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[Official Guidance]

Text of Draft 2019 IRS Form 1095-C: Employer-Provided Health Insurance Offer and Coverage (PDF)

Dec. 4, 2019. "This Form 1095-C includes information about the health insurance coverage offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible."

Internal Revenue Service [IRS]


New Edition Announced! Get Your Copies for Less!

Sponsored by International Foundation of Employee Benefit Plans [IFEBP]

The new 2020 edition of Ready Or Not: Your Retirement Planning Guide is here! Order your copies right now and get them at the 2019 edition prices. Make sure your participants are ready for retirement with this helpful guide. Order for your participants today! Learn more

[Guidance Overview]

Feds Finalize Transparency Rules for Hospitals, Propose Them for Health Plans

"Several of the provisions in the proposed rules include the qualifier that the information supplied by the plan be accurate at the time of the request. That qualifier is a double-edged sword: Plans can rely on it as a shield, where cost information changes between the time an individual first makes inquiry and the time the individual receives the relevant care. But it also requires plans to ensure that, at the time of the request, the plans' internet tools have accurate, up-to-date information, particularly about charges that would be made by various providers."


[Guidance Overview]

Health Care and Price Transparency: The Latest Summary

"The proposed rule requires insurance and group health plans to provide cost information regarding specific health care items and services to members on request. It is expected that the information will be provided in a form similar to an Explanation of Benefits (EOB). The information must include ... seven elements to the extent they affect a member's cost-sharing liability."

Ballard Spahr LLP

[Guidance Overview]

State Innovation Waivers: Frequently Asked Questions (PDF)

24 pages. "Under a state innovation waiver, a state can apply to waive ACA requirements related to qualified health plans, health insurance exchanges, premium tax credits, cost-sharing subsidies, the individual mandate, and the employer mandate. The state can apply to waive any or all of these requirements, in part or in their entirety." [Report R44760, updated Dec. 2, 2019]

Congressional Research Service [CRS]

[Guidance Overview]

Proposed Transparency Notice Available on DOL Website

"In conjunction with proposed 'transparency in coverage' regulations requiring group health plans and insurers to make extensive price and cost-sharing disclosures ..., the DOL has posted three appendices containing a proposed model disclosure notice and proposed negotiated rate and allowed amount data elements for required disclosures under the regulations.... Model Notice ... Negotiated Rate Data Elements ... Allowed Amount Data Elements."

Thomson Reuters / EBIA

Justices to Hear Argument Next Week on ACA Risk Corridors and Implied Repeals

"[T]he insurers emphasize [that] the government made a clear promise in the ACA ... Relying on that promise, ... the insurers 'joined the exchanges, set their premiums, and incurred significant losses in providing health coverage.' ... [T]he federal government rejects any suggestion that, by creating the risk-corridor program, Congress decided to leave the government on the hook for sums that could reach into the billions of dollars. Instead, the government argues, the ACA left the funding question open, and Congress decided to limit the funding for the risk corridors to the money HHS collected under the program[.]" [Moda Health Plan v. U.S., Nos. 2017-1994, 2017-1224, 2017-2154, 2017-2395 (Fed. Cir. Nov. 6, 2018; cert. pet. granted Jun. 24, 2019; oral arg. sched. Dec. 10, 2019)]


Hospitals Sue CMS Citing Price Transparency Final Rule as Anything But Transparent

"Plaintiffs first argue that the term 'standard charges' means a hospital's usual and customary chargemaster charges and that Congress, thus, granted CMS limited or narrow authority to mandate disclosure of only that specific type of charge ... Plaintiffs [also] allege violation of the First Amendment, in that the Final Rule unconstitutionally compels speech that does not advance a substantial government interest.... Finally, the enormous burden associated with gearing up to comply with the Final Rule is challenged as being 'way out of line with any projected benefits associated with the rule.' " [American Hospital Assoc. et al. v. Azar, No. 19-3619 (D.D.C. complaint filed Dec. 4, 2019)]

Morgan Lewis

Court Questions Insurer Behavioral Health Treatment Guidelines

"The plaintiff argued that care criteria developed by the American Psychiatric Association, or APA, were more consistent with accepted standards of medical care than the United Behavioral Health guidelines, but the insurance company disagreed. Although the court concluded there was nothing improper about the development of treatment guidelines by insurance companies, the court began by addressing a significant problem with the defendant's use of the United Behavioral Health, or UBH, guidelines[.]" [S.B. v. Oxford Health Insurance, Inc., No. 17-1485 (D. Conn. Nov. 5, 2019)]

DeBofsky Sherman Casciari Reynolds P.C.

Employee's COBRA Claim Was Not Subject to Health Plan Arbitration Provision

"Citing the plan's arbitration clause, the employer sought to stay the proceedings and compel arbitration of the COBRA claim.... The district court held that the employee's COBRA claim, which was brought under ERISA Section 502(a), was expressly excepted from the plan's arbitration clause.... [T]he court concluded that even if the plan's arbitration clause was ambiguous, this ambiguity ... must be construed against the drafting party." [Desselle v. Ivy Creek Healthcare LLC, No. 19-338 (M.D. Ala. Dec. 2, 2019)]

Thomson Reuters Practical Law

Editor's Pick Implementing a Statewide Healthcare Cost Benchmark: How Oregon and Other States Can Build on the Massachusetts Model (PDF)

48 pages. "[This white paper] examines the four state benchmarking programs and offers guidance for other states considering similar programs... [1] An overview of the [Massachusetts] program ... [2] A summary of the 2019 law authorizing the [Oregon] benchmarking program ... [3] An overview of the Delaware and Rhode Island benchmarking programs.... [4] An analysis of seven areas that all benchmarking programs must address based on state goals, local market dynamics, and state resources."

Manatt, Phelps & Phillips, LLP

HISIM2: CBO's New Health Insurance Simulation Model

38 presentation slides. "CBO analysts use the agency's revised health insurance simulation model, HISIM2, to generate estimates of health insurance coverage and premiums for the population under age 65. The model is used in conjunction with other models to develop baseline budget projections ... It is also used to estimate the effects of proposed changes in policies that affect health insurance coverage. This presentation provides an overview of the model."

Congressional Budget Office [CBO]

Nevada's 'Leave for Any Purpose' Law Clarified

"[E]ligible employees in Nevada are entitled to accrue 0.01923 hours of paid leave for each hour worked, up to 40 hours per benefit year that can be used for 'any purpose'. The law takes effect on January 1, 2020. On October 4, 2019, the Nevada Labor Commissioner issued an advisory opinion ... to clarify certain aspects of this law. Of particular note, this guidance addresses how to determine employer size and the requirement to include information about the leave benefit in the employer's workplace policies."



Making a Killing in American Health Care: a Step-by-Step Guide

"Do you want to be the highly-paid CEO of a hospital/'health' system? Do you need to pay for a new $356 million medical campus? Master this how-to guide and you'll be on your way."


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