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Implications of the COVID-19 Pandemic on Medical Loss Ratio for Health Plans
December 2, 2020 WEBCAST
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[Official Guidance]

CMS Issues Final Rule to Amend HHS Risk Adjustment Data Validation Program

"The final rule addresses stakeholder feedback and will provide states and issuers with more stability and predictability, promote program integrity, and foster increased competition.... [T]he rule finalizes changes to two technical aspects of the HHS-RADV program, the error rate calculation and the application of HHS-RADV results." 

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

[Guidance Overview]

CMS Releases Interim Final Rule Establishing Reimbursement for Part B Drugs Based on International Pricing

"Who is and who is not subject to the model? ... What drugs are and are not subject to the model? ... How is the MFN price determined using international benchmarks? ... How is the payment amount determined? ... What other adjustments can be made to the payment amount? ... Non-payment provisions of note." 

Arent Fox

[Guidance Overview]

Is International Drug Pricing Suddenly at Our Doorstep?

"[1] Which patients and providers are included? [2] Which drugs are included? [3] How will included drugs be paid for? [4] How will patients be impacted? [5] Is the IFR the same as the model previously proposed? [6] What are the MFN Model's federal price-reporting implications? [7] What does CMS estimate the costs to be?" 

Ropes & Gray LLP

[Guidance Overview]

Massachusetts Paid Family and Medical Leave: Answers to Employer Questions

"[1] Can employers require that employees use accrued paid time off (PTO) prior to using PFML leave? ... [2] How does an unlimited PTO policy interact with PFML? ... [3] Can employers require employees to exhaust PFML benefits before using additional employer-provided family, medical, or temporary disability benefits? ... [4] May employers provide additional family, medical, or temporary disability leave benefits on top of PFML benefits? ... [5] Are new mothers entitled to both medical leave and bonding leave after giving birth? ... [6] Are employers required to allow employees to take PFML on an intermittent or reduced leave schedule? ... [7] What happens in the event an employee does not return from PFML leave?" 

Foley & Lardner LLP

[Guidance Overview]

California’s New FSA Notice Requirement Leaves Employers Asking Questions

"Employers that have employees residing in California are now required ... to provide notification in two different forms to employees about deadlines for withdrawing funds from flexible spending accounts (FSAs). One of the forms of notification may be electronic.... The notice requirement purports to apply to all FSAs, including dependent care FSAs, health care FSAs, and adoption assistance FSAs. Virtually all other aspects of implementing the law are left open to interpretation." 

Covington & Burling LLP, via Lexology; free registration required

Group Health Plan Sponsors and the COVID-19 Vaccine

"There will be a phased-in distribution process initially targeting health care providers and vulnerable groups. Once a vaccine is approved, most group health plans will have to cover it (and related administration costs) within 15 days, at no cost. There are significant legal issues involved in addressing whether employers can mandate that employees receive vaccinations, and there is no guidance at this time on the COVID-19 vaccine." 

Segal

Employee Leave Can Be Complicated

"During 2020, much of the focus regarding leave has been on the [FFCRA]. But workers also may be eligible to take time off under the Family and Medical Leave Act (FMLA), the Americans with Disabilities Act (ADA), and state and local laws." 

Society for Human Resource Management [SHRM]; membership may be required to view article

Balancing Lower U.S. Prescription Drug Prices and Innovation

"The high prices U.S. patients pay for drugs are a key driver of pharmaceutical company financial performance, generating large profits relative to many other industries and an estimated three-quarters of worldwide drug company profits. As a result, lowering U.S. drug prices would likely have an outsized impact on overall incentives to innovate." 

The Brookings Institution

Florida Submits Drug Importation Proposal to HHS

"In 2019, Governor Ron DeSantis and the Florida Legislature initiated this program to lower prices of prescription drugs that are vital to maintaining the health and quality of life for millions of Floridians.... The State will begin by importing a few drug classes which will include maintenance medications to help individuals and consumers that have chronic health conditions such as asthma, COPD, diabetes, and HIV/AIDS." 

Florida Governor Ron DeSantis

[Opinion]

Trump Unveils Disputed, Long-Shot Drug Rules Upending Payment System

"One policy changes drugmakers’ rebates to pharmacy middlemen such that they can’t fluctuate based on the price of the drug. With fixed payment arrangements, these pharmacy liaisons can expect less money. The rule also allows for discounts to go directly to customers at the pharmacy counter. Middlemen, also known as pharmacy benefit managers, help insurers organize their drug coverage lists and determine which products get preferential treatment. The other rule ties federal reimbursement for drugs administered in doctors’ offices to lower prices paid in other countries." 

Bloomberg Law

[Opinion]

Litigation Filed to Challenge Administration’s Final Rule Permitting State-Sponsored Drug Importation from Canada

"FDA has noted it is struggling to keep up with approving medicines while working around the clock to support COVID-19 therapeutics and vaccine development. Despite this, the administration is willing to divert precious FDA resources away from these efforts and to expose Americans to the risks that come with drug importation schemes." 

Council for Affordable Health Coverage [CAHC]

Press Releases

Christine Coburn Joins OneAmerica® as Employee Benefits VP of Underwriting
OneAmerica

The Boston Globe Names Sentinel Benefits & Financial Group a Top Place to Work for 2020
Sentinel Benefits

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Most Popular Items in the Previous Issue

The HSA Shoebox Rule
ABD Insurance & Financial Services

Text of HHS Final Regs: Removal of Safe Harbor Protection for Rebates Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection for Certain Point-of-Sale Reductions in Price on Prescription Pharmaceuticals and Certain Pharmacy Benefit Manager Service Fees (PDF)
Office of Inspector General [OIG], U.S. Department of Health and Human Services [HHS]

Administration Finalizes Most-Favored Nation Drug Pricing Rule
Rachel Sachs, in Health Affairs Blog