"Because the group health plan is ultimately responsible for the submission, an employer who contracts with a third-party administrator to complete the attestation on a [self-insured] group health plan's behalf should consider adding contractual language to the agreement providing the employer with protections in the event that the filing is not performed correctly.... For fully insured group health plans, both the insurer and the group health plan are required to annually submit a gag clause attestation."  MORE >>

"Despite providing significantly more details, many unanswered questions remain.... If left up to the reporting plan sponsor to answer these questions, those using specialized vendors for MH/SUD services will have more challenges to ensure consistency in consolidating the required reports between M/S and MH/SUD vendors and care management firms.... The requirement for a named fiduciary to review the analysis and certify that it complies with the content requirements is a significant development that puts trustees and other fiduciaries at risk for a failure to make sure the comparative analysis complies with the new requirements."  MORE >>

"In September 2022, a Texas district court dismissed most of the plaintiffs' constitutional claims, but concluded in part that covered services based on certain U.S. Preventive Service Task Force recommendations were invalid.... This Legal Sidebar provides background on the preventive services requirement, examines the Braidwood case, and discusses legal considerations for Congress." [Braidwood Management, Inc. v. Becerra, No. 20-0283 (N.D. Tex. Sep. 7, 2022; on appeal to 5th Cir. No. 23-10326)] [LSB11040 Sep. 12, 2023]  MORE >>

"Take action now to stave off the pending surge in class action litigation against health and welfare plan sponsors and fiduciaries.... Plaintiffs' firms are actively looking for potential employee plaintiffs who participate in group health plans.... Manage risks by establishing a health and welfare plan fiduciary committee to conduct formal, well-documented processes to monitor health plan activities and service provider performance and fees."  MORE >>

"Among employers, 62 percent have seen an increase in weight loss drug spending in the last year, 18 percent have seen a decrease and 16 percent have seen no change. In the next year, employers plan to offer preventive solutions (30 percent), digital weight loss solutions that include medications (29 percent), digital weight-loss solutions (27 percent), weight loss drug coverage (26 percent), and fitness and exercise benefits (23 percent)."  MORE >>

15 pages. "From 2017 to 2022, prices for medical services commonly provided in outpatient settings were significantly higher when delivered in a hospital outpatient department, and they grew rapidly over the six years. By comparison, prices for the same services were significantly lower when delivered in an ambulatory surgery center or a physician's office, and price growth over time was relatively modest. These findings suggest that site- neutral payments -- billing the same amount for the same service regardless of site of care -- across care delivery settings would result in substantial savings for employers, employees, and patients."  MORE >>

"In an increasingly digital and virtual world, human connections maintain their appeal. This means live benefits fairs and events are back.... With more and more organizations sharing environmental, social and governance (ESG) practices, you have a great opportunity to reflect those priorities in benefits communications.  ... Think beyond emails, PDFs and flipbooks for your digital strategy."  MORE >>

"[A] growing number of health systems around the country have started charging patients when physicians and other clinicians send replies to their messages.... Billing for e-visits, however, raises knotty questions about the balance between fairly compensating providers for their time and enhancing patients' access to care.... A large part of the motivation for the billing is to reduce the messaging. Soon after the pandemic hit, health systems saw a 50% increase in emails from patients, with primary care physicians facing the biggest burden[.]"  MORE >>

"While some states have moved forward with coverage requirements for OTC contraceptives, operational issues and concerns such as pharmacy and pharmacists' capacity to submit claims for OTC products, a lack of uniformity and oversight of health plans' billing protocols, and low awareness of these policies remain as implementation challenges. While required coverage of OTC contraception without a prescription and without patient cost-sharing would increase access, it could also create a precedent for coverage of other OTC treatments, raising issues of cost for insurers and state Medicaid programs."  MORE >>

"In plan year 2018, HHS introduced the high-cost risk pool (HCRP) program to augment the existing ACA risk adjustment program, helping mitigate the costs associated with high-cost claimants. HCRP issuer charge trends exceed medical trends and are expected to continue at this level. As high-cost events and treatments increase in frequency, ACA issuers must consider how the HCRP interplays with their strategy."  MORE >>

"In essence, the Ninth Circuit failed to ask the most critical question: What is the point of even having insurance if the insurer can override recommendations for medically necessary covered treatment that are based on expert consensus opinions, and that are made by medical professionals who have first-hand knowledge of their patients' needs? Moreover, guidelines are not rules, and should not be used as a substitute for medical judgments specific to each patient's needs and circumstances." [Wit v. United Behavioral Health, Nos. 20-17363 and 21-15193 (9th Cir. Aug. 22, 2023)]   MORE >>

"Taxpayers affected by Hurricane Idalia in parts of Georgia that began Aug. 30, 2023, now have until Feb. 15, 2024, to file various individual and business tax returns and make tax payments ... [I]ndividuals and households affected by Hurricane Idalia that reside or have a business in Appling, Atkinson, Bacon, Berrien, Brantley, Brooks, Bulloch, Camden, Candler, Charlton, Clinch, Coffee, Colquitt, Cook, Echols, Emanuel, Glynn, Jeff Davis, Jenkins, Lanier, Lowndes, Pierce, Screven, Tattnall, Thomas, Tift, Ware, and Wayne counties in Georgia qualify for tax relief."  MORE >>

"Last week, DOL sent a new proposed 'fiduciary rule' to [OMB] for review.... This highly anticipated rulemaking would be DOL's third attempt to reinterpret the 'investment advice' fiduciary definition in ERISA and replace the five-part regulatory test that has largely been in place since 1975.... Also last week, DOL sent a new association health plan (AHP) proposed regulation to OMB. According to DOL, it will explore in the rulemaking whether to replace its 2018 regulation ... with an alternative set of criteria for determining when an employer association may act indirectly in the interest of an employer under ERISA section 3(5) for purposes of establishing a multiple employer group health plan."  MORE >>