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Health & Welfare Plans Newsletter

March 20, 2023

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[Official Guidance]

Text of Federal Independent Dispute Resolution (IDR) Process Guidance for Disputing Parties (PDF)

39 pages; updated Mar. 2023. "This guidance document is effective for payment determinations made on or after February 6, 2023 for items and services furnished on or after October 25, 2022 for plan years ... beginning on or after January 1, 2022 ... This document provides guidance to disputing parties who are seeking to resolve a claim for payment for [out of network] health care items or services through the Federal IDR Process.... This document provides information on how the disputing parties engage in open negotiation prior to the Federal IDR Process, initiate the Federal IDR Process, select a certified IDR entity, and meet the requirements of the Federal IDR Process."  MORE >>

U.S. Department of Health and Human Services [HHS]; U.S. Department of Labor [DOL]; and U.S. Treasury Department

[Official Guidance]

Text of Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities (PDF)

43 pages; updated Mar. 2023. "This guidance document is effective for payment determinations made on or after February 6, 2023 for items and services furnished on or after October 25, 2022 for plan years ... beginning on or after January 1, 2022 ... This document includes information on how the parties to a payment dispute may initiate the Federal IDR Process and describes the requirements of the Federal IDR Process, including the requirements that certified IDR entities must follow in making a payment determination. This document also includes ... guidance on confidentiality standards, record-keeping requirements, and the process for revocation of IDR certification, as well as how parties may request an extension of certain time periods for extenuating circumstances."  MORE >>

U.S. Department of Health and Human Services [HHS]; U.S. Department of Labor [DOL]; and U.S. Treasury Department

[Guidance Overview]

2024 Brings Significant Increases in ACA Penalties for Employers: Are You Prepared?

"With the higher penalty amounts, employers who do not offer minimum essential coverage (MEC) or who offer unaffordable coverage or coverage that does not provide minimum value to their full-time employees could face additional financial exposure compared to previous years.... Employers should invest in tools or seek assistance from professionals to streamline their reporting process and avoid costly mistakes."  MORE >>


District Court Finds That Plaintiff Waived Right to Pursue ERISA Claim

"The Court noted that at least one court has declined to consider the value of the ERISA claim presently being litigated ... [and] concluded that even if it were to consider the potential benefits that Plaintiff would be entitled to if she were to prevail in the litigation, that factor alone did not overcome the clarity of the Agreement or the fact that Plaintiff consulted her disability attorney before signing it." [Schuyler v. Sun Life Assurance Co. of Canada, No. 20-10905 (S.D.N.Y. Mar. 7, 2023)]  MORE >>

Roberts Disability Law

Fungibility in Workplace Benefits Choices: Evidence from Health Savings Accounts (PDF)

"Most employees do not treat HSAs as long-term savings and instead use their HSAs to pay for current health care expenses with before-tax dollars.... Employees with greater financial literacy and liquidity are more likely to treat their HSAs as savings, but even most of this group does not. Employees tend to discount employer HSA deposits relative to cash and do not view HSA dollars as fungible with lower health insurance premiums."  MORE >>


Provider Directories Remain Inconsistent, Despite No Surprises Act Provisions

"Researchers ... used artificial intelligence to analyze health plan provider directories for over 40% of U.S. physicians, and found inconsistencies for 81% of doctors across five major insurers ... Most of the inconsistencies were among addresses among physicians listed as practicing in multiple locations."  MORE >>


Overview of Health Insurance Exchanges

46 pages. "This report provides an overview of key aspects of the health insurance exchanges, including types and administration of exchanges, eligibility and enrollment, plan costs and financial assistance, insurer participation, and exchange financing. It also includes information about policy changes enacted under [ARPA] and ... the Inflation Reduction Act, as well as recent administrative policy changes, including those made in response to the [COVID-19] pandemic and related economic recession." [R44065 updated Mar. 17, 2023]  MORE >>

Congressional Research Service [CRS]

Interim Summary Report on Permanent Risk Adjustment for the 2022 Benefit Year (PDF)

12 pages. "[This report] is based on issuers submitting at least 90% of three quarters of claims data and 90% of enrollment data for the 2022 benefit year." [Also available: Appendix A: Interim 2022 Benefit Year Risk Adjustment State Averages with State Billable Member Months (XLSX); and Appendix B: Interim 2022 Benefit Year Risk Adjustment Geographic Cost Factor (XLSX)]  MORE >>

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

Benefits in General

[Official Guidance]

Text of IRS Disaster Relief Notice CA-2023-03, for Victims of Severe Winter Storms, Flooding, Landslides and Mudslides in California

"Victims of severe winter storms, flooding, landslides and mudslides in California beginning March 9, 2023, now have until Oct. 16, 2023, to file various individual and business tax returns and make tax payments ... [I]ndividuals and households ... that reside or have a business in Alpine, Amador, Butte, Calaveras, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Los Angeles, Madera, Mariposa, Mendocino, Merced, Mono, Monterey, Napa, Nevada, Orange, Placer, Plumas, Sacramento, San Benito, San Bernardino, San Francisco, San Joaquin, San Mateo, San Luis Obispo, Santa Barbara, Santa Clara, Santa Cruz, Sierra, Sonoma, Stanislaus, Trinity, Tulare, Tuolumne and Yuba counties qualify for tax relief."  MORE >>

Internal Revenue Service [IRS]

Employee Benefits Jobs

View job as DC Consultant Administrator
            for Boutique TPA Firm is Southern California

DC Consultant Administrator

Boutique TPA Firm is Southern California

Remote / Burbank CA

Selected New Discussions

COBRA Premium for Uninsured Fully Self-Funded Benefits

"An employer offers a couple of medical benefits (medical travel, infertility) to the extent not otherwise covered by insurance and which are completely self-funded, i.e. paid entirely out of general funds and not backed up by stop-loss. There is no employee pay portion and there is no enrollment, all employees are covered by virtue of being an employee. COBRA seems to apply -- the fundamental question is, what is the COBRA premium, if any, and can the employer require the employee to make an affirmative election for continuation coverage in the absence of any 'premium' per se or would the employer have to offer it to all separated employees since there is no premium? The medical travel benefit is entirely new, so there's no experiential cost to the employer as of yet, but the infertility benefit has been in place for a number of years, so could you hack up the claims experience of that benefit to arrive at a 'premium?' Since the employer can charge 'up to' 102% of the premium cost, if it's too difficult to arrive at what the premium would be, could the employer simply decide that it will charge zero, but the employee must still make an affirmative election to continue coverage?"

BenefitsLink Message Boards

Last Issue's Most Popular Items

IRS Answers Questions About Reimbursement of Medical Expenses Related to Nutrition, Wellness, and General Health

Internal Revenue Service [IRS]

States Act to Strengthen Surprise Billing Protections Even After Passage of No Surprises Act

The Commonwealth Fund

Navigating Mental Health Benefits Claims: Know Your Rights

DeBofsky Law

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

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