"Employers are facing conflicting information about coverage of transgender services. Employers with fully-insured plans should contact their carrier to confirm the plan complies with local law. For employers with self-insured plans, the path forward is less clear."  MORE >>

"[T]he Sixth Circuit concluded that no deference was owed to a claim decision made by a company's benefits department because the plan document neither named the benefits department as the entity with discretionary authority to decide claims nor permitted the benefits committee to delegate its discretionary authority to the benefits department." [Laake v. Benefits Committee, Western & Southern Fin. Group Co. Flexible Benefits Plan, Nos. 22-3182, 21-4178 (6th Cir. May 19, 2023)]  MORE >>

"The preamble to regulations regarding the emergency services requirements states that plans covering emergency services may not 'deny benefits for a participant, beneficiary, or enrollee with an emergency medical condition that receives emergency services, based on a general plan exclusion that would apply to items and services other than emergency services.' The decision in this case, under which a plan could apply an exclusion for complications that arise from a non-covered expense (here, bariatric surgery) to emergency services resulting from the excluded complications, appears to conflict with that guidance." [Shafer v. Zimmerman Transfer, Inc., No. 22-2275 (8th Cir. Jun. 7, 2023)]  MORE >>

"Health plan fiduciaries could be at risk from plaintiffs claiming that fiduciaries breached their fiduciary duties by [1] not receiving and reviewing broker and consultant service fee disclosures and determining the compensation is reasonable, [2] not having adequate procedures in place for hiring and monitoring third-party administrators and pharmacy benefit managers, or [3] failing to determine that the health and prescription drug plan's negotiated network discounts reflect market pricing and are comparable to the claims experience of similar plans."  MORE >>

"Rather than choosing between the health of an employee or the company ROI, there are two key strategies employers and their advisors can use to manage costs and risks associated with specialty medications: [1] Identifying wasteful practices, such as inappropriate use. [2] Adding a layer of protection within a pharmacy benefits plan."  MORE >>

"The measures establish a state-based exchange for policies sold under the [ACA] and give the Illinois Department of Insurance the authority to modify or reject proposed rate increases.... [B]eginning in 2025, companies that offer individual and small group health insurance policies will have to submit their proposed rates for the following year to the Insurance Department, which will post those flings on its website. After a 30-day public comment period, the department will either approve, modify or reject the proposed rate changes."  MORE >>