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Health & Welfare Plans Newsletter

November 16, 2023

2 New Job Opportunities 2 New Job Opportunities


[Official Guidance]

Text of CMS Proposed Regs: Notice of Benefit and Payment Parameters for 2025 (PDF)

460 pages. "This proposed rule includes payment parameters and provisions related to the HHS-operated risk adjustment program, as well as 2025 user fee rates for issuers offering qualified health plans (QHPs) ... This proposed rule also includes proposed requirements related to the auto re-enrollment hierarchy; essential health benefits; failure to file and reconcile; non-standardized plan option limits and an exceptions process; standardized plan options; special enrollment periods (SEPs) ... network adequacy; public notice procedures for section 1332 waivers; prescription drug benefits ... and State flexibility on the effective date of coverage in the Basic Health Program (BHP)." [Also available: Fact Sheet]  MORE >>

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Official Guidance]

Text of CMS Memo: Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year (PDF)

"[T]he 2025 maximum annual limitation on cost sharing is $9,200 for self-only coverage and $18,400 for other than self-only coverage. This represents an approximately 2.6 percent decrease from the 2024 parameters of $9,450 for self-only coverage and $18,900 for other than self-only coverage.... [T]he 2025 required contribution percentage under section 5000A of the Code [is] 7.28 percent ... a decrease of approximately 0.69 percentage points from the 2024 value."  MORE >>

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Official Guidance]

Text of 2025 CMS Draft Letter to Issuers in the Federally-Facilitated Exchanges (PDF)

27 pages. "This 2025 Draft Letter provides updates on operational and technical guidance for the 2025 plan year for issuers seeking to offer qualified health plans (QHPs) ... It also describes how parts of this 2025 Draft Letter apply to issuers in State-based Exchanges on the Federal Platform (SBE-FPs).... The 2025 Draft Letter focuses on guidance that has been updated for the 2025 plan year[.]"  MORE >>

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Official Guidance]

Text of CMS Draft 2025 Actuarial Value Calculator Methodology (PDF)

23 pages. "The AV Calculator represents an empirical estimate of the AV calculated in a manner that provides a close approximation to the actual average spending by a wide range of consumers in a standard population. This document is meant to detail the specific methodologies used in the AV calculation.... [CMS] will accept comments on the draft 2025 AV Calculator [XLXM], as well as the draft 2025 AV Calculator User Guide and [this] draft 2025 AV Calculator Methodology until ... January 2, 2024. "  MORE >>

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Guidance Overview]

Selected State Health Developments, Third-Quarter 2023 (PDF)

"More than a dozen jurisdictions focused on leave issues during the third quarter of 2023 ... Several states announced 2024 PFML rates. Illinois, New Jersey and Puerto Rico passