Health & Welfare Plans Newsletter

January 30, 2019

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[Guidance Overview]

Employers Following Pre-ACA Break In Service Rules Leave Themselves Exposed to Section 4980H Penalties

"Applying the 13 week rule there are two scenarios. In the first scenario the employer has a break in service that is 13 weeks or longer.... The second scenario occurs when the break in service falls short of 13 consecutive weeks. This is where pre-ACA practices are creating problems."
Accord

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[Guidance Overview]

Draft 2020 Letter to Issuers and Actuarial Value Calculator

"CMS will maintain the same approach in 2020 as it did in 2018 or 2019 in areas that include plan ID crosswalks, licensure and good standing, service areas, network adequacy, discriminatory benefit design, quality reporting, prescription drug benefit offerings, cost-sharing reduction variations, data integrity review, consumer support tools and related issues, and the summary of benefits and coverage. Where the 2020 draft letter differs from the 2019 letter, it generally does so by incorporating changes contained in the proposed 2020 payment rule."
Katie Keith, in Health Affairs

[Guidance Overview]

San Francisco Increases Healthcare Costs and Requirements for Employers in 2019

"As of 2019, San Francisco employers with 20-99 employees worldwide must spend $1.95 per hour, and those with 100 or more employees worldwide must spend $2.93 per hour. Businesses with less than 20 employees remain exempt from the [health care security ordinance (HCSO)]. The 2019 'Exemption Threshold' (minimum amount for managerial, supervisory, and confidential employees to be exempt from the HCSO) has increased to $48.46 per hour or $100,796 per year."
ReedSmith

Calendar Year Health Plans Must Complete Online CMS Disclosure by March 1, 2019

"The plan sponsor must complete the disclosure within 60 days after the beginning of the plan year. Sponsors of insured plans may choose to file within 60 days after the beginning of the insurance contract year, but whatever approach is adopted, it should be used consistently.... A CMS filing is also required within 30 days of termination of a prescription drug plan and for any change in a plan's creditable coverage status."
Lockton

Editor's Pick First Phase of New Association Health Plans Reveal Promising Trends

"Regional associations launched 71 percent of new AHPs.... 4 out of 5 new AHPs are insured through a third-party insurance company as opposed to self-funded. Maximum savings claims average higher for self-funded plans than fully-insured plans, though both are in double digits.... Half of new AHPs are limited to companies of 2-50 employees. 43 percent of new AHPs are available to sole proprietors and the self-employed. Benefit information trends toward comprehensive health coverage that includes items such as mental health benefits and prescription drug coverage alongside mandated benefits such as maternity."
AssociationHealthPlans.com

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Congress Wades Into Debate Over High-Cost Prescription Drugs; Pharma Execs Refuse to Testify

"Senators railed against pharmaceutical executives [at a Jan. 29 hearing] for declining to testify before Congress about out-of-control drug prices, as lawmakers on both sides of the U.S. Capitol kicked off investigations sure to rattle one of the nation's most powerful industries."
Kaiser Health News

Editor's Pick Essential Facts About Medicare and Prescription Drug Spending

"[1] Medicare's share of the nation's retail prescription drug spending has increased from 18% in 2006 to 30% in 2017.... [2] Prescription drugs covered under both Part B and Part D accounted for 19% of all Medicare spending in 2016.... [3] Ten drugs accounted for 17% of all Part D spending in 2016 ... [4] Prescription drugs accounted for $1 in every $5 that Medicare beneficiaries spent out-of-pocket on health care services in 2016, not including premiums."
Henry J. Kaiser Family Foundation

New Year Brings Hospital Pricing Transparency

"[T]he amounts posted are the 'full price' amounts, sometimes referred to as 'rack rates' or the 'chargemaster' ... [A]lmost no one actually pays these prices.... Insurance companies and third-party administrators negotiate discounts ... [C]onsumers who are covered by insurance may only pay a portion of these rates through copayments or coinsurance.... [E]ven uninsured consumers may negotiate discounts ... [In] many cases, the items or services listed are given highly technical, often confusing names. Even an experienced health care professional may have trouble understanding them."
HUB International

Know the Specifics of Your Health and Welfare Stop-Loss Policy (PDF)

"Specific stop-loss coverage protects a plan sponsor from large claims for individual participants during a policy period, while aggregate stop-loss coverage protects a plan sponsor from overall total plan claims during a policy period. This article focuses primarily on specific stop-loss policies ... However, some states require a plan sponsor that has a specific stop-loss policy to also have an aggregate stop-loss policy."
Milliman

[Opinion]

Comprehensive Reform to Lower Prescription Drug Prices

"Even when manufacturers do account for the value of their drugs, it is largely based on their own studies and data -- which are often not made public. There are two main problems that comprehensive legislation should address. [1] Steep launch prices of new drugs ... [2] Price hikes on existing drugs."
Center for American Progress

Benefits in General

The Naked CEO: Personal Liability for Board Members and C-Suite Under ERISA

"The United States spends approximately $3 trillion a year on health care, making the oversight of company health plans an attractive target for plaintiffs.... The plaintiffs' bar is now arguing that ... employee premiums and other costs, such as co-pays, types of coverage, pharmacy rebates, should be considered protected ERISA plan assets, and that every decision a plan sponsor makes with respect to use of those plan assets is a fiduciary decision."
Crowell & Moring

Press Releases

Gail S. Ennis Sworn In as Inspector General for the Social Security Administration
Office of the Inspector General [OIG], U.S. Social Security Administration [SSA]

NTSA 2019 Elite Advisors Honored
National Tax-Deferred Savings Association [NTSA]

Most Popular Items in the Previous Issue

The ACA's Employer Shared Responsibility Provisions (PDF)
Congressional Research Service [CRS]

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Lois Baker, J.D., President  loisbaker@benefitslink.com
David Rhett Baker, J.D., Editor and Publisher  davebaker@benefitslink.com
Holly Horton, Business Manager  hollyhorton@benefitslink.com

BenefitsLink Health & Welfare Plans Newsletter, ISSN no. 1536-9595. Copyright 2019 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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