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[Official Guidance]

Text of Agency Final Rule: Transparency in Coverage (PDF)

556 pages. "The final rules set forth requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request to a participant, beneficiary, or enrollee (or his or her authorized representative), including an estimate of the individual's cost-sharing liability for covered items or services furnished by a particular provider. Under the final rules, plans and issuers are required to make this information available on an internet website and, if requested, in paper form, thereby allowing a participant, beneficiary, or enrollee (or his or her authorized representative) to obtain an estimate and understanding of the individual's out-of-pocket expenses and effectively shop for items and services. The final rules also require plans and issuers to disclose in-network provider negotiated rates, historical out-of-network allowed amounts, and drug pricing information through three machine-readable files posted on an internet website, thereby allowing the public to have access to health coverage information that can be used to understand health care pricing and potentially dampen the rise in health care spending. The Department of Health and Human Services (HHS) also finalizes amendments to its medical loss ratio (MLR) program rules to allow issuers offering group or individual health insurance coverage to receive credit in their MLR calculations for savings they share with enrollees that result from the enrollees shopping for, and receiving care from, lower-cost, higher-value providers.... The final rules are effective [60 days after publication in the Federal Register]." [Also available: press release and Fact SheetIcon to read more

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

[Official Guidance]

Text of Agency Interim Final Rule: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (PDF)

241 pages. "This [Interim Final Rule with Comment Period (IFC)] implements requirements in the CARES Act that providers of COVID-19 diagnostic tests make public their cash prices for those tests and establishes an enforcement scheme to enforce those requirements.... This rule also amends regulations regarding coverage of preventive health services to implement section 3203 of the CARES Act, which shortens the timeframe within which non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage must begin to cover without cost sharing qualifying coronavirus preventive services, including recommended COVID-19 immunizations. This IFC also revises regulations to set forth flexibilities in the public notice requirements and post award public participation requirements for State Innovation Waivers under section 1332 of the [ACA] during the public health emergency for COVID-19....

"These regulations are effective on [the date of display for public inspection at the Office of the Federal Register], except for amendatory instruction 36, which is effective on January 1, 2021.... Except as otherwise specified ... these regulations are applicable from the effective date until the end of the public health emergency for COVID-19 as determined by the HHS Secretary." 

[Also see: CMS press release and fact sheet; COVID-19 vaccine resources for providers, health plans and State Medicaid programs; and FAQs on billing for therapeutics.] Icon to read more

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]; Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]; Internal Revenue Service [IRS]; and U.S. Department of the Treasury

[Guidance Overview]

Exceptional Usefulness and Quality iconWhen Can Employers Terminate COBRA Coverage During the COVID-19 Outbreak Period?

"With the lack of guidance from the DOL and IRS ... it makes sense for a plan to treat a qualified beneficiary's COBRA coverage status during the election period and payment period -- which are lengthened by the outbreak period -- using the same method as the plan treats a qualified beneficiary's COBRA coverage status during the election and payment periods absent the outbreak period. And, whatever option a plan chooses, it must make sure that a qualified beneficiary's COBRA coverage status during the election and payment periods is clearly communicated to any health care provider that inquires." Icon to read more

Miller Johnson

[Guidance Overview]

Upcoming Deadline iconSick and Safe Leave: New York State Releases FAQs and New York City Issues Notice

"New York City amended the Earned Safe and Sick Time Act (ESSTA) to align the City's sick leave mandates more closely with those under the [State's Paid Sick Leave Law (PSLL)]. However, a number of key differences remain, such as with regard to both employee and employer notice requirements. Where conflicts exist between ESSTA and the PSLL, covered employers must comply with the law most beneficial to employees. This Advisory provides a chart comparing the two laws and highlighting their differences." Icon to read more

Epstein Becker Green

Will Congress Extend FFCRA Paid Sick and Paid FMLA Leave Into 2021?

