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[Guidance Overview]
ERISA Claims Procedures for Disability Benefits to Get an ACA Makeover
"Procedures would need to be designed to ensure independence and impartiality of the persons making the decision.... Denial notices would be required to provide a full discussion of the basis for denial and the standards behind the decision.... Claimants would need to be given access to their entire claim file and permitted to present evidence and testimony during the review process."
(Jackson Lewis)
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[Guidance Overview]
Administration Finalizes Regs Implementing Array of ACA Insurance Reforms
"The final rules make ... virtually no changes in the interim rules as interpreted by current guidance. What the final rules do in many instances, however, is to incorporate existing guidance into final rule form. As guidance is not as legally authoritative as are regulations, this clarifies the legal status of existing interpretations of the rules. The finalization of these rules also makes it more difficult for a future administration to change them as the Obama administration nears its final year. The final rule will go into effect on January 1, 2017[.]"
(Timothy Jost, in Health Affairs)
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DOL Continues to Warn Employers of Investigation of Systemic FMLA Issues
"[T]he DOL's interest in systemic issues means that the agency will regularly broaden its FMLA enforcement to identify compliance problems that impact multiple employees and multiple employer locations.... [T]he DOL's systemic investigations will generally take aim at three types of information: [1] statistical -- leave trends, leave requests, leave approvals and responses to leave requests by supervisor, job group, type of request or any other grouping; [2] anecdotal -- based on interviews with employees, supervisors, administrators and managers; and [3] documents -- records of leave requests, notices provided, leave determinations, employer's FMLA policy and handbook, and medical certifications and re-certifications."
(FMLA Insights)
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U.S. Employee Wellness Programs and Access to Obesity Treatment in Employer-Sponsored Health Insurance
"Respondents were asked whether their employer [1] requires participation in a wellness program to receive full health benefits, [2] sets goals for weight and other health indicators, and [3] includes coverage for evidence-based obesity treatment in their health plan.... The study found 16% of employers required participation in wellness programs to receive full health benefits. Most programs set targets for weight and related health indicators, but they did not typically provide coverage for evidence-based obesity treatments."
(American Journal of Managed Care)
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Five Telemedicine Trends Transforming Health Care in 2016
"It is expected that the global telemedicine market will expand at a compound annual growth rate of 14.3 percent through 2020, eventually reaching $36.2 billion, as compared to $14.3 billion in 2014.... These five trends will drive telemedicine's continued growth and transformation of health care delivery in 2016: [1] Expanding Reimbursement and Payment Opportunities ... [2] Uptick in International Arrangements ... [3] Continued Momentum at the State Level ... [4] Retail Clinics and Employer Onsite Health Centers on the Rise ... [5] More ACOs Using Technology to Improve Care and Cut Costs."
(Foley & Lardner LLP)
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Without Clear Statement of Claims Administrator's Discretionary Authority, Court Refuses Deferential Review
"The court walked through a 'labyrinth' of provisions in various documents cited by the employer and the claims administrator before concluding that, even if taken together (adopting the most generous interpretations of several inartful attempts at incorporation by reference), these provisions still did not amount to the requisite grant of discretionary authority.... This case highlights the importance of clarity in making, documenting, and adhering to grants of discretionary authority.... [D]ifferent procedures and decisionmakers for different benefits should be spelled out explicitly." [Noah U. v. Tribune Co. Medical Plan, No. 2:14-cv-03062 (C.D. Cal. Oct. 7, 2015)]
(Thomson Reuters / EBIA)
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District Court Says 'Aetna's Goal Was to Deny the Plaintiff's Claim'
"The court was disturbed by Aetna's insistence on 'objective medical evidence' in the absence of a policy requirement mandating such evidence. Moreover, the court found that the nature of [the employee's] impairment made it impossible for him to produce the type of evidence that Aetna demanded. The court was also dubious about the validity of Aetna's vocational assessment and also questioned its medical consultants' findings.... [The court] pointed out that Aetna did not have a license to ignore reliable evidence, yet it appeared to the court that Aetna did just that." [Charles v. UPS Long Term Disability Plan, No. 12-06223 (E.D. Pa. Oct. 29, 2015)]
(DeBofsky & Associates, PC)
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Work Incentives in the Social Security Disability Benefit Formula
"The return to working an additional year at an income level just large enough to earn Social Security credits for the year is large and positive through age 60. However, the return to working an additional full year is substantially smaller and becomes negative at approximately age 57. Thus, older workers face strong incentives to earn enough to obtain creditable coverage through age 60, but they face disincentives for additional earnings. In addition, workers ages 61 and older face work disincentives at any level of earnings."
