"The 2013 final MHPAEA regulations use -- but do not define -- the terms, 'processes,' 'strategies,' 'evidentiary standards' or 'other factors.' ... [T]he Departments now propose to define these other terms.... Under the proposal, 'processes'' relate to the application of an NQTL, while ''strategies'' relate to their design.... Evidentiary standards are not themselves considered factors; rather, they are considered or relied upon in designing or applying a factor. This invites the question: What happens when a plan or issuer only relies upon a single evidentiary standard to design or apply an NQTL?"  MORE >>

"In an effort to curb federal government and patient spending, several drug pricing reforms were included in the Inflation Reduction Act (IRA), which ... began taking effect in 2023 and include changes to the Part D benefit design as well as the introduction of a new drug price inflation control.... Together with contracted prices, rebates are a key factor in health insurers' choices about whether to include a specific prescription drug on a Part D formulary and in which tier. Therefore, rebates impact the finances of all stakeholders in the prescription drug distribution chain"  MORE >>

"[The court] opined that the Act's discount prohibition requires that cost-sharing and copayments be the same for all network pharmacies 'whether retail or mail-order; standard or preferred.' ... [It] found that this prohibition ... directs or forbids an element of plan structure or benefit design. Next, the court noted that the Act's provider participation requirement forces plans to 'include many more brick-and-mortar pharmacies…. Because adding pharmacies costs plans money, this is a choice that plans might not otherwise make.' It found that this requirement also impermissibly affects plan structure or benefit design." [PCMA v. Mulready, No. 19-0977 (10th Cir. Aug. 15, 2023)]  MORE >>

"Noting ERISA's broad venue provisions permitting jurisdiction 'where the plan is administered, where the breach took place, or where a defendant resides or may be found' ... the Court found that venue in the District of Utah would be proper as Plaintiff resided and worked in Utah, received benefits checks in Utah, and had his benefits terminated while residing in Utah. As to the second requirement, whether transfer is appropriate and in the interest of justice, the Court considered nine factors ... [and] concluded that the District of Utah was clearly the proper forum for the matter[.]" [Penrose v. New York Life Insurance Company & Life Insurance Company of North America, No. 22-2184 (S.D.N.Y. Sep. 22, 2023)]  MORE >>

"[A] California Court of Appeal ... agreed with a lower court decision granting summary judgment in favor of a payor by finding that the payor did not enter into a binding agreement with an out-of-network substance use treatment provider during a prior authorization and verification of benefits communication. The court's ruling has implications for out-of-network providers that rely on quasi-contractual theories to recover money from payors for services they rendered to members/insureds based on verification of benefits and prior authorization calls." [AToN Center, Inc. v. United Healthcare Ins. Co., No. D080122(Calif. Ct. App. Jul. 27, 2023)]  MORE >>

"Employer-sponsored health plans in 2024 may resort again to passing costs on to their workers as medical inflation heats up, aided by demand for weight-loss drugs such as Wegovy ... Medical plan costs are forecast to rise 7% to 7.5%, and costs for outpatient prescription drugs are expected to go up 10% ... In addition to health-care price increases, medical use is rising back to pre-COVID levels[.]"  MORE >>

"Using [a large language model (LLM)] that can comb a patient record and sense keywords through prompts that a business leader would be able to identify, the provider can drive the coders to the information that's going to be most useful to them to generate the codes and get the claims out the door ... [A] hospital that can't recruit and retain enough staff to perform claims follow-up ... may benefit from [robotic process automation (RPA)] that checks payer portals for claim payment status[.]"  MORE >>

"In a move that would allow more individuals to save more for their health care expenses in retirement, the House Ways and Means Committee on Sept. 28 approved legislation to significantly expand the health savings account (HSA) contribution limits, as well as broaden the number of individuals eligible for HSAs.... [T]he Committee approved the Bipartisan HSA Improvement Act of 2023 (HR 5688) ... and the HSA Modernization Act of 2023 (HR 5687) ... which together are estimated to cost approximately $70 billion over 10 years[.]"  MORE >>

"Taxpayers affected by seawater intrusion ... that began Sept. 20, 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 the Seawater Intrusion that reside or have a business in Jefferson, Orleans, Plaquemines, and St. Bernard parishes, qualify for tax relief."  MORE >>