"The FFCRA enjoyed overwhelming bipartisan support.... There is No Indication FFCRA has had a deleterious impact on American businesses.... The Government already has signaled the pandemic will extend well into the new year.... A recent study has shown that the availability of FFCRA leave actually has reduced the spread of COVID-19." Icon to read more

FMLA Insights

Aetna Pays $1,000,000 to Settle Three HIPAA Breach Reports

"[On] April 27, 2017, Aetna discovered that two web services used to display plan-related documents to health plan members allowed documents to be accessible without login credentials and subsequently indexed by various internet search engines. Aetna reported that 5,002 individuals were affected by this breach ... In addition to the monetary settlement, Aetna will undertake a corrective action plan that includes two years of monitoring." Icon to read more

U.S. Department of Health and Human Services [HHS]

HIV-Related Disclosures (and More) Lead to $1 Million HIPAA Settlement

"HHS's investigation revealed that the insurer: [1] Failed to conduct a periodic technical and nontechnical evaluation following environmental or operational changes affecting the security of PHI. [2] Impermissibly disclosed the PHI of approximately 18,500 individuals. [3] Failed to limit disclosed PHI to the minimum necessary to accomplish the intended purpose. [4] Failed to implement appropriate administrative, technical, and physical safeguards to protect PHI in its possession." Icon to read more

Thomson Reuters Practical Law

Employers Paid 67 Percent of Premiums for Family Health Care Coverage in 2020

"Employers paid 67 percent of premiums for family medical care coverage in March 2020. Civilian workers participating in these plans paid the remaining 33 percent. Employers paid 59 percent of premiums for workers with the lowest 25 percent of wages and 71 percent of premiums for workers with the highest 25 percent of wages." Icon to read more

U.S. Bureau of Labor Statistics [BLS]

Million-Dollar Prescription Drugs: Can Stop Loss Keep Living Up to Its Name?

"[Many people have heard] about the $1 million+ drugs already here and those coming to market over the next few years.... [The authors] recently surveyed a number of prominent stop loss vendors in the market to identify what strategies were in place to help employers manage these claimants. As it turns out: 91% of the respondents had no plans to offer multi-year financing for payment of these drugs, 91% had no plans to offer performance-based payments, and 73% did not offer a separate insurance policy or rider to cover these medications at 100%." Icon to read more

Chelko Center for Benefits Management

Benefits in General

Exceptional Usefulness and Quality iconCan We Destroy the Paper Records for Our ERISA Plans and Retain Our Records in Electronic Form?

"While requirements vary somewhat from agency to agency and some special rules may apply, those imposed by the DOL for the use of electronic recordkeeping [include]: ... [1] The electronic records must be maintained in reasonable order in a safe and accessible place, and in a manner in which they can be easily inspected, examined, and reproduced.... [2] The electronic recordkeeping system must have reasonable controls to ensure the confidentiality, integrity, accuracy, authenticity, and reliability of the electronic records, and adequate records of the management practices for the electronic system must be established and implemented." Icon to read more

Thomson Reuters / EBIA

DOL to Issue Guidance, Ramp Up Investigations on Cybersecurity

"The [DOL] is working on a guidance package addressing cybersecurity issues as they relate to plan sponsors and third-party providers ... Tim Hauser, Deputy Assistant Secretary for National Office Operations at [EBSA], also indicated that he expects to see more focus in the department's investigations on the adequacy of various cybersecurity programs, especially for large plans in terms of making sure the providers they hire are observing good cybersecurity practices." Icon to read more

American Retirement Association [ARA]

Selected Discussions
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Claims Administrator Caused HIPAA Breach That Affected Multiple Covered Entities and Over 500 Total Individuals But in Different Covered Entities

"Claims administrator caused a breach that affected multiple Covered Entities, including over 500 total individuals. Client is one Covered Entity but the breach only affects 20 of its employees. Does my client need to send out a public notice for the 500+ individual breach? In other words, is the 500 individual notification requirement an aggregate of all individuals affected, even if they are from different Covered Entities?" Icon to read more

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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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