"[As] of mid-2020, while employer offer of same-sex spousal coverage has increased over time, it remains less common than opposite sex spousal coverage. These increases follow two other Supreme Court rulings (United States v. Windsor and Obergerfell v. Hodges) which guaranteed the right to marriage nationwide and paved the way for wider access to health insurance through the workplace[.]"

"The plaintiffs say that nearly 12,000 people will lose their health care next month -- about a third of those participating in the union's plan. Moreover, they say, many of those losing coverage are senior citizens who in many cases have paid into the plan for decades. Members will have to prove earnings of at least $25,950 to get health coverage through the union. Under the new rules, however, that income cannot include pensions or residuals[.]"

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.

24 pages. "The AV Calculator represents an empirical estimate of the AV calculated in a manner that provides a close approximation to the actual average spending by a wide range of consumers in a standard population. This document is meant to detail the specific methodologies used in the AV calculation.... The draft 2022 AV Calculator is available [online].... [T]he 2022 AV Calculator does not affect any 2021 plans, and will only be applicable for 2022 plans.... [CMS] will accept comments on the draft 2022 AV Calculator, as well as the draft 2022 AV Calculator User Guide and the draft 2022 AV Calculator Methodology until ... December 24, 2020."

"The Trump administration added more than 60 telehealth services that will be reimbursable during the public health emergency caused by the COVID-19 pandemic. Those changes to telehealth coverage will also be allowed permanently in rural areas."

"The Ninth Circuit dismissed the provider's claims, concluding that: [1] The provider's claim for benefits, which it brought as the beneficiary's assignee, was based on the alleged MSP violation. [2] The provider could not bring a claim for equitable relief under ERISA because the assignment form did not include an assignment of equitable claims." [DaVita Inc. v. Amy's Kitchen, Inc., No. 19-15963 (9th Cir. Nov. 24, 2020)]

"A recent survey ... found that about one in six (15 percent) employers are planning to offer or considering the HRA option, with larger employers expressing an even stronger interest. It makes every sense that they should do so, given the widespread benefits: employers gain predictability in health-care costs, while workers gain a bigger choice of plans and coverage they can take with them from job to job.... The HRA regime seems far preferable to the well-intentioned, albeit bureaucratic and clunky, regime outlined in the AEI paper."

"This disruptive period provides a rare opportunity for health plans and providers to partner in targeted areas of benefit to members, patients, and communities. In particular, working together to strengthen patients' sense of value and trust in preventive and chronic care while maintaining COVID-19 safety precautions will be critical to reducing preventable morbidity and mortalities, as well as unnecessary costs."

"2021 is destined to be the Year of the Big Reset as employers and employees adjust to what the coronavirus has brought about in terms of needs and expectations.... [1] The reset on health plans -- and benefit programs ... [2] The growing need for mental health and financial wellness support ... [3] Focus sharpens on COVID vaccines and specialty drug cost pressure continues."

"The Supreme Court decided to take the latest constitutional challenge to address four legal questions: [1] Whether Texas and the individual plaintiffs have standing to bring the lawsuit to challenge the individual mandate. [2] If the plaintiffs have standing, whether the TCJA rendered the individual mandate unconstitutional. [3] If unconstitutional, whether the remaining portions of the ACA can survive. [4] If the entire ACA is found to be unconstitutional, whether the entire law should be unenforceable nationwide or whether it should be unenforceable only to the extent that provisions injure the individual plaintiffs." [California v. Texas, No. 19-840; Texas v. California, No. 19-1019 (cert. pet. granted Mar. 2, 2020; oral arg. Nov. 10, 2020)]

"[K]eeping employees happy is a function of not only having meaningful work to do, but also compensating them appropriately for that work. In recent years, this has led to an ever-growing number of 'perks' that firms offer employees to keep them happy, from retirement benefits to health insurance, to education reimbursement to student loan support, and gym memberships, and employer-provided meals. But in the end, employers can't just pile on a never-ending stream of employee benefits and perks in the hopes that it will help employees to retain; at some point, the question becomes: what are the best 'perks' and employee benefits that really, actually help to retain employees?"

