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<< Older News  |  December 5, 2020

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All News > Health Plan Administration

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2021 Health Plan Compliance Calendar (PDF)
VCG Consultants Link to more items from this source
Dec. 4, 2020

"Employers must comply with certain filing and disclosure requirements each year in connection with their group health plans. This chart summarizes some of the key requirements and is designed to be used as a tool to help facilitate annual compliance."

Tags: Health Plan Administration

COVID-19 Relief for Health Plans: How Long Does It Last?
Mercer Link to more items from this source
[Guidance Overview]
Dec. 4, 2020

"Some relief measures apply only during the COVID-19 Public Health Emergency -- not to be confused with the COVID-19 National Emergency. Some apply only in 2020 and some are permanent. Keeping track of what you need to do and how long the relief lasts can be a compliance challenge. Here's a summary to help you keep it all straight."

Tags: COBRA  •  Coronavirus (COVID-19)  •  Health Plan Administration

Health Plan Fiduciaries Breached ERISA's Fiduciary Duties by Failing to Remit Participant Contributions
Thomson Reuters Practical Law Link to more items from this source
Dec. 4, 2020

"A Virginia district court has held that an employer and its owner violated their ERISA fiduciary duties by: [1] Failing to remit participant contributions that were withheld under an ERISA health plan to the plan's insurer. [2] Using the participant contributions, which were plan assets, to pay the employer's other operating expenses. [3] Not informing the plaintiff-participant that her health plan coverage had lapsed due to their failure to remit the withheld contributions." [Hammer v. Johnson Senior Ctr., No. 19-0027 (W.D. Va. Nov. 30, 2020)]

Tags: Fiduciary Duties  •  Health Plan Administration

Ninth Circuit Finds Anti-Assignment Clause Inapplicable, Requires Plan to Pay Assignee
Thomson Reuters / EBIA Link to more items from this source
Dec. 4, 2020

"[T]he court closely examined both the anti-assignment clause and the plan's incorporation-by-reference language. A dissenting judge disagreed with both elements of the ruling, concluding that the anti-assignment clause was part of the plan ... [T]he bottom line is that the plan must pay the hospital for benefits already paid to participants -- and either absorb the cost or seek reimbursement from those participants, if plan language so allows." [Martin Luther King, Jr., Community Hospital v. Community. Ins. Co., No. 19-55053 (9th Cir. Oct. 2, 2020; unpub.)]

Tags: Health Plan Administration

Health and Welfare Benefits: 2020 Year in Review (PDF)
Alston & Bird Link to more items from this source
[Guidance Overview]
Dec. 3, 2020

35 presentation slides. Topics: [1] Legislative Developments; [2] Regulatory Developments -- Non-COVID: Final Health Plan Transparency Rules, ICHRA Final Rule and Follow-up Guidance on Pay-or-Play and Non-Discrimination Requirements, DOL Electronic Disclosure Rule (for qualified plans), New SBC requirement for 2021, 2021 NBPP (includes some important HSA guidance re: coupons), Direct Primary Care, and Grandfather Rule Relief; [3] Misc. Sub-Regulatory Developments: 2021 Cost-of-living Adjustments for Popular Benefits; [4] Health Plan Litigation Developments; [5] Recap of Coronavirus Impact on Employer H&W Benefits; [6] State Law Potpourri; [7] Cafeteria Plan, Grace Period, and Carry-Over Relief; and [8] COBRA, Claims and Appeals, and Special Enrollment Extensions.

Tags: COBRA  •  Coronavirus (COVID-19)  •  Health Plan Administration  •  Health Plan Design

HHS Issues Final Rule on Transparency in Coverage for Health Care Services
Seyfarth Shaw LLP Link to more items from this source
[Guidance Overview]
Dec. 3, 2020

"The final Rule requires certain disclosures regarding prices and cost-sharing information for certain healthcare items and services provided by non-grandfathered group health plans and insurance issuers. The Rule generally applies to traditional health plan coverage, and does not apply to account-based group health plans (such as HRAs, including individual coverage HRAs, or health FSAs), excepted benefits, or short-term limited-duration insurance. The Rule requires two categories of disclosures: disclosures to the public, and disclosures to plan participants."

