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[Official Guidance]

Text of CMS Proposed Regs: Basic Health Program; Federal Funding Methodology for Program Year 2021

53 pages. "This document proposes the methodology and data sources necessary to determine federal payment amounts to be made for program year 2021 to states that elect to establish a Basic Health Program under the [ACA] to offer health benefits coverage to low-income individuals otherwise eligible to purchase coverage through Affordable Insurance Exchanges."

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

[Official Guidance]

Text of CMS Procedural Guidance for States to Recommend Restricting Certain Excepted Benefit Health Reimbursement Arrangements from Reimbursing Premiums for Short-Term, Limited-Duration Insurance (PDF)

"If a state wishes to submit a recommendation to restrict reimbursement of STLDI premiums by excepted benefit HRAs meeting the applicable criteria (or discontinue a previously approved restriction), the applicable state authority must submit a written recommendation to HHS.... The written recommendation submitted by the applicable state authority must include evidence that the reimbursement of STLDI premiums by excepted benefit HRAs established by insured or partially insured small employers in the state has caused significant harm to the state's small group market, including on small group market premiums.... A state can elect to have a previously-approved restriction on reimbursement of STLDI premiums by excepted benefit HRAs in its state discontinued."

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

[Guidance Overview]

Massachusetts Issues New Guidance on Reimbursement for Qualifying Paid Leave Plans

"[The Massachusetts Department of Family and Medical Leave] provided clarification as to the requirements for an employer to qualify for reimbursement for benefits that it has paid as part of its private paid temporary disability, family, or medical leave policy.... First, the leave program or policy must be granted to workers for one of the PFML's qualifying reasons.... Second, the program or policy must be separate from other types of leave that the employer offers, such as sick leave, annual leave, vacation, personal leave, or paid time off (PTO)."

Epstein Becker Green

Agencies Issue FAQs Clarifying Applicability of Updated 2021 SBC Template and Related Materials

"The first FAQ reiterates that the 2021 versions of the SBC template, instructions, coverage example guide and narratives, and optional coverage examples calculator must be used beginning with the first day of the first open enrollment period for any plan year beginning on or after January 1, 2021, with respect to coverage for plan years beginning on or after that date. The second FAQ clarifies that the coverage examples calculator is not required to be used.... Separately, the agencies announced that the 2021 versions of the SBC materials have been reposted to correct 'minor errors' identified in several documents, including the template."

Thomson Reuters / EBIA

Price Transparency: New Requirements and Considerations for Hospitals

"Who is affected by this rule? ... What information needs to be made public? ... How will compliance with the requirement be monitored and enforced? ... Will increased transparency impact healthcare costs? ... Will there be an impact on provider-payer contracting ... Will providers pay the penalty instead of reporting their rates ... Will the final rule provisions face legal challenges ... What about quality?"


Patients Stuck with Bills After Insurers Don't Pay as Promised

"While prior authorization was traditionally required only for expensive, elective or new procedures, such as a hip replacement or bypass surgery, some insurers now require it for even the renewal of some prescription drugs.... Prior authorizations may now include a line or two saying something like: 'This is not a guarantee of payment.' This loophole allows insurers to change their minds after the fact -- citing treatments as medically unnecessary upon further review, blaming how billing departments charged for the work or claiming the procedure was performed too long after approval was granted."

Kaiser Health News

Editor's Pick State of North Carolina Finds a Relatively Painless Way to Curb Retiree Health Care Costs

"Rather than wait for a crisis, North Carolina took steps to phase out its retiree medical costs in an orderly and predictable fashion. First, in 2006, it raised the required years of service to qualify for retiree health care from five to 20 years. Second, in 2017, the state eliminated health insurance benefits for retirees hired after Jan. 1, 2021. The result will be a steady decline in the number of workers qualifying for OPEB over the next two decades until it reaches zero in 2041."


Unpacking the Timing of Supreme Court's Consideration of Texas ACA Challenge

"[T]he Supreme Court of the United States announced that it will consider whether to hear the appeals in California v. Texas and House v. Texas during its conference on February 21, 2020.... If the Court [accepts] the petition during its February 21 conference (which we would know that day or on the following Monday), it is possible for the case to be heard and decided this term, with a decision issued in June 2020. This, however, seems unlikely." [U.S. House of Representatives v. Texas, No. 19-481 (cert. pet. filed Jan. 3, 2020)]

Katie Keith, in Health Affairs

Pittsburgh Paid Sick Leave Ordinance to Take Effect March 15, 2020

"[T]he City of Pittsburgh Law Department recently released guidelines for administering the Act, which requires employers with 15 or more employees to provide up to 40 hours of paid sick time per year while employers with fewer than 15 employees may provide up to 24 hours of unpaid sick time during the first year following the Act's effective date. Beginning March 15, 2021, employers with fewer than 15 employees must provide up to 24 hours of paid sick leave per year."


California Governor Planning Big Changes to State Leave Laws

"California already has several types of job-protected leaves of absence for employees. Even so, most job-protected leaves are limited depending on the size of the employer.... One of the Governor's new trailer bills ... seeks to amend CFRA and PDLL to apply to all employers, regardless of size. This would be a drastic expansion to job-protected leaves in California."

Jackson Lewis P.C.


Editor's Pick Bipartisan Rx for America's Health Care: A Practical Path to Reform (PDF)

64 pages. "These recommendations encompass changes that would increase federal spending in some cases and reduce it in others. Overall, it is the intent and expectation of the experts participating that the plan should modestly improve the government's fiscal outlook. If necessary, the policies recommended here could be adjusted to achieve this goal.... While no member of the group would necessarily support each individual recommendation on its own, collectively, they represent a comprehensive plan on how to balance sound policy and political viability that can break the status quo and strengthen America's health care system."

Bipartisan Policy Center

Benefits in General

[Guidance Overview]

Failing to File Form 5500 Just Became More Costly

"The IRS now has the authority to assess a penalty for late filers up to $250 a day, up to a maximum penalty of $150,000 per plan year. But even with the increase in the IRS penalties, they still pale in comparison to the penalties that can be assessed by the DOL... [E]ffective for penalties assessed after January 15, 2020, the per day DOL penalties have increased from $2,194 to $2,233, with no maximum."


Editor's Pick Employee Benefits Liability Coverage vs. Fiduciary Liability

"[S]ome plan sponsors believe that they do not need to spend additional premium dollars to purchase fiduciary liability insurance when they have EBL coverage as part of their commercial package general liability insurance policy. As discussed more fully [in this article], including an analysis of a recent court case, a fiduciary liability insurance policy provides significantly broader coverage than the limited administration coverage in a standard EBL policy to protect employee benefit plans and its fiduciaries. Even the defense of routine benefit claims can be excluded from coverage under an EBL policy, which is why plan sponsors need to protect their plans and plan fiduciaries with quality fiduciary liability insurance coverage."

Euclid Specialty Managers

Press Releases

Most Popular Items in the Previous Issue

Engaging and Monitoring Health Plan TPAs: Understanding Your Fiduciary Obligations (PDF)
International Foundation of Employee Benefit Plans [IFEBP], 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

Article submission: Online form, or email to

BenefitsLink Health & Welfare Plans Newsletter, ISSN no. 1536-9595. Copyright 2020, 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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