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Health & Welfare Plans Newsletter

July 1, 2022

4 New Job Opportunities 4 New Job Opportunities


[Official Guidance]

Text of CMS Summary Report on Permanent Risk Adjustment Transfers for the 2021 Benefit Year (PDF)

37 pages. "The risk adjustment program is working as intended ... Excluding results from the high-cost risk pool ... [1] Risk adjustment state transfers as a percent of premiums increased compared to the 2020 benefit year.... [2] The amount of paid claims remains strongly correlated with risk adjustment state payments and charges[.]'

  • Appendix A: HHS Risk Adjustment Program State-Specific Data (XLSX)
  • Appendix B: HHS Risk Adjustment Geographic Cost Factor (GCF) (XLSX)
  • Appendix C: Table 4: Issuer-Specific Information for Non-Merged Market Issuers (XLSX)
  • Appendix D: Table 5: Issuer-Specific Information for Merged Market Issuers (XLSX)
  • Appendix E: Table 8: Default Risk Adjustment Charge (XLSX)
  • Appendix F: Table 9: Default Risk Adjustment Charge Allocation (XLSX)


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

[Guidance Overview]

Exceptional Usefulness and Quality icon Addressing Employee Health Plan Exception Requests: Enrolling Independent Contractors

"The main concern is that offering coverage to an independent contractor likely creates a multiple employer welfare arrangement (MEWA). MEWA status is generally infeasible for reasons related to additional compliance burdens, insurance carrier limitations, and state law restrictions that are not preempted by ERISA."  MORE >>


[Guidance Overview]

Colorado Moves Forward on Paid Family and Medical Leave

"Employers with Colorado workers will need to establish a process for collecting and remitting contributions.... While employers will have the opportunity to opt out of participation in the state-run program by obtaining approval for a private plan, no specific guidance is available so far on those requirements.... [Employers] with established paid leave programs that don't opt for a private plan will need to determine how to coordinate the state program with their existing plans."  MORE >>


Alert (High Risk Issue) icon Eleventh Circuit: Monetary Benefits Claim for Fiduciary Breach Under ERISA's Catch-All Remedy Provision Can Proceed

"The participant did not receive [the evidence of insurability] form with his enrollment paperwork. The HR staff did not notify the participant that the form was necessary or missing.... Despite the form's absence, the employer [d]educted premiums corresponding to $500,000 in coverage for a three-year period [and] [p]rovided the participant a benefits summary indicating that he had $500,000 in coverage.... The court held that ... [ERISA Section 502(a)(3)] permitted the beneficiary to sue to recover money benefits lost because of a plan's fiduciary breach involving the plan enrollment process." [Gimeno v. NCHMD, Inc., No. 21-11833 (11th Cir. Jun. 28, 2022)]  MORE >>

Thomson Reuters Practical Law

Alert (High Risk Issue) icon Eleventh Circuit: Widow Can Recover Life Insurance Benefits Even Though Deceased Employee Was Never Enrolled in the Plan Due to Plan Administrator's Mistakes

"[D]istrict courts have come to accept the premise that, in light of the Supreme Court's recognition in Amara of equitable remedies for fiduciary errors, the value of the absent life insurance benefits should be recoverable as equitable relief independent of the plan and the lack of coverage for that amount under the plan itself. The acceptance of this premise has now progressed to the Circuit Court of Appeal level[.]" [Gimeno v. NCHMD, Inc., No. 21-11833 (11th Cir. Jun. 28, 2022)]  MORE >>

Stephen Rosenberg, The Wagner Law Group

Alert (High Risk Issue) icon District Court Decides Health Plan's Exclusion of Gender Affirming Care Violates Title VII and U.S. Constitution

"The trial court found that the plan's exclusion discriminated based on sex and transgender status in violation of the U.S. Constitution's Equal Protection Clause and because of sex in violation of Title VII of the Civil Rights Act of 1964. The court declined to rule on claims alleged under [ACA] Section 1557, pending the issuance of proposed regulations[.]" [Kadel v. Folwell, No. 19-0272 (M.D.N.C. Jun. 10, 2022)]  MORE >>

Thomson Reuters / EBIA

Upcoming Deadline icon How Much Health Insurers Pay for Almost Everything Is About to Go Public

"As of July 1, health insurers and self-insured employers must post on websites just about every price they've negotiated with providers for health care services, item by item.... The federally required data release could affect future prices or even how employers contract for health care. Many will see for the first time how well their insurers are doing compared with others."  MORE >>

Kaiser Health News

International Prescription Drug Price Comparisons: Current Empirical Estimates and Comparisons with Previous Studies

