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Employee Benefits Jobs
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Webcasts and Conferences
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[Guidance Overview]
2016 Payment Notice and Final Call Letter: CMS Gives with One Hand and Takes Away with the Other
"[T]he Announcement outlines payment and risk adjustment methodology changes that will impact payments for MA (Part C) and Part D plans and the retiree drug program benefit parameters in the 2016 contract (calendar) year. The Call Letter describes policy modifications and other considerations for plan sponsors preparing bids for the 2016 contract (calendar) year.... These changes will affect a wide range of stakeholders, including MA and Part D plan sponsors, participating providers, pharmacy benefit managers, pharmacies, drug manufacturers, and the vendors that provide services and products to these segments of the health care industry."
(Epstein Becker Green)
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Text of Federal District Court Order: Claims Administrator's Application of Internal Guidelines Is a Fiduciary, Not a Settlor, Function
"Plaintiffs have alleged that UBH, as the claims administrator with discretion to adjudicate claims for coverage, has promulgated internal guidelines that it uses to determine whether a claimant seeking mental illness or substance use disorder out-patient treatment is entitled to coverage.... [T]hese allegations are sufficient to show, at least at the pleading stage of the case, that UBH was acting as a fiduciary when it adopted these guidelines and therefore may be liable for a breach of fiduciary duty on the basis of this condition....While a plan can act as a settlor, setting the terms of coverage and determining the scope of the plan, it is less clear that a third-party administrator can play that role.... [T]he Plans at issue in this case do not permit UBH to change their terms through the adoption of internal policies." [Alexander v. United Behavioral Health,
No. 14-cv-05337-JCS (N.D. Cal. Apr. 7, 2015)]
(U.S. District Court for the Northern District of California)
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Benefit Design and the Rush, Hush, and Crush Cycles
"[W]hen notified toward the end of the plan year of impending reductions to their medical plans for the upcoming plan year, savvy members often 'rush' off to get deferred elective medical care in order to take advantage of the current richer plan design.... Subsequently, if more elective medical procedures are performed in the last quarter of the previous year during this rush period, there is a slowdown or 'hush' in medical care in the first few quarters of the new plan year.... In the second year of the new plan, as costs return back to normal levels there is a trend 'crush' compared with the previous year because it's compared with a lower base level of claims from the first year of the new design."
(Healthcare Payer News)
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Widespread Slowdown in Health Spending Growth: Implications for Future Spending Projections and the Cost of the ACA (PDF)
"In October 2014, the current forecast suggested that national health expenditures will be $2.5 trillion less over the 2014-2019 period than under the ACA baseline forecast from September 2010 ... Clearly, not all of the spending reduction is due to the ACA: much is due to the recent recession and a long period of slow income growth, the growth of high deductible private health plans, cost constraints within state Medicaid programs, and Medicare policies unrelated to the ACA (e.g. sequestration). But it is also likely that the law contributed; though how much is impossible to estimate."
(Urban Institute)
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Health Care Coverage and Access in the Four Most Populous States
"Across the country's four largest states, uninsured rates vary for adults ages 19 to 64 ... Differences also extend to the proportion of residents reporting problems getting needed care because of cost, which was significantly lower in New York and California compared with Florida and Texas. Similarly, lower percentages of New Yorkers and Californians reported having a medical bill problem in the past 12 months or having accrued medical debt compared with Floridians and Texans. These differences stem from a variety of factors, including whether states have expanded eligibility for Medicaid, the state's uninsured rate prior to the [ACA] taking effect, differences in the cost protections provided by private health insurance, and demographics."
(The Commonwealth Fund)
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Federal Marketplace More Adept Than States at Enrolling Customers
"[I]t's possible that more people over-reported their income on state-based exchanges for 2014 coverage and were subsequently shifted to the Medicaid program this year.... Such shifting could make it appear that some states had lost enrollees when instead they just moved to Medicaid.... But it's not clear why state-based exchanges would experience such shifts to a greater degree than states where the exchange is run by the federal government."
(Kaiser Health News)
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Assessing the Effectiveness of the Health Coverage Tax Credit (PDF)
"The health coverage tax credit (HCTC) expired on January 1, 2014. This federal income tax credit subsidized most of the cost of qualified health insurance for eligible taxpayers and their family members.... For each year the HCTC was available, fewer than 30,000 individuals participated, out of hundreds of thousands of individuals who potentially were eligible for the tax credit. Possible reasons explaining such low participation included not knowing the tax credit was available, barriers to finding qualified insurance, complexity of the application and enrollment process, and difficulties paying the part of the premium not covered by the tax credit. Concerns were raised about whether the HCTC was equitable, since it provided a large tax subsidy to some unemployed workers but not others, and whether it was efficient, since it had what some analysts considered large administrative
costs." [CRS Report RL32620]
(Congressional Research Service [CRS])
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Two Maps Explain How Much the Supreme Court Could Damage Obamacare
"[N]ew maps from the Washington Center for Equitable Growth help illustrate just how much is at stake, showing which states would be hit hardest if the Supreme Court struck down the subsidies that help people afford coverage on insurance marketplaces."
(The Washington Post; subscription may be required)
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Press Releases
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