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Health & Welfare Plans Newsletter

September 19, 2023

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[Guidance Overview]

Massachusetts Sets 2024 Individual-Mandate Coverage Dollar Limits

"The Massachusetts Health Connector has published 2024 dollar limits on deductibles and other cost sharing for minimum creditable coverage (MCC) ... Providing MCC is not an employer mandate, but many employees use employment-based health coverage to satisfy the individual mandate. In addition, health plan reporting requirements compel plan sponsors (or their vendors) to determine whether their coverage meets MCC standards."  MORE >>


Ninth Circuit Affirms Denial of ERISA Attorneys' Fees to Plaintiff Who Achieved a Remand to the Plan Administrator But Did Not Prevail After the Remand

"[T]he court found that Sedgwick did not act in bad faith or intentionally misinterpret the disability plan.... The court found that there would be no deterrent value of a fee award since the error was unintentional, Plaintiff did not bring the lawsuit to benefit others, and ultimately Plaintiff did not prevail. Balancing the factors, the court was left with no 'definite conviction' that the district court made a clear error of judgment." [Alves v. Hewlett-Packard Comprehensive Welfare Benefits Plan, No. 22-55621 (9th Cir. Sep. 14, 2023)]  MORE >>

Roberts Disability Law

COBRA Notice Need Not Be Single Notification

"[T]he court explained that while COBRA requires the administrator to 'notify' qualified beneficiaries of their COBRA rights, it does not limit this notification to a single notice. As long as an administrator timely notifies a beneficiary of their COBRA rights, it has complied with the requirements of the statute. Moreover, since the address to which the former employees were required to send COBRA payments was included in the second COBRA notice, the court ruled that the employer had fulfilled its notice obligation." [Bryant v. Walgreen Co., No. 23-1294 (N.D. Ill. Aug. 29, 2023)]  MORE >>

The Wagner Law Group

District Court Ruling Provides a Win for Patients and Payers and a Huge Loss for Air Ambulance Companies

"The median price of air ambulance transport by private equity or publicly-traded parent companies was $32,051 in 2016 (and has only increased). Those rates were 60% higher than the average amount for rides provided by hospitals, nonprofits, and independent companies. As a result of this ruling, an air ambulance bill will be significantly less as hospital-based air ambulance fees will continue be included (and single case agreements will continue to be excluded) in the calculation of the QPA." [Association of Air Medical Services v. HHS, No. 21-3031 (D.D.C. Aug. 4, 2023)]  MORE >>


NAIC Releases Draft Model Bulletin Regarding Use of AI by Insurers

"The draft Model Bulletin encourages insurers to develop, implement and maintain a written program for the use of AI systems that is designed to mitigate the risk that the use of AI systems in making or supporting decisions affecting insurers' customers will result in decisions that are arbitrary or capricious, unfairly discriminatory or that otherwise violate unfair trade practice laws.... It remains to be seen whether and to what extent state insurance departments will adopt and distribute the Model Bulletin in its final form."  MORE >>


One Year Later, Where Are the 'Transparency in Coverage' Compliance Studies?

"[The authors] posit that [the] lack of compliance monitoring is not for lack of interest but rather because of the complexity of the landscape to which the regulation applies. As such, in this piece, we lay the groundwork for compliance studies by outlining the agencies responsible for enforcing compliance with the TiC rule, delineating the universe of entities that are required to comply with it, and discussing how compliance might be assessed."  MORE >>

Health Affairs Forefront

A Look Into House Efforts on Hospital and Health Plan Price Transparency (PDF)

10 pages. "Three House committees -- Energy and Commerce, Ways and Means and Education and the Workforce -- each approved legislation that would advance price transparency objectives. Generally, these bills seek to codify (and in some respects, modify) the requirements around hospital and health plan price transparency as previously implemented by [CMS].... This [article] compares the hospital and health plan transparency provisions of these primary pieces of legislation and compares them with current regulations. "  MORE >>

McDermott Will & Emery LLP

Save Billions or Stick with Humira? Drug Brokers Steer Americans to the More Costly Choice

"For real competition to take hold, the big pharmacy benefit managers, or PBMs, the companies that negotiate prices and set the prescription drug menu for 80% of insured patients in the United States, would have to position the new drugs favorably in health plans. They haven't, though the logic for doing so seems plain."  MORE >>

KFF Health News

HHS Announces First Ten Drugs for Medicare Pricing Negotiation – Should Employers Care?

