Health & Welfare Plans Newsletter

July 9, 2018

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Jobs

Conversion/Transition Specialist
Acuff & Associates, Inc.
in TN

Senior Pension Administrator - Combo DB/DC Plans
Primark Benefits
Telecommute

Employee Benefits Associate
Ogletree, Deakins, Nash, Smoak & Stewart, P.C.
in IL

Relationship Manager
ERISA Services, Inc.
in TN, Telecommute

Retirement Plan Services Manager
CCOERA
in CO

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Webcasts, Conferences

How Companies Can Make Specialty Pharmacy Drugs More Affordable
August 8, 2018 in TX
Worldwide Employee Benefits Network [WEB] - Houston Chapter

New ERISA Regulations for Disability Claims and Appeals
August 13, 2018 WEBCAST
Lorman Education Services

What is PGx and How is it Being Used to Improve Safety and Outcomes?
August 28, 2018 in TX
Worldwide Employee Benefits Network [WEB] - Dallas Chapter

►See 132 Upcoming Webcasts and Conferences

►See 1399 Recorded Webcasts


Discussions

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[Official Guidance]

Text of CMS 2019 Guidance on Annual Eligibility Redetermination (PDF)

"For benefit year 2019, the alternative procedures ... are the same as the alternative procedures specified by the Secretary for benefit year 2018, as described in the published guidance titled Guidance on Annual Redeterminations and Re-enrollments for Exchange Coverage for 2018, with all references to years advanced by one.... These procedures will be used by all Exchanges using the federal eligibility and enrollment platform."
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

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[Guidance Overview]

Association Health Plans: A Detailed Look at the Final Rule

"[E]xpect ongoing activity at the state and federal levels to regulate and monitor new AHPs.... Also expect many states to enact new coverage mandates on AHPs, similar to EHBs.... [T]he overall effect on premiums in the marketplace will depend heavily on state regulation and the design of AHPs."
Greensfelder

District Court Finds Two-Decade Pattern of Insurer's 'Extraordinary' Steps to Deny Disability Claims

"The court queried whether Reliance based its denial on substantial evidence. Its answer: No.... The court then queried whether Reliance has a conflict of interest. Its answer: Yes. The court found over 100 decisions in the last 21 years criticizing Reliance's disability decisions.... [T]he court noted that Reliance submitted no evidence showing that it has taken steps to mitigate its conflict of interest.... [T]he court found that Reliance abused its discretion by denying Nichols' benefits." [Nichols v. Reliance Standard Life Ins. Co., No. 17-42 (S.D. Miss. June 29, 2018).
Kantor & Kantor

Want to Fix Health Care? Start with Employers

"Focusing on improving outcomes and lowering costs for employer-insured workers will be a quicker path than trying to reform the pharmaceutical or health insurance industries ... because employers are increasingly desperate to stem their rising costs, so have a vested interest in making care more efficient and less wasteful."
CNBC

What Does a Drug Cost? It Depends on Where You Live

"Some disparities obviously result from a higher cost of living -- New York and San Francisco were the most expensive cities in the country for drugs. But prices can vary widely even between similar cities in the same state: Cleveland's pharmacy prices were 2.5 percent above the national average, while not far away, Columbus had prices that were nearly 22 percent below average. In Cleveland, the generic version of Paxil, the antidepressant, costs about $46.94, while in Columbus, someone would pay $20.87."
The New York Times; subscription may be required

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Health Insurance Marketplace: Carriers' Participation in States and Counties in 2019

"A year ago, rate filings caused widespread anxiety, as multiple carriers announced withdrawals from the ACA market, and state officials struggled to fill bare counties. Many of those remaining filed enormous rate increases. In 2018, marketplace enrollment was stable, while unsubsidized enrollment continued its multi-year decline. So far, this year's rate filing season has been sprinkled with news of entry and expansion, and proposed rate hikes that are generally more moderate. With no announced market exits thus far, it seems likely that in 2019 there will be net entry into the ACA marketplace."
Robert Wood Johnson Foundation

United States District Court Ruling Puts Risk Adjustment on Hold

"On February 28, 2018, the United States District Court for the District of New Mexico issued a decision invalidating use of the statewide average premium by [CMS] in the risk adjustment transfer formula established under section 1343 of the [ACA] for the 2014-2018 benefit years ... In light of a contrary decision by the United States District Court for the District of Massachusetts, the government moved the New Mexico district court to reconsider its decision, and CMS is currently awaiting the court's ruling.... The New Mexico district court's ruling currently bars CMS from collecting or making payments under the current methodology[.]"
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

Latest In ACA Risk Adjustment Litigation

"CMS states that it is seeking a 'quick resolution' in the case but is, in the meantime, prohibited from collecting or making payments under the current risk adjustment methodology for 2014 to 2018. (Risk adjustment payments for 2019 are not at issue; the payments for 2017 were not expected until the fall of 2018.)"
Katie Keith, in Health Affairs

How Employers Should Respond to ACA Penalty Letters

"Letter 226-J gives employers the opportunity to refute the assessed penalty amount by filing Form 14764. Depending on the applicable large employer's response the IRS has begun to issue one of five versions of IRS Letter 227 as a response to the action the employer chooses to take on Letter 226-J.... [T]he IRS is already preparing to send out the next wave of 226-J letters for the 2016 fiscal year."
Employee Benefit News

[Opinion]

Blue Cross Blue Shield Association Statement on Risk Adjustment Payment Freeze

"Without a quick resolution to this matter, this action will significantly increase 2019 premiums for millions of individuals and small business owners and could result in far fewer health plan choices. It will undermine Americans' access to affordable coverage, particularly for those who need medical care the most."
Blue Cross and Blue Shield Association

Benefits in General

Circuit Split About ERISA Proper Party Defendants and Service of Process May Be Resolved by Supreme Court

"The Colorado Supreme Court's decisions upholding the dismissal of claims against two separate disability plans under ERISA may be under review by the [U.S.] Supreme Court, following submission of the joint petition for a writ of certiorari ... Petitioners asked the Supreme Court to review the following two issues: [1] a Circuit split regarding whether and when an ERISA benefit plan is a proper defendant in a benefit claim; and [2] whether an ERISA plan's agent for service of process must be an actual human or can be a group, corporation or other entity."
Robinson & Cole LLP

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BenefitsLink Health & Welfare Plans Newsletter, ISSN no. 1536-9595. Copyright 2018 BenefitsLink.com, Inc. All materials contained in this newsletter are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior written permission of BenefitsLink.com, Inc., or in the case of third party materials, the owner of those materials. You may not alter or remove any trademark, copyright or other notices from copies of the content.

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