Health & Welfare Plans Newsletter

December 10, 2018

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[Official Guidance]

Text of CMS Appendix B: Sample Translated Taglines (PDF)

25 pages. "Updated with minor corrections to the information posted March 30, 2016. Entities that relied on the information in the March 30, 2016 appendices for 2016 or 2017 Plan Year materials will not be penalized." [Source: CCIIO website, Dec. 10, 2018]
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

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[Official Guidance]

Text of Department of Defense Interim Final Rule: TRICARE Pharmacy Benefits Program Reforms

17 pages. "This interim final rule implements Section 702 of the National Defense Authorization Act for Fiscal Year 2018 [which] makes significant changes to the TRICARE Pharmacy Benefits Program, specifically it: [1] updates co-payment requirements; [2] authorizes a new process for encouraging use of pharmaceutical agents that provide the best clinical effectiveness by excluding coverage for particular pharmaceutical agents that provide very little or no clinical effectiveness relative to similar agents and for giving preferential status to agents that provide enhanced clinical effectiveness; and [3] authorizes special reimbursement methods, amounts, and procedures to encourage use or high-value products and discourage use of low-value products with respect to pharmaceutical agents provided as part of medical services from authorized providers."
U.S. Department of Defense

[Official Guidance]

Text of CMS Final Regs: Adoption of the Methodology for the HHS-Operated Permanent Risk Adjustment Program for the 2018 Benefit Year

"This final rule adopts the HHS-operated risk adjustment methodology for the 2018 benefit year. In February 2018, a district court vacated the use of statewide average premium in the HHS-operated risk adjustment methodology for the 2014 through 2018 benefit years. Following review of all submitted comments to the proposed rule, HHS is adopting for the 2018 benefit year an HHS-operated risk adjustment methodology that utilizes the statewide average premium and is operated in a budget-neutral manner[.]"
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Guidance Overview]

CMS Issues Final Rule on 2018 Risk Adjustment Methodology; Litigation Likely to Continue

"The final rule made no changes from the proposed rule and readopted a portion of the risk adjustment methodology that had been challenged in a lawsuit in New Mexico. Similar to a recent final rule for the 2017 plan year (that has since been challenged), CMS did not make substantive changes from previous risk adjustment regulations. Instead, the agency provided a more thorough explanation of its assumptions in developing the risk adjustment methodology."
Katie Keith, in Health Affairs

Top Health Industry Issues of 2019: The New Health Economy Comes of Age (PDF)

54 pages. "The US health industry is looking less like a special case, an asterisk in the US economy, and is beginning to behave like other industries.... In the digital arena in 2019, life sciences companies will market digital therapeutics and connected devices targeting atrial fibrillation, hemophilia, substance abuse, birth control, depression, diabetes, epilepsy and other conditions. In 2019 the health industry will see value lines created by innovative providers and payers that have figured out how to subsist ... by serving almost entirely Medicaid or cash-strapped patients."
PwC

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Telemedicine Could See Uptick in 2019 with Change in Rules for Online Prescribing

"The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (Ryan Haight Act) ... imposed a federal prohibition on form-only online prescribing for controlled substances.... One of the exceptions mandated that the Drug Enforcement Administration (DEA) create a special registration process to enable a prescribing practitioner to deliver, distribute, dispense, or prescribe a controlled substance to a patient who has not been medically examined in-person via telemedicine ... Over the course of the next year, the Attorney General will have to determine the 'limited circumstances' in which a special registration may be issued."
Bloomberg BNA

How Carrier Negotiations Could Disrupt Your Health Insurance

"Often, these contract negotiations get resolved at the eleventh hour and the facilities never actually lose their in-network status. Sometimes, however, these contract negotiations can continue on beyond the expiration of the previous contract, which leaves the facility out-of-network until a resolution can be found. Members can become an unfortunate pawn in these negotiations.... [E]nsure that you are communicating with your employees so that they understand how their out-of-pocket expenses may be impacted."
Hill, Chesson & Woody

Double Jeopardy in Health: It's Time for Employers to Care

"A rise in drug prices, at an average rate of 6.3 percent per year, has led payers to increasingly shift costs to patients through the placement of drugs in higher tiers.... These formulary policies give rise to a sort of 'double jeopardy,' wherein the sickest employees face the largest financial burden. However, the interests of employers and employees may be more closely aligned than people realize, especially once the hidden costs are taken into account."
Health Affairs

Lessons From Recent FMLA And ADA Decisions, Part 1 (PDF)

"[This] series sets out six lessons that employers should learn from recent cases to ensure legal compliance and minimize litigation risk. Part one of the series covers the following topics: [1] recognizing when an employee provides notice; [2] understanding when a medical condition will be considered a serious health condition and/or a disability; and [3] understanding and proving what constitutes an essential job function."
Dechert LLP, via Law360

Two Hundred Years of Health and Medical Care: The Importance of Medical Care for Life Expectancy Gains

"While common theories about medical care cost growth stress growing demand, [this] analysis highlights the importance of supply side factors, including the major public investments in research, workforce training and hospital construction that fueled a surge in spending over the 1955‑1975 span. There is a stronger case that personal medicine affected health in the second half of the twentieth century than in the preceding 150 years.... [S]pending increased faster than life expectancy, although the ratio stabilized in the past two decades."
National Bureau of Economic Research [NBER]

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David Rhett Baker, J.D., Editor and Publisher
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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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