"[If] the drug manufacturers are required to participate in these negotiations or withdraw their drugs from the Medicare and Medicaid market, it is logical to assume that the manufacturers will be financially impacted. Because drug research and development is costly, drug manufacturers will likely want to offset the revenue lost from other sources. As a result, the two types of plans that will not reap the benefits of lower costs from the Medicare Drug Price Negotiation Program -- individual and employer- sponsored health plans -- are likely to see further increases in prices"  MORE >>

Arthur J. Gallagher & Co.

Medicare's Affordability Problem: Cost Burdens Faced by Older Enrollees

"This data brief examines the financial burden of care that people age 65 and older with Medicare face, and how that burden differs for people with traditional Medicare and Medicare Advantage.... [The study examines] the extent to which beneficiaries [1] are underinsured with high out-of-pocket costs or deductibles relative to their income; [2] are experiencing cost-related barriers to receiving care; [3] have problems paying medical bills; and [4] have difficulty paying Medicare premiums."  MORE >>

The Commonwealth Fund

Employee Benefits Jobs

View job as 3(16) Retirement Plan Consultant
            for EGPS, Inc.

3(16) Retirement Plan Consultant

EGPS, Inc.


View job as 3(16) Retirement Plan Consultant for EGPS, Inc.

Selected New Discussions

Buyer 'Can't' Offer COBRA to Dependents Losing Coverage?

"Employee (E) of Seller (S), a small company with a group health plan covered by Florida mini-COBRA, has twins age 28 on the coverage, thanks to Florida law that requires allowing certain unmarried dependents to remain covered to age 30. Buyer (B) acquires all of the S stock in mid-July, 2023, and E continues working for S, with the twins remaining on the coverage, as before. S terminates its group health plan on July 31, and E, along with other S employees and their dependents, enrolls in B's group health plan effective August 1. Only the twins are left out in the cold.

"B's plan is subject to COBRA. Though operating in Florida, B's coverage is underwritten in Illinois, where it also does business. The policy does not extend coverage to dependents beyond age 26, consistent with Illinois law. B refuses to offer continuation coverage to the twins, who lost coverage when the S plan terminated, insisting that the carrier won't allow it because the twins are older than 26. In a phone conversation with the Florida Office of Insurance Regulation, I was informed that a company doing business in Florida but 'headquartered' in another state does not have to follow Florida's coverage rules, at least insofar as allowing certain dependents to remain on the coverage to age 30.

"My contention is that federal law, in the form of COBRA, supersedes whatever state law may have to say on the subject, and that B became responsible to the twins under COBRA when B acquired S, followed by S's termination of its plan. The twins 'aged off' of coverage at that time, thereby experiencing a COBRA qualifying event when they lost coverage due to B's policy failing to pick them up because of its lower age threshold for terminating dependent coverage. Sound reasonable? Even if B is unable to enroll the twins on its coverage, isn't B still under some obligation to them for failing to honor their COBRA rights? Perhaps B can help offset the cost of the twins obtaining Marketplace coverage, for example."

BenefitsLink Message Boards

Press Releases

Study Shows Employers Save 25% Through Onsite and Nearsite Wellness Centers

Premise Health

Centivo Named Insurance Employer of the Year in 2023 Stevie Awards for Great Employers


New Coalition of Transparent PBM Companies Seeks to Fix Nation's Broken Drug Pricing System


National Alliance Urges Action to Achieve Fair Pricing for Hospital Services

National Alliance of Healthcare Purchaser Coalitions

Webcasts and Conferences
(Health & Welfare Plans)

Mental Health Parity Update for Plan Sponsors: What You Need to Know

September 27, 2023 WEBINAR

Groom Law Group

It's Time to Start Planning for 2024: Year-End Deadlines, Including Secure 2.0

September 28, 2023 WEBINAR

Boutwell Fay LLP

Wait, What? FMLA/ADA Cases That Make You Say, 'Hmmm?'

October 11, 2023 WEBINAR

Frost Brown Todd LLC

Last Issue's Most Popular Items

Upcoming Key Compliance Deadlines and Reminders for Fourth Quarter 2023


AI Is Radically Transforming Benefit Plan Management (PDF)

Roland Criss, via Journal of Compensation and Benefits

Global Average Medical Trend Rate Expected to Reach 10.1 Percent in 2024, Surpassing 2023 Rate


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

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