Tags: Health Plan Administration  •  Health Plan Costs

Healthcare Cost Transparency Rules Finalized
Mercer Link to more items from this source
[Guidance Overview]
Dec. 3, 2020

"The new rules require most employer-sponsored group health plans and health insurance issuers to disclose price and cost-sharing information up front, giving enrollees estimates of any out-of-pocket expense they will have to pay to meet their plan's cost-sharing requirements. Health plan sponsors and insurance issuers will also have to give patients and other stakeholders access to previously unavailable pricing information, using a standardized format that allows easy cost comparisons."

Tags: Health Plan Administration  •  Health Plan Costs

Agencies Releases Advance Copies of Form 5500 Series Annual Return/Report for 2020 (PDF)
Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]; Internal Revenue Service [IRS]; and Pension Benefit Guaranty Corporation [PBGC] Link to more items from this source
[Official Guidance]
Dec. 2, 2020

"The Form 5500 and Form 5500-SF instructions have been revised to reflect that the Form 5500-SF can no longer be used by a one-participant plan or a foreign plan in place of filing of the Form 5500-EZ with the IRS. Effective for plan years beginning after 2019, one-participant plans and foreign plans can file the Form 5500-EZ electronically using the EFAST2 filing system....

"Administrative Penalties: The instructions have been updated to reflect an increase to $2,233 per day in the maximum civil penalty amount assessable under [ERISA] section 502(c)(2) ...

"Schedule H Part III - Accountant's Opinion: To conform to the new Statement on Auditing Standards 136, 'Forming an Opinion and Reporting on Financial Statements of Employee Benefit Plans Subject to ERISA,' the instructions for the questions on line 3a regarding the accountant's opinion have been revised. Line 3b and its instructions have been updated to permit filers to indicate more accurately whether there have been any permissible limitations on the scope of the audit pursuant to the Department's regulations.

"Schedules H and I, Line 4l and Form 5500-SF, Line 10f: The instructions ... have been revised to increase the required minimum distribution age from 70½ to 72 ...

"Schedules H and I, Line 5c ... has been revised to make clear that if the plan was covered by PBGC at any time during the plan year, filers should check the 'Yes' box....

"Schedule R: Line 14 has been revised to provide multiemployer plans with a choice of three counting methods to count inactive participants and to require that an attachment be provided depending on the counting method chosen....

"Information copies of the forms, schedules and instructions are available on the EBSA website."

Tags: Health Plan Administration  •  Reporting to Government Agencies  •  Retirement Plan Administration

Sixth Circuit Opinion Outlines Ways to Defend Disgorgement and Breach of Fiduciary Duty Claims Under Section 1132(a)(3)
Lane Powell PC Link to more items from this source
Dec. 2, 2020

"[T]ypically claimants seeking ERISA-governed benefits make claims for recovery under Section 1132(a)(1)(B). Now you are likely seeing more simultaneous assertions of equitable claims for breach of fiduciary duty and disgorgement under Section 1132(a)(3). A successful claimant asserting this theory may recover additional forms of monetary relief, and may get broader discovery. But the availability of relief under Section 1132(a)(3) claims is narrow ... So, how do you defend Section 1132 (a)(3) equitable claims?" [Davis v. Hartford Life & Accident Ins. Co., No. 19-6091 (6th Cir. Nov. 19, 2020)]

Tags: Fiduciary Duties  •  Health Plan Administration  •  Retirement Plan Administration

Cancer Survivorship: Challenges and Opportunities for Employers (PDF)
Northeast Business Group on Health Link to more items from this source
Dec. 2, 2020

48 pages. "[A] cancer diagnosis and treatment together comprise just one part of the patient journey. What happens when people move beyond active treatment to survivorship? ... [This guide] is designed to provide you with information on the challenges and opportunities associated with cancer survivorship and practical guidance on creating a workplace that supports people living with cancer and is productive for all."

Tags: Health Plan Administration

Text of HHS Proposed Key Dates for Calendar Year 2021: Qualified Health Plan Data Submission and Certification; Rate Review; and Risk Adjustment (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Guidance Overview]
Dec. 2, 2020

"This [3-page chart] summarizes key dates for calendar year 2021 regarding some activities and policies that are outlined in other documents."

Tags: Health Plan Administration

Reminder: New SBC Templates and Glossary Required for Plan Years After December 31, 2020
Cheiron Link to more items from this source
[Guidance Overview]
Dec. 2, 2020

"In 2019 [CMS] revised the Summary of Benefits and Coverage (SBC) materials and supporting documents for use for plan and policy years that begin on or after January 1, 2021. The revisions to the forms and templates reflect the elimination of the individual mandate requirement, which became effective for the 2019 plan year.... All SBC materials for plan and policy years beginning on and after January 1, 2021 must comply with the new requirements." [Editor's note: Links to CMS materials and supporting documents are available here.]