(National Bureau of Economic Research [NBER])
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It's About Time: Effects of the ACA Dependent Coverage Mandate on Time Use
"[T]he ACA's dependent coverage provision has reduced job-lock, as well as the duration of the average doctor's visit, including time spent waiting for and receiving medical care, among persons ages 19-25. The latter effect is consistent with a substitution from hospital ER utilization to greater routine physician care. The extra time has gone into socializing, and to a lesser extent, into education and job search. Availability of insurance and change in work time appear to have increased young adults' subjective well-being, enabling them to spend time on activities they view as more meaningful than those they did before insurance became available."
(National Bureau of Economic Research [NBER])
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Many Say High Deductibles Make Their Marketplace Insurance All But Useless
"Sara Rosenbaum, a professor of health law and policy at George Washington University ... said the rising deductibles were part of a trend that she described as the 'degradation of health insurance.' ... [A]fter reviewing the available plans, [a 29-year-old Houston consumer] concluded: 'The deductibles are ridiculously high. I will never be able to go over the deductible unless something catastrophic happened to me. I'm better off not purchasing that insurance and saving the money in case something bad happens.' "
(The New York Times; subscription may be required)
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CBO Presentation: Forecasting Enrollment and Subsidies in the ACA Exchanges
14 presentation slides. "This presentation reviews CBO's original and more recent projections of enrollment in health insurance policies through the exchanges established under the Affordable Care Act and the subsidies (including both premium tax credits and cost-sharing subsidies) provided to those enrollees, illustrating how the estimates have changed over time. CBO's projections of 2014 exchange enrollment and subsidies are also compared with the actual enrollment and subsidies paid in that year."
(Congressional Budget Office [CBO])
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[Opinion]
Why is the Cost Soaring for Health Insurance Through Your Employer?
"As of 2006, just 10% of all respondents in KFF's survey had workers enrolled in a plan with an average deductible above $1,000. Today this figure sits at 46%, having risen in every year since 2006. Of course, for some individuals and families the thought of a $1,000 deductible sounds dreamy. The average family with a high-deductible plan pays an average of $4,332 before contributions from the insurance company kick in.... If you ... want to point fingers for higher healthcare costs and deductibles, then you're going to need two hands. First, it's as simple as employers wanting to pass along the rising costs for premiums onto their employees.... The other finger should be pointed at drug developers, which more or less have insurers wrapped around their finger."
(Motley Fool)
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[Opinion]
How the ACA Inadvertently Threatens the Financial Health of Small Businesses, and What States Should Do About It
"By financing their own health care plans, [companies] stay exempt from the community rating requirements ... [and] from the federal and state taxes on most health care premiums that are paid to traditional insurers.... One possible improvement would be for state regulators to require that every stop-loss reinsurer under its jurisdiction provide small firms with advance notice of three months before canceling a stop-loss policy or materially raising its premiums. The notice would give the employer a bit of leeway to figure out an alternative. Another idea would be to expand and enhance the role of the brokers that small companies hire to handle their reinsurance needs.... A final possibility would be to extend the reach of the new health insurance exchanges operating under the Small Business Health Options Program, or SHOP."
(Robert C. Pozen, via The Brookings Institution)
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