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NQ Client Services Manager
Newport Group
in Lake Mary FL / Dallas TX

Retirement Plan Administrator / Consultant
Heartland Consulting Group, Inc.
in Overland Park KS / MO

Sr. Pension Actuarial Consultant
in San Diego CA

Assistant Team Leader
Nova 401(k) Associates
in Houston TX / Dallas TX / Austin TX / Scottsdale AZ / Telecommute

Retirement Specialist
Alerus Financial
in Albert Lea MN / Arden Hills MN / Fargo ND

Benefits Analyst
Directors Guild of America - PPHP
in Los Angeles CA

Marketing Campaign Manager
Ubiquity Retirement + Savings
in San Francisco CA / Telecommute

National Market President
Alerus Financial
in Grand Forks ND / Fargo ND / Minneapolis MN / East Lansing MI

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[Official Guidance]

Text of CMS Cost-Sharing Reduction Reconciliation Issuer to MIDAS Inbound Specification (PDF)

19 pages. "The purpose of this document is to provide the details on cost-sharing reduction (CSR) reconciliation files that issuers submit to the Multidimensional Insurance Data Analytics System (MIDAS). This specification document (version 4.0) is applicable to CSR reconciliation for the 2018 benefit year as well as restatements for benefit year 2017." Also online:

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]


Now is a great time to join Worldwide Employee Benefits Network (WEB)

Sponsored by WEB - Worldwide Employee Benefits Network

Worldwide Employee Benefits Network provides me a forum for education and information exchange with other Benefits Executives. Join today.

[Official Guidance]

HHS-Developed Risk Adjustment Model Algorithm 'Do It Yourself (DIY)' Software Instructions for the 2018 Benefit Year: Updated April 4, 2019 (PDF)

25 pages. "The methodology that HHS will use when operating a risk adjustment program on behalf of a State for the 2018 benefit year 5 will calculate a plan average risk score for each covered plan based upon the relative risk of the plan's enrollees, and apply a payment transfer formula in order to determine risk adjustment payments and charges for plans within a State market risk pool. The HHS risk adjustment methodology addresses thr ee considerations: [1] adverse selection in the individual and small group markets; [2] plan metal level differences and permissible rating variation; and [3] the need for risk adjustment transfers that net to zero." Also available: DIY Tables 04.04.2019 [XLSX, 1MB] and HHS HCC software [ZIP, 1MB].
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Guidance Overview]

New DOL Opinion Letter Clarifies that Employers May Not Delay FMLA Leave Designations

"[E]mployers should be providing notice of determination within five (5) days of making the designation, and should not designate more than 12 (or 26) weeks as FMLA-qualifying leave, even if the employee requests to have more than 12 (or 26) weeks designated as FMLA leave or to have an FMLA-qualifying leave treated as non-FMLA leave. Employers should keep records of the information used to make the FMLA qualification determination, including records evidencing receipt of the information."
Winston & Strawn LLP

SDNY Hands Self-Insured Health Plans a Total Win

"In what can only be described as a complete and total win for self-insured health plan sponsors, the Southern District of New York recently upheld a plan's prohibition on assignments of benefits. While a number of cases exist upholding prohibitions on assignments of benefits, what makes this case unique is that the court utterly and methodically destroyed virtually every argument that has been advanced by plaintiffs on this issue." [Medical Society of the State of New York vs. Unitedhealth Group, No. 16-5265 (SDNY, March 28, 2019)]
Kilpatrick Townsend, via Lexology; free registration required

Do You Know Where Your Health Plan Data Is?

"OCR describes a recent enforcement action involving a health care provider's use of a cloud-service data storage provider without first entering into a business associate agreement with the service provider.... Employers sponsoring group health plans ... would be prudent to verify where their protected health information might be stored and transmitted and whether they have business associate agreement in place with all vendors who come into contact with the protected health information."
Jackson Walker


New ERISA Regulations for Disability Claims and Appeals

Sponsored by Lorman and BenefitsLink

Apr. 18 webinar will explain what new practices to follow, how to change past practices to become compliant with the new regulations, and the risks of non-compliance.BenefitsLink discount.

Cigna, Express Scripts Capping Insulin Co-Pays to $25 for Participating Commercial Members

"Cigna and its pharmacy benefit manager Express Scripts [are] launching a program for patients with diabetes in its commercial plans so that they pay no more than $25 for a 30-day supply of insulin.... [T]he average out-of-pocket (OOP) cost for insulin was $41.50 for a 30-day supply last year; under the new program, eligible patients will save approximately 40%."
American Journal of Managed Care

Employee Benefit Offerings for a Multigenerational Workforce (PDF)

12 pages. "Age distribution of a population is an important indicator of what types of benefits will be valuable and necessary to an employee.... Millennials require more maternity, infertility and parental leave benefits, based solely on their stage of life (child bearing years). Generation X is supporting older children, and potentially will be until the dependent is 26 years old. Baby boomers can expect to have dependents off their plan in the near future."