Tags: Health Plan Administration

Vary Your Tools for Communicating About Employee Benefits
Inside Business Link to more items from this source
Dec. 2, 2020

"Perception of company benefits has a direct impact on employee satisfaction, productivity, retention, and recruitment.... Current trends are showing that each of the four or five generations which may be represented in your organization have different concerns."

Tags: Coronavirus (COVID-19)  •  Health Plan Administration  •  Retirement Plan Administration

Text of HHS Proposed Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Manager Standards; Updates to State Innovation Waiver (Section 1332 Waiver) Implementing Regs
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 30, 2020

395 pages. "This proposed rule sets forth payment parameters and provisions related to the risk adjustment program; cost-sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges and State-based Exchanges on the Federal platform. It includes proposed changes related to special enrollment periods; Navigator program standards; direct enrollment entities; the administrative appeals processes with respect to health insurance issuers and non-federal governmental group health plans; the medical loss ratio program; acceptance of payments by issuers of individual market Qualified Health Plans; and other related topics. It proposes clarifications to the regulation imposing network adequacy standards with regard to Qualified Health Plans that do not use provider networks. It proposes changes to the regulation requiring the reporting of certain prescription drug information by qualified health plans or their pharmacy benefit managers. It also proposes a new direct enrollment option for Federally-facilitated Exchanges and State Exchanges. This proposed rule also proposes changes related to section 1332 State Innovation Waivers." [Also see: Fact Sheet and Press Release]

Tags: Health Plan Administration  •  Health Plan Design  •  Health Plan Policy

Text of HHS Final Regs: HHS-Operated Risk Adjustment Data Validation Under the ACA's HHS-Operated Risk Adjustment Program
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 30, 2020

83 pages. "This final rule adopts certain changes to the risk adjustment data validation error estimation methodology beginning with the 2019 benefit year for states where [HHS] operates the risk adjustment program. This rule is finalizing changes to the HHS-RADV error estimation methodology, which is used to calculate adjusted risk scores and risk adjustment transfers, beginning with the 2019 benefit year of HHS-RADV. This rule also finalizes a change to the benefit year to which HHS-RADV adjustments to risk scores and risk adjustment transfers would be applied beginning with the 2020 benefit year of HHS-RADV."

Tags: Health Plan Administration  •  Health Plan Costs

Text of IRS Final Regs Clarifying Premium Tax Credit Unaffected by Suspension of Personal Exemption Deduction
Internal Revenue Service [IRS] Link to more items from this source
[Official Guidance]
Nov. 30, 2020

14 pages. "This document includes final regulations under sections 36B and 6011 of the Internal Revenue Code that clarify that the reduction of the personal exemption deduction to zero for taxable years beginning after December 31, 2017, and before January 1, 2026, does not affect an individual taxpayer's ability to claim the premium tax credit. These final regulations affect individuals who claim the premium tax credit."

Tags: Health Plan Administration  •  Health Plan Costs

The 2022 Proposed Payment Notice: Exchange Provisions
Katie Keith, via Health Affairs Blog Link to more items from this source
[Guidance Overview]
Nov. 30, 2020

"In the proposed rule's most dramatic change, CMS would allow states to opt into an Exchange Direct Enrollment (Exchange DE) option where states could transition away from a single, centralized exchange (HealthCare.gov) to enrollment via private sector entities (insurers, web-brokers, and agents and brokers)."

Tags: Health Plan Administration  •  Health Plan Design

The 2022 Proposed Payment Notice: Medical Loss Ratios, Special Enrollment Periods, and More
Katie Keith, via Health Affairs Blog Link to more items from this source
[Guidance Overview]
Nov. 30, 2020

"CMS proposes to amend the definition of prescription drug rebates and other price concessions in its MLR formula.... The 2022 proposed payment notice includes no changes regarding the coverage of essential health benefits (EHB) and instead merely lays out timelines for state reporting.... CMS proposes a series of changes to special enrollment periods (SEPs) for exchange enrollees who become newly eligible for APTC and for those who are eligible for a SEP but did not receive timely notice of the triggering event. CMS also addresses the cessation of employer contributions to COBRA."

