes in Individual and Small Group Behavioral Health Coverage Following the Enactment of Parity Requirements
"[ASPE] assessed the degree to which behavioral health coverage and medical/surgical coverage in individual and small group plans changed after federal parity requirements in coverage took effect in 2014. The results focus on changes in scope of coverage (what conditions and services are covered) and level of coverage (quantitative restrictions, such as the co-payment and limits on visits). The findings suggest that parity legislation may have had the intended effect." (Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
CMS' ACA Guidance, Oversight Under Scrutiny
"Top Congressional Democrats [asked GAO] to determine if guidance issued by CMS in October 2018 in relation to the Section 1332 waivers states can pursue is subject to legislative oversight. Meanwhile, a report said none of the 8 states that have approval to create a work requirement for their Medicaid expansion pool of beneficiaries have plans to track whether enrollees find jobs or improve their health." (American Journal of Managed Care)
Employer-Sponsored Health Insurance Still the Most Popular Option
"[M]ost people that have coverage through their employer are more concerned about deductibles, drug prices, premiums and 'surprise medical bills' than they are universal coverage[.]" (BenefitsPro)
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