"[T]he public health emergency ... is now effective through April 11, 2023.... [G]roup health plans must continue to provide coverage related to the testing (including certain over-the-counter tests) and diagnosis of COVID-19 without cost-sharing requirements ... Similarly, coverage for the COVID-19 vaccine must be provided (by non-grandfathered group health plans) without cost sharing for both in- and out-of-network providers."  MORE >>

"In matters that go to litigation, the Ninth Circuit held that a district court may not rely on rationales that the plan administrator did not raise as grounds for denying a claim for benefits. By failing to make arguments during the administrative process, but raising them for the first time at litigation, this can be found to be a violation of the 'full and fair review' afforded by ERISA." [Collier v. Lincoln Life Assurance Company of Boston, No. 21-55465 (9th Cir. Nov. 21, 2022)]  MORE >>

"The court considered and rejected Standard's arguments including that: [1] extratextual evidence shows that the 2018 amendments were not meant to apply to claims filed before April 1, 2018; [2] Zall waived the argument about the amended regulation in the district court by failing to raise it during the administrative review process or allege it in the complaint, and [3] applying the 2018 amendments to claims filed as far back as 2002 would make them impermissibly retroactive." [Zall v. Standard Ins. Co., No. 22-1096 (7th Cir. Jan. 19, 2023)]  MORE >>

"The Sixth Circuit then ruled that, regardless of whether FMLA leave is to be continuous or intermittent, an employee need only provide notice to the employer one time for each qualifying reason. However, the employee must advise the employer as soon as practicable if dates of scheduled leave were initially unknown." [Render v. FCA US LLC, No. 21-2851 (6th Cir. Nov. 16, 2022)]  MORE >>

"The court held that under the plain language of Section 1557, the insurer's TPA activities constitute the operation of a health program or activity.... The insurer argued that under the 2020 regulations, Section 1557 does not apply to its TPA activities because those actions are not 'healthcare activities' and because it does not receive any federal financial assistance for them, but the court rejected those arguments, explaining that the 2020 regulations are clearly contrary to the statute and appear to be arbitrary, capricious, and contrary to law." [C. P. v. Blue Cross Blue Shield of Ill., No. 20-6145 (W.D. Wash. Dec. 19, 2022)]  MORE >>

"The nonrefundable administrative fee increased from $50 to $350. CMS says the case load of disputes is nearly ten times greater than initially estimated, resulting in the fee increase. Hospital groups fear this price hike will hinder medical groups from initiating the IDR process."  MORE >>

"Over the past few years, dual pieces of federal legislation have attempted to curb costs in the healthcare industry, one aimed at hospitals and another targeting insurers. While the initial efficacy of the rules is yet to be determined, they have set a new tone and precedent in the U.S. healthcare industry -- namely, that government entities at the federal and state levels are taking a more intentional approach to monitoring and controlling costs that affect consumers."  MORE >>

"Self-insurance ... entails assuming more risk of adverse claims. And the terms of this type of coverage are about to get even more complicated.... 25% of large employers now report claims of over $1 million.... The emergence of gene therapy drugs is not significant enough to disrupt the market, but the pipeline of these curative medications is extensive."  MORE >>

"The offering is available as of Jan. 1 for 5 million fully insured members, and self-insured employers can also purchase the program as an employer benefit. Through the program, adults with symptoms of mild depression, stress and anxiety can access support for their mental health needs through virtual modules as well as one-on-one video conferences, phone calls or messaging with coaches."  MORE >>

"This white paper explores risk and cost profile changes for various stakeholders, both in aggregate and specific to certain populations, and discusses possible risk mitigation strategies for plan sponsors after the Part D benefit redesign is fully implemented in 2025."  MORE >>

"[T]he Inflation Reduction Act (IRA) [set] into motion a series of changes to the way that Medicare and its beneficiaries pay for prescription drugs. Much has been written about the act's individual provisions, but little has been said about how they fit together as a whole. In fact, these seemingly standalone reforms act together to reshape access and affordability of branded prescription drugs under Medicare Part D, while also leaving the door open to further reforms."  MORE >>

"Victims of severe storms, straight-line winds, and tornadoes beginning January 12, 2023, now have until May 15, 2023, to file various individual and business tax returns and make tax payments.... [I]ndividuals and households affected by severe storms, straight-line winds, and tornadoes that reside or have a business in Autauga and Dallas counties qualify for tax relief."  MORE >>