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November 18, 2019 logo logo
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[Guidance Overview]

Administration Proposes Transparency Rule for Group Health Plans and Health Insurers

"The Departments estimate savings of about $128 million per year due to lower medical costs for insurers and consumers while consumers would receive $67 million less in MLR rebates each year. The rule would also lead to slightly higher premium tax credits, by about $12 million per year, to address premium increases of about 0.03 percent from individual market insurers. The bulk of costs would be borne by insurers and third-party administrators."

Katie Keith, in Health Affairs


Recognizing and Addressing COBRA

Sponsored by Lorman and BenefitsLink

Dec. 10 webinar will cover the legislative rationale that underlies COBRA continuation coverage as well as the nuts and bolts of compliance. BenefitsLink discountLearn more

Hospitals Get Ready to Fight CMS in Court Again, This Time Over Transparency

"The American Hospital Association, Association of American Medical Colleges and Children's Hospital Association ... are filing a legal challenge alongside member hospitals. The hospital groups charged that the rule will 'introduce widespread confusion, accelerate anticompetitive behavior among health insurers and stymie innovations in value-based care.' "


HHS Unveils Finalized Health Care Price Transparency Rule for Hospitals

"The hospital rule is slated to go into effect in January 2021. It is part of an effort by the Trump administration to increase price transparency in hopes of lowering health care costs on everything from hospital services to prescription drugs. But it is controversial and likely to face court challenges."

Kaiser Health News

Validity of Association Health Plan Rules Argued at D.C. Court of Appeals

"The panel seemed particularly interested in the intersection between ERISA and the ACA under the final rule, which agency is tasked with interpreting each statute, and the [DOL's] rationale for adopting the rule in the first place.... If the D.C. Circuit affirms the lower court’s decision, much of the final rule would remain invalidated." [State of New York v. U.S. Dept. of Labor, No. 18-1747 (D.D.C. Mar. 28, 2019; notice of appeal filed by DOL on Apr. 26, 2019; oral argument (MP3 audio file) Nov. 14, 2019)]

Katie Keith, in Health Affairs

Congress Readying Renewal of PCORI Fee with Employer-Friendly Changes

"House-Senate negotiators are leaning toward a 10-year extension along with changes to the underlying program outlined in a letter recently sent to a bipartisan group of senators by employer and insurer groups. Draft Senate legislation addresses several employer suggestions, including consideration of relative cost and value in evaluating health outcomes and the clinical effectiveness of medical treatments and services."



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Affordability of Healthcare for Employees Cited as Chief Focus of U.S. Employers

"When surveyed on their priorities for the next 5 years, 42% of large and midsize (500 or more employees) chose 'addressing healthcare affordability for low-paid employees' as an important or very important strategy. Employers have started halting requirements for members to pay more out-of-pocket costs, as even some larger employers who had offered a high-deductible plan with a Health Savings Account (HSA) as their only medical plan have decided to add a traditional Preferred Provider Organization or a Health Maintenance Organization as an option."

American Journal of Managed Care

FMLA Retaliation Case Illustrates the Practical Significance of Effective HR Documentation

"[The decision by the supervisor (Logan)] to terminate Simpson's employment and his submission of the formal paperwork to implement the discharge were made before Simpson invoked her rights under the FMLA and before Logan knew she had applied for medical leave.... [H]ad Logan delayed just a few days in sending his email to human resources -- or not sent it at all -- Simpson, arguably, might have been better able to show causality." [Simpson v. Temple Univ., No. 18-2272 (E.D. Penn. Oct. 23, 2019)]

Ogletree Deakins

When Social Security Disability Benefit Decisions Do Not Have to Be Considered for ERISA Disability Claim

"Hartford's decision came one year before the Social Security judgment. When the administrator's decision occurs prior to the Social Security disability decision, it cannot take the latter information into account." [Ortiz v. The Hartford, No. 18-636 (D.N.M. Nov. 4, 2019)

Lane Powell PC

Opening Medicare to Americans Aged 50 to 64 Would Cut Their Insurance Costs, but Drive Up Insurance Prices for Younger People

"Under most scenarios examined, the study estimates that the premium to buy into Medicare would be about $10,000 per year in 2022. For many potential enrollees, this amount is a good deal compared to the ACA-compliant individual insurance market ... While older exchange enrollees currently pay higher premiums, the analysis finds that, as a group, their care is less expensive relative to their high premiums.... [E]nabling adults aged 50 to 64 to move to Medicare could increase premiums for those remaining in the individual health insurance market by between 3% and 9%."

RAND Corporation

Does One Medicare Fit All? The Economics of Uniform Health Insurance Benefits

"[T]hree major shifts make a uniform design less efficient today than when Medicare began in 1965. First, rising income inequality makes it more difficult to design a single plan that serves the needs of both higher- and lower-income people. Second, the dramatic expansion of expensive medical technology means that a generous program increasingly crowds out other public programs valued by the poor and middle class. Finally, as medical spending rises, the tax-financing of the system creates mounting economic costs and increasingly untenable policy constraints."

National Bureau of Economic Research [NBER]; purchase required for full document


Cost-Based Predictive Models Have Racial Bias, So Will Health Plans and Providers Stop Using Them?

"[H]ealth plans and providers use predictive models that rely heavily on past health expenditures to project future spending, rate each patient's level of risk for future health problems and provide additional resources based on those risk scores. However, this cost data doesn't account for the fact that, overall, black patients utilize health services at lower rates than white patients.... It's well past time for population health models to shift their focus from medical expenditures to actual health outcomes. "

evolent health

Selected Discussions
on the BenefitsLink Message Boards

Successful Avoidance of Employer Shared Responsibility Payments?

"Has anyone been successful in avoiding the proposed ESRP for clients who did not offer coverage? I know reasonable cause is not an acceptable reason for not offering coverage, but I was wondering if anyone has been successful in either avoiding or reducing a proposed ESRP pursuant to a 226-J letter."

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Press Releases

Most Popular Items in the Previous Issue

Text of Agency Proposed Regs: Transparency in Coverage by Health Insurance Issuers and Group Health Plans
U.S. Department of Health and Human Services [HHS]; Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]; and Internal Revenue Service [IRS], Inc.
1298 Minnesota Avenue, Suite H
Winter Park, Florida 32789
(407) 644-4146

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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