"U.S. prices were 256 percent of those in the 32 comparison countries combined. In comparisons with individual countries, U.S. prices ranged from 170 percent of prices in Mexico to 779 percent of prices in Turkey. The gap between U.S. prices and prices in other countries was larger for brand-name originator drugs. U.S. prices were 84 percent of prices in all non-U.S. countries for unbranded generics. U.S. prices were 190 percent of prices in other countries after adjusting U.S. prices downward to account for rebates and other discounts."  MORE >>

Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS]

Making Changes to Caregiving Benefits in the Era of Hybrid Work

"While a hybrid work model -- a combination of in-office and remote work -- may offer the best of both worlds, employers need to consider the unique needs of caregivers when crafting their policies.... Caregiving solutions should be flexible and based on employees' personal and work circumstances."  MORE >>

Employee Benefits Report

Exceptional Usefulness and Quality icon Post-Dobbs: FAQs for Employers and Other Benefit Plan Sponsors (PDF)

"Can a group health plan reimburse travel expenses in excess of the applicable IRS limits? ... Do plan sponsors have to consider mental health parity concerns when adding travel benefits to access reproductive coverage? ... Can employers just 'pay as you go' outside a group health plan, and offer ad-hoc taxable reimbursements of travel expenses to access reproductive care? ... Can a separate health reimbursement arrangement (HRA) be created solely for reimbursing travel expenses to access reproductive care? ... Does Dobbs impact infertility benefit coverage under a group health plan?"  MORE >>


Effect of the Overturn of Roe v. Wade on Employer-Sponsored Group Health Plans

"[E]xpanding reproductive health services, including the addition of a travel and lodging reimbursement benefit, should be considered under the umbrella of a welfare benefit plan, which for non-governmental and non-church plan employers has the benefit, subject to limitations, of the preemption of state laws pursuant to [ERISA].... If expanded travel and lodging reimbursement provisions are desired, consideration should be given to applying these new provisions to all benefits covered under the plan[.]" [Dobbs v. Jackson Women's Health Org., No. 19-1392 (S. Ct. Jun. 24, 2022)]  MORE >>

Armstrong Teasdale

Big Employers Are Offering Abortion Benefits. Will the Information Stay Safe?

"Human resources departments are required to keep some medical data closely held, but a determined law enforcement agent with a search warrant or subpoena could ultimately get access to patient data. That will complicate life for the dozens of corporations promising to protect, or even expand, the abortion benefits for employees and their dependents."  MORE >>

Kaiser Health News

Federal Subsidies for Health Insurance Coverage for People Under 65: 2022 to 2032

"[N]et federal subsidies ... in 2022 for insured people under age 65 are $997 billion, or 4.0 percent of gross domestic product (GDP). In 2032, that annual amount is projected to reach $1.6 trillion, or 4.3 percent of GDP.... Medicaid and the Children's Health Insurance Program (CHIP) account for about 42 percent of the federal subsidies annually during the period; Subsidies for employment-based coverage, about 37 percent; Payments for Medicare enrollees under age 65, about 14 percent; and Subsidies for coverage obtained through the marketplaces established by the [ACA] or through the Basic Health Program, about 7 percent."  MORE >>

Congressional Budget Office [CBO]


CBO's Misleading Description of the Tax Exclusion for Employer-Sponsored Health Insurance

"How does the federal government spend/​support/​subsidize ESI? Under the federal 'tax exclusion for employment‐​based coverage,' the money that employers and workers spend on ESI 'is exempt from federal income and payroll taxes.' Catch that? What the federal treasury is actually doing with respect to ESI is… nothing."  MORE >>

Cato Institute

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Press Releases

The Cerrado Group Announces MAP Retirement as Newest Member Firm

The Cerrado Group

Church Pension Group Releases Its 2022 Annual Report

Church Pension Group [CPG]

SageView Expands Pacific Northwest Presence with Seattle Office Led By Jon Chambers

SageView Advisory Group

Webcasts and Conferences
(Health & Welfare Plans)

The Overturning of Roe v. Wade: What to Know and What’s Next?


McDermott Will & Emery LLP

Group Health Plan Considerations Post-Dobbs: A Practical Guide for Employers

July 6, 2022 WEBCAST


Last Issue's Most Popular Items

Impact of the Dobbs Decision on Cafeteria Plans and Medical Travel

Alston & Bird, via TRI-AD

Proactive Considerations for Employers and Potential Approaches to Abortion-Related Benefits

Ice Miller LLP

Overturning of Roe v. Wade Creates Challenging Legal Issues for Self-Funded Health Plan Sponsors

McAfee & Taft

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BenefitsLink Retirement Plans Newsletter, ISSN no. 1536-9587.

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