Amicus Briefs in Texas on ACA Case; CMS Issues Proposed BHP Methodology

"On April 1, 2019, stakeholders filed amicus briefs in Texas v. United States. These organizations reflect a 'who's who' in the health care arena -- from insurers to hospitals to doctors to patient advocates.... [CMS has] proposed methodology for determining the amount of federal funds for the Basic Health Program (BHP) that states will receive in 2019 and 2020. As proposed, changes to the methodology would reduce federal BHP payments to states by 3 percent -- about $300 million -- for 2019 and 2020."
Katie Keith, in Health Affairs

Department of Justice to Appeals Court: Strike Down Entire ACA

"If the entire ACA is struck down, the impact on health coverage in the U.S. generally -- including that provided through large employer health plans -- would be enormous.... Just as it took several years to implement the ACA -- from its enactment in 2010 to the opening of the ACA marketplaces in 2014 -- it would seem likely that any unwinding dictated by a court decision would also occur over the course of several years."

Amazon Alexa Now HIPAA-Compliant, Allows Secure Access to Data

"Perhaps more significant than the individual uses is Alexa's ability to now traffic in patient information that is protected by [HIPAA] ... The company said its Alexa Skills Kit, a cloud-based service used to build voice tools, can be used by health firms to create products that transmit and receive patient data. The move will embolden hospitals, insurers, and other health care firms to expose Alexa to more sensitive details of patients' lives and medical conditions, and potentially embed the technology deeper into clinical settings."


American Academy of Actuaries Letter to CMS on Changes to Safe Harbors for Rebates Involving Prescription Pharmaceuticals (PDF)

"[These] comments focus on the Medicare Advantage (MA) and Medicare Part D bid development processes.... Major changes such as those in the proposed rule typically require the full multi-year bid development period to properly incorporate the changes into insurer bids and operations.... [B]ecause direct subsidy and low-income premium subsidy amounts are a function of plan bids, there needs to be consistency in bidding approaches to ensure equitable outcomes among plans. Moreover, it could be difficult to implement the necessary operational changes in such a short time period should a 2020 implementation date be finalized."
American Academy of Actuaries


The FAMILY Act Costs More than Expected

"A new report suggests that the Democrats' FAMILY Act paid leave proposal is substantially more costly than previously estimated. The difference is meaningful: using more realistic assumptions, the cost of national paid leave is 7-fold greater than previous estimates, and taxpayers would be picking up the tab."
Cato Institute

Benefits in General

Benefit Plan Class Action Payouts by Large Corporations Top $6 Billion

"[L]arge corporations have paid out $6.2 billion in class-action lawsuits in which employees claimed that the companies acted improperly in the administration of their 401(k) or defined-benefit pension or retiree health plans. That's the total of 201 settlements and verdicts since the beginning of 2000 ... The largest settlement, $480 million, was reached in 2014 in a retiree health benefits suit brought against Daimler AG on behalf of workers at the German company's U.S. truck manufacturing plants."
Good Jobs First

Review of 2018 ERISA Enforcement Actions by EBSA

"Total monetary recoveries increased for the third year in a row, due to historically high recoveries from EBSA's civil enforcement actions. Although civil enforcement recoveries reached a historic high -- the third largest in over a decade -- the trend of increased criminal investigations and decreased civil investigations continued in FY 2018."
Eversheds Sutherland

Editor's Pick Fiduciary Litigation Update (PDF)

32 presentation slides, from ABA EBC 2019 Midwinter Meeting. Topics: [1] Fiduciary burden of proof and loss causation; [2] Fiduciary disclosure claims; [3] Fiduciary status and prescription drug litigation; [4] ESOP litigation; [5] Church plan litigation.
Employee Benefits Committee [EBC], American Bar Association

Selected Discussions
on the BenefitsLink Message Boards

COBRA: Employee Died / 6 Children / 4 Different Moms

An employee died, had six children on the plan. Employee was divorced. Four different moms. We are not aware of any court orders. We provide subsidized COBRA for 24 months. Questions: To whom do we offer COBRA and and at what rate? Do we offer at the subsidized employee + child(ren) rate (and net out the employee only rate) to each mom?
BenefitsLink Message Boards

Press Releases

PSCA Opens Annual 403(b) Benchmarking Survey
PSCA [Plan Sponsor Council of America]

Most Popular Items in the Previous Issue

The ACA Is Still Here: A Summary of Key Developments and Issues (PDF)
Employee Benefits Committee [EBC], American Bar Association

Legal Privilege Issues Arising in Employee Benefit Matters (PDF)
Employee Benefits Committee [EBC], American Bar Association

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Lois Baker, J.D., President
David Rhett Baker, J.D., Editor and Publisher
Holly Horton, Business Manager

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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