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]

"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)."

"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."

"There will be a phased-in distribution process initially targeting health care providers and vulnerable groups. Once a vaccine is approved, most group health plans will have to cover it (and related administration costs) within 15 days, at no cost. There are significant legal issues involved in addressing whether employers can mandate that employees receive vaccinations, and there is no guidance at this time on the COVID-19 vaccine."

"Preventive services are a key component of many health insurance plans. The introduction of the [ACA] brought about many legislative changes intended to improve the health of people in the United States. One such change was the introduction of mandatory coverage with no cost sharing for services determined to be preventive. Historically, preventive service status has been determined based on clinical evidence. This paper examines the evolution and future of preventive services."

"Coinsurance reduces use of inpatient care and specialist physician office visits more than copayments do. However, while most employers already use coinsurance for inpatient care, only 44 percent use coinsurance for office visits.... [E]mployers seeking to manage use of health care services and spending -- especially among high users of health care services -- may look to moving from copayments to coinsurance for office visits as a way to do so."

"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."

"Manufacturing workers were most affected by loss of jobs with employer health insurance because manufacturing has one of the highest rates of ESI coverage (66 percent). ... [B]ecause only 40 percent of workers in retail had ESI prepandemic, these workers accounted for 12 percent of lost jobs with ESI."

"The state-level facts sheets explore the prevalence of mental illness and substance use and related deaths, and access, affordability, and costs of care. Key findings include: ... [1] Average biweekly data for October 2020 found that 37.7% of adults in the U.S. reported symptoms of anxiety and/or depressive disorder, up from 11.0% in 2019. [2] The states with the highest percentage of adults reporting symptoms of anxiety and/or depressive disorder in October 2020 were New Mexico (43.7%), Nevada (42.6%), Kentucky (42.4%), Louisiana (41.4%), and California (41.2%)."

"The new AMA policy encourages employers to: [1] Provide robust education to help patients make good use of their benefits to obtain the care they need. [2] Take steps to collaborate with their employees to understand employees' health insurance preferences and needs. [3] Tailor their benefit designs to the health insurance preferences and needs of their employees and their dependents. [4] Pursue strategies to help enrollees spread the costs associated with high out-of-pocket costs across the plan year."

"The winning combination is probably a mix of established ideas (such as the bedrock of company health insurance) and new ones shaped by the pandemic (more flexible schedules). This simple chart organizes benefits into a hierarchy according to cost to the employer -- as well as tiers within each price level to show which benefits tend to be more foundational. This may help you set or adjust your priorities for 2021."

30 pages. "Because the Limited Partners are working owners and bona-fide partners, they may participate in the single employer welfare benefit plan set up by DMP, so long as DMP employs at least one common-law employee. Accordingly, [DOL Advisory Opinion 2020-01A] is set aside as arbitrary and capricious under the APA and contrary to law under ERISA and Defendants are ENJOINED from refusing to acknowledge the ERISA-status of the Plan or refusing to recognize the Limited Partners as working owners of DMP." [Data Marketing Partnership, LP v. DOL, No. 19-800 (N.D. Tex. Sep. 28, 2020)]

"For those ... ages 55 to 64, most are worried about their ability to afford health insurance before reaching the current Medicare eligibility age of 65. Fifty-seven percent of the employed group is worried ... Thirty-three percent of those employed and unemployed and under 65 are planning to reduce preventive care appointments and/or everyday household purchases like groceries to afford health insurance before they reach 65.... Thirty-eight percent of the non-working group gets health insurance through either a former employer or a partner's employer[.]"

"In this analysis, [the authors] ... estimate the shares of a typical nongroup insurance premium attributable to an array of different benefits. [They] also estimate the financial implications for people using those benefits should they be eliminated from the nongroup insurance benefit package."