"Self-funded plans will struggle to meet the content requirements listed above given their heavy reliance on TPAs for network structure and adequacy, pricing, etc.... [M]any plans have sought help from third-parties such as consultants or legal counsel to assist in drafting and reviewing the NQTL analysis on behalf of the plan.... To the extent a plan relies on an outside consultant or expert, the plan must include an assessment of each expert's qualifications and whether the plan ultimately relied upon the expert's evaluation."  MORE >>

"[Technical Release 23-01] offers a data-driven approach to network composition and network access requirements. The Departments invite comment on the type, form and manner of data that plans should be required to collect and evaluate along with other relevant data as part of their comparative analyses. The Departments also invite comments on a potential enforcement safe harbor under which plans would be permitted to demonstrate compliance."  MORE >>

10 pages. "This guide: [1] helps you figure out whether your health plan must provide parity and follow these rules; [2] explains the protections the law provides; [3] highlights 'red flags' to look out for; [4] tells you how to learn about your mental health and substance use disorder benefits; and [5] walks you through what to do if coverage of your mental health and substance use disorder benefits has been denied."  MORE >>

"The 2023 Report to Congress includes a list of six NQTL enforcement priorities for MHPAEA compliance efforts by [EBSA]. This list adds two additional enforcement priorities that were not identified in the 2022 Report to Congress.... [1] Impermissible exclusions of key treatments for mental health conditions and substance use disorders and [2] Adequacy standards for MH/SUD provider networks."  MORE >>

"Only three months after oral argument, the U.S. Court of Appeals for the Tenth Circuit issued a decision agreeing with the Pharmaceutical Care Management Association (PCMA) that Oklahoma's Patient's Right to Pharmacy Choice Act is preempted by ERISA because it interferes with central matters of plan administration by restricting ERISA plans from structuring their pharmacy networks in a particular manner. The court also held that ERISA preempted the Act's provision that would bar pharmacy benefit managers (PBMs) from denying, limiting, or terminating a pharmacy's contract because one of its pharmacists is on probation with the state pharmacy board." [PCMA v. Mulready, No. 19-0977 (10th Cir. Aug. 15, 2023)]  MORE >>

"While the association argued that all amounts charged under any type of contract should be included when determining the median rate, the court explained that the NSA directs HHS to include only the payment rates that are contracted for under the generally applicable terms of a plan or policy. Thus, excluding single case agreements from QPA calculations was reasonable." [Assoc. of Air Med. Serv. v. HHS, No. 21-3031 (D.D.C. Aug. 9, 2023)]  MORE >>

"Because the Medicaid/CHIP Model Notice lists the states that provide premium assistance, the DOL has said that an employer can meet its notification obligation by simply providing the Model Notice to all employees, regardless of where they live."  MORE >>

"The average stop-loss coverage premium increase is 8.4 percent for the nearly 250 health plans in Segal's national medical stop-loss database's 2023 dataset.... The average premium increase for groups that maintained similar specific stop-loss benefit levels as the prior year is 13.4 percent."  MORE >>

"[L]ist prices for 25 top Medicare Part D drugs have increased by an average of 226 percent -- or more than tripled -- since they first entered the market, greatly exceeding the corresponding rate of general inflation. Further, the analysis of these 25 individual products finds that lifetime list price changes increase dramatically the longer a product has been on the market and that, on average, nearly 60 percent of the current list price is due to price increases after the product entered the market."  MORE >>

"Obesity care is emerging as an employee benefits need. What should employers and plan sponsors consider when designing offerings? ... [1] What obesity services or medications does the plan cover? ... [2] Does the plan offer intensive behavior change support? ... [3] Do you offer easily accessible healthy food options? ... [4] Is movement integral to company culture?"  MORE >>

" 'The Tenth Circuit decision is inconsistent with what other federal courts have decided, and it seems to depart from the Supreme Court's unanimous Rutledge decision, which clearly held that PBMs can't hide behind ERISA. It must be overturned.' said B. Douglas Hoey, CEO of the National Community Pharmacists Association (NCPA)."  MORE >>

"Victims of severe storms and flooding in parts of Illinois that began on June 29, 2023, now have until Oct. 31, 2023, to file various individual and business tax returns and make tax payments ... [I]ndividuals and households affected by severe storms and flooding that reside or have a business in Cook County qualify for tax relief."  MORE >>