Tags: COBRA  •  Health Plan Administration  •  Health Plan Design  •  Prescription Drug Costs

The 2022 Proposed Payment Notice: Risk Adjustment
Katie Keith, via Health Affairs Blog Link to more items from this source
[Guidance Overview]
Nov. 30, 2020

"This post considers the proposed changes to the risk adjustment program related to user fees, recalibration of the risk adjustment models, the model itself, enrollment duration factors, and changes to risk adjustment data validation (RADV) requirements[.]"

Tags: Health Plan Administration  •  Health Plan Costs

UnitedHealth ERISA Ruling Exposes Faults in Behavioral Health Coverage
DeBofsky Sherman Casciari Reynolds P.C. Link to more items from this source
[Opinion]
Nov. 30, 2020

"The court's judgment goes directly to the heart of America's health care system, which does not always render coverage decisions that are consistent with medical necessity and in accordance with treatment recommended by patients' medical providers but instead has ... put insurers' profits ahead of patients' health. The Wit rulings are also a major step toward bringing an end to the stigmatization of those with mental illness and fulfilling the promise of the Mental Health Parity and Addiction Equity Act." [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Nov. 3, 2020)]

Tags: Health Plan Administration

Miscommunication Between Employer and Insurer About Employee’s Medical Leave Causes Loss of Coverage -- and a Lawsuit
Thomson Reuters / EBIA Link to more items from this source
Nov. 25, 2020

"Because the plan required the company to notify the insurer regarding changes in eligibility, the court concluded that the employer could have been acting as a functional fiduciary with respect to the eligibility decision. But finding a genuine dispute as to whether the insurer or the employer was ultimately responsible for the erroneous decision to deny coverage, the court allowed the case to proceed." [Schmidt v. Overland Xpress, LLC, No. 12-0397 (S.D. Ohio Sep. 28, 2020)]

Tags: Health Plan Administration

Text of IRS Notice 2020-84: Adjusted Applicable Dollar Amount for Fee Imposed by §§ 4375 and 4376 (PDF)
Internal Revenue Service [IRS] Link to more items from this source
[Official Guidance]
Nov. 25, 2020

"The applicable dollar amount that must be used to calculate the fee imposed by Sections 4375 and 4376 for policy years and plan years that end on or after October 1, 2020, and before October 1, 2021, is $2.66. The increase from the prior amount is calculated by multiplying the adjusted applicable dollar amount for policy years and plan years ending in the previous Federal fiscal year, $2.54, by the percentage increase of the projected per capita amount of National Health Expenditures published by HHS on March 19, 2020."

Tags: Health Plan Administration  •  Health Plan Costs

When to Consider a New Benefits Administration Platform
bswift Link to more items from this source
Nov. 23, 2020

"[H]ow do you know when it's time to consider a new benefits administration solution? ... [1] You rely on paper enrollment and your in-house HR team.... [2] You want to improve your data flow.... [3] You want a more integrated experience.... [4] Your account team isn't able to deliver for your needs today ... or tomorrow.... [5] You want to boost employee engagement."

Tags: Health Plan Administration

Editor's Pick The HSA Shoebox Rule
ABD Insurance & Financial Services Link to more items from this source
Nov. 23, 2020

" [IRS Notice 2004-50] confirms that as long as the requirements are followed, 'there is no time limit on when the distribution must occur.' ... The HSA Shoebox Rule Requirements: [1] The expense was incurred after the HSA was established; [2] The individual keeps records sufficient to later show that the distributions were exclusively to pay or reimburse qualified medical expenses; [3] The qualified medical expenses have not been previously paid or reimbursed from another source; and [4] The medical expenses have not been taken as an itemized deduction in any prior taxable year."

Tags: HSAs  •  Health Plan Administration

Better Prediction of Rising Health Spending to Improve Cost Containment
National Institute for Health Care Management [NIHCM] Link to more items from this source
Nov. 20, 2020

"Spending patterns over two years were best described by classifying patients into five groups: minimal users comprised 11 percent of the population; low-, moderate- and high-cost patients accounted for 15, 25, and 41 percent, respectively; and patients with rising costs were 8 percent of the population.... Across patients with similar baseline spending, the odds of subsequently incurring rising spending were higher for patients using fewer medications, having fewer office visits, seeing a larger number of different physicians and using tobacco. These factors suggest patients to target for intervention."

Tags: Health Plan Administration  •  Health Plan Costs  •  Health Plan Design


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