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Program Manager IV Operations Director
State of Maryland DBM Division of Employee Benefits
in Baltimore MD

Director Sales Consulting - ESOP
Principal Financial Group
in AL / FL / NC / TN

Defined Benefit Retirement Plan Consultant / Actuary
First American Bank
in Elk Grove Village IL

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[Official Guidance]

Interim Summary Report on Risk Adjustment for the 2018 Benefit Year (PDF)

13 pages. "The HHS-operated risk adjustment methodology determines each plan's risk adjustment transfer amount ... For the 2018 benefit year, HHS applied this methodology in all 50 states and the District of Columbia.... Beginning for the 2018 benefit year, HHS introduced the high-cost risk pool (HCRP) within the HHS-operated risk adjustment methodology.... Additionally, the 2018 benefit year is the first year risk adjustment risk scores account for certain drug classes in the risk adjustment models for adults in the individual and small group (or merged) markets."
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]


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[Guidance Overview]

Massachusetts Private Paid Family Leave Plan Exemption Applications for Employers Will Be Available April 29

"Beginning April 29, 2019, the Massachusetts Department of Family and Medical Leave will offer approved plan applications for employers seeking an exemption from collecting, remitting, and paying contributions under the PFML that would otherwise be due beginning on July 1, 2019.... For an application to be granted, the Department will assess whether the benefits offered to the employees under the private plan are greater than or equal to the benefits provided by the PFML."

ERISA Health Plan Fiduciaries Defeat DOL's Excessive Fee Claims

"[T]his decision provides a roadmap to navigating fiduciary obligations to health plans. Whether fiduciaries have the principal obligation to assess fees or the obligation to monitor another fiduciary, the obligations are similar to those of defined contribution plan fiduciaries. The defendants' process included regular review of TPA services and fees, reasonable reliance on retained advisors, negotiation of reduced fees and informal collections of information in the marketplace." [Acosta v. Chimes District of Columbia, Inc., No. 15-3315 (D. Md. Feb. 26, 2019)]
McDermott Will & Emery

What's Hiding in Your Specialty Drug Claim Costs?

"Specialty medication claims have long been paid out through the medical benefit -- most notably those for cancer therapies.... Like the price variability [of] tests like MRI's, the site of service dictates what is paid.... [There are] significant variances in how much health care providers are reimbursed for the same quantity of the same amount of the same drug. The difference, again, is the site of service."

Mental Health Treatment Guidelines: Highlights from Wit v. United Behavioral Health

"The court ... found that the Guidelines were fundamentally flawed ... via significant involvement by the Financial Department in their development and the Guidelines' unwavering and inflexible language.... [A]lthough every class member's health benefit plan includes ... a requirement that the requested treatment must be consistent with generally accepted standards of care, the court found that there was no evidence in the record that the much more restrictive words in the Guidelines could be ignored when they are in conflict with generally accepted standards of care." [Wit v. United Behavioral Health, Nos. 14-2346, 14-5337 (N.D. Cal. Mar. 5, 2019)]
Dickinson Wright PLLC

Federal vs. New York Family and Medical Leave Law, Part 4

"In addition to the federal FMLA, New York has laws regarding pregnancy leave, adoptive parents leave, blood donation leave, bone marrow donation leave, military spouse leave and paid family leave (effective Jan. 1, 2018).... [A] chart reviews leave requests, certification requirements, as well as other laws."
Strategic Benefit Services

Jury to Decide If HR Manager Was 'Dishonest' in Claiming Discharged Employee Falsified FMLA Documents

"A supervisor's statement that 'she did not know, and did not want to say' whether an employee's absence for her hand injury would be covered under her approved intermittent FMLA leave to care for her ill father didn't constitute unlawful interference; the employee knew HR was instead the proper contact, a federal court in West Virginia ruled, granting in part the employer's summary judgment motion." [McCoy v. Diamond Electric Mfg. Corp., No. 17-4329 (S.D.W.V. Feb. 19, 2019)]
Wolters Kluwer; free registration required

Editor's Pick HHS's Proposed Modification of Pharmacy Rebate Safe Harbors (PDF)

"The proposed regulations do not explicitly impact the commercial market, although voluntary alignment with Medicare is a possibility, and HHS Secretary Azar has called for follow-up legislation. The regulations also do not change the safe harbor with respect to drugs purchased through Medicare Part B fee-for-service plans, federal rebates collected for Medicaid MCO claims, or federal or supplemental rebates received directly by Medicaid state agencies."

A Look at Universal Health Coverage in Eight Countries

"Other high-income nations manage to insure all their residents and spend less per capita than the U.S. But some of them do that by covering everyone through a regulated system of health plans, while others truly have a single public plan for everyone.... [This article takes] a closer look at how eight of our peer countries get to universal coverage, how much they pay for their health care, and what role private insurance plays in each."
The Commonwealth Fund

'Medicare for All' Could Eliminate the $600 Billion Insurance Industry

"It's hard to overstate the magnitude of such an overhaul. UnitedHealth was ranked fifth on the 2018 Fortune 500 list, grossing more than $226 billion last year; Anthem and Aetna (premerger with CVS) were both in the top 50. Those three companies alone employed more than 364,000 people in 2017. The prospect of all of that simply vanishing has the industry preparing for a fight."


'Medicare for All' Would Abolish Private Insurance -- 'There's No Precedent in American History.'

"At the heart of the 'Medicare for all' proposals ... is a revolutionary idea: Abolish private health insurance.... But doing away with an entire industry would also be profoundly disruptive. The private health insurance business employs at least a half a million people, covers about 250 million Americans, and generates roughly a trillion dollars in revenues. Its companies' stocks are a staple of the mutual funds that make up millions of Americans' retirement savings."
The New York Times; subscription may be required

Benefits in General

Modernizing Benefits for Multinational Companies

"Companies need to consider the numerous countries in which they operate; the need to coordinate stakeholders across multiple functions and geographies; variations in social benefits and local regulatory frameworks; and responding to rapidly evolving technology, employee expectations and dynamics.... [T]he quest for modernization is important if companies want to attract, retain and engage the talent necessary for their business success in an increasingly complex and global world.... [A] systematic approach is critical."
Willis Towers Watson

Why Should HR Consider Outsourcing Employee Benefits Administration?

"Outsourcing to multiple vendors allows HR managers to look for the best point solutions to address specific needs for their organization, such as a benefits administration platform. These point solutions are often the provider's core focus, which usually results in a higher level of innovation compared with the 'we can do it all' HR offerings. Integration across vendor platforms is often seamless and allows systems to work together, given the rapid pace of innovation in HR technology, application programming interfaces (APIs), and SaaS-based solutions."
HR Daily Advisor

Press Releases

DOL Obtains Consent Judgment and Order Protecting Participants and Beneficiaries of Failing MEWA
Employee Benefits Security Administration [EBSA], U.S. Department of Labor

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