Health & Welfare Plans Newsletter

March 22, 2019

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Wolters Kluwer
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Nyhart
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Ogletree Deakins Law Firm
in Indianapolis IN

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PACETPA
in Clovis CA

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NRECA
in Arlington VA

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Sacramento County Employees' Retirement System
in Sacramento CA

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[Official Guidance]

IRS Q&As: Information Reporting by Employers on Form 1094-C and Form 1095-C

Updated Mar. 22, 2019. "These Q&As provide additional information about completing Form 1094-C and Form 1095-C for calendar year 2018 that are to be filed in 2019. The Q&As may be used in conjunction with the Instructions for Forms 1094-C and 1095-C, which provide detailed information about completing the forms."
Internal Revenue Service [IRS]

[Advert.]

Wellness Programs: EEOC Enforcement Actions and Complying with Federal and State Laws

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[Guidance Overview]

Employer Tax Credit for Paid Family and Medical Leave

"When enacted, this credit was made available for two years, 2018 and 2019. The credit's primary sponsor, Senator Deb Fischer, called this credit a 'two-year pilot program,' after which there would be an opportunity to evaluate whether the credit was achieving its intended goals. This [article] [1] provides an overview of the employer credit for paid family and medical leave; and [2] highlights some issues to consider when evaluating the credit."
Congressional Research Service [CRS]

[Guidance Overview]

New Jersey Expands Paid Family Leave Benefits

"Employers with 30 or more employees within the requisite time frame will be subject to the law.... [The] new law expands the current definitions of child, parent and family member.... Changes effective July 1, 2020: [1] Increase in duration of paid leave benefits ... [2] Increase in weekly payment amount during paid leave ... [3] Expanded reasons for paid leave ... [4] New anti-retaliation protections."
Duane Morris LLP

District Court Ruling on Insurer's Mental Health Treatment Guidelines May Become National Template

"[This court's] recognition that 'safe' does not equate to 'effective' demolishes the myth that pushing for lower levels of care is acceptable care. The ruling also precludes insurers from denying claims where treatment is necessary to prevent further medical deterioration even if the patient has plateaued and no further improvement is expected. [This] ruling will dictate the future of all litigation over behavioral health care, which is already evolving away from challenges brought under the [MHPAEA] into arguments relating to the legitimacy of clinical guidelines utilized to determine both coverage and level of care." [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Mar. 5, 2019)]
DeBofsky, Sherman & Casciari, P.C.

Court Allows Patients to Pursue Claims Premised on Excessive Fees to Access PHI

"The providers (or their recordkeepers) attempted to charge amounts exceeding the permissible fees for individual access requests under HIPAA, which the patients refused to pay. The patients then sued under state consumer-protection laws -- no private right of action exists under HIPAA.... Citing HHS's access guidance, the court noted that requests by individuals to have a copy of their PHI sent to a third party are subject to the same fee limitations that apply to requests by individuals to have their PHI sent to themselves." [Rios v. Partners in Primary Care, P.A., No. 18-0538 (W.D. Tex. Feb. 15, 2019)]
Thomson Reuters / EBIA

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Kentucky Launches Probe Into Drug Overcharges by Pharmacy Benefit Managers

"[Kentucky Attorney General Andy Beshear is] seeking details on how PBMs have determined, billed and paid drug reimbursement rates over the past five years in Kentucky ... A report released last month by the state indicated that two PBMs took in $123.5 million last year from the state Medicaid program by paying pharmacies a lower rate to fill prescriptions, while charging the state more for the same drugs[.]"
Reuters

State Laws Ban Surprise Medical Bills -- This Patient Got One for $227,000 and Fought Back

"Large 'surprise bills' ... have become a national epidemic outraging patients and politicians alike. Solutions have been elusive to date ... Lawmakers in Olympia this year are trying for the fourth time to pass legislation banning the practice that leaves consumers with huge out-of-pocket costs.... While the protection would be beneficial to patients, there has been formidable and effective pushback from insurers, hospitals and doctors."
Kaiser Health News

U.S. Health Care Coverage and Spending, 2017

"Private health insurance spending, as a percentage of all health consumption expenditures, has increased by about 12 percentage points since 1960. This growth is partially due to increases in enrollment and, when considered alongside the implementation and expansions of Medicare and Medicaid, corresponds with the drop in out-of-pocket spending since 1960."
Congressional Research Service [CRS]

GAO Report on Private Health Insurance: Enrollment Remains Concentrated Among Few Issuers, Including in Exchanges

"Enrollment in private health insurance plans continued to be concentrated among a small number of issuers in 2015 and 2016. In the overall large group market, small group market, and individual market, the three largest issuers held 80 percent of the market or more in at least 37 of 51 states.... For the small group market exchanges, in each year, three or fewer issuers held 80 percent or more of the market in at least 42 of the 46 state exchanges for which GAO had data." [GAO-19-306, Mar. 21, 2019]
U.S. Government Accountability Office [GAO]

What Characterizes the Marketplaces with One or Two Insurers?

Updated for 2018 and 2019 experience. "[T]he number of markets with one or two marketplace insurers has decreased between 2018 and 2019 ... In regions with one insurer, the median benchmark premium (for the second lowest cost silver plan) for a 40-year-old nonsmoker is $592 per month in 2019 compared with $376 in rating regions with 5 or more insurers.... [In] recent years, premium growth has been higher in rating regions with one insurer than in those with 5 or more insurers."
Urban Institute

Fact Sheets: Who Are the Remaining Uninsured?

"This interactive map and the related fact sheets provide state, county, and congressional district data on declines in uninsured rates between 2013 and 2017 ... They also provide data on the remaining uninsured ... [In] every state, the large majority of the uninsured live in working families."
Center on Budget and Policy Priorities

[Opinion]

Improving ACA Subsidies for Low- and Moderate-Income Consumers Is Key to Increasing Coverage

"[U]ninsured rates nationally decrease with income across the income scale; the same pattern also holds in nearly every state.... 'Silver loading,' which increases financial assistance, appears to have increased take-up of marketplace coverage.... Major subsidy improvements ... would likely extend coverage to at least several million people, at a cost of several hundred billion dollars over ten years."
Center on Budget and Policy Priorities

Benefits in General

ERISA Plan Controversies: Rising the Stakes for Unprepared Sponsors and Fiduciaries (PDF)

16 presentation slides. Topics include: [1] What's the exposure? [2] How do these lawsuits get filed? [3] Modus operandi of plaintiffs' lawyers. [4] A glimmer of hope: victories in two recent trials. [5] Ways to minimize exposure to lawsuits challenging fees and investment selection. [6] Lawsuits relating to company stock and actuarial equivalence. [7] Lawsuits against health and welfare plans challenging fees. [8] ERISA issues to watch.
McDermott Will and Emery

Press Releases

Most Popular Items in the Previous Issue

DOL Fact Sheet: Adjusting ERISA Civil Monetary Penalties for Inflation (PDF)
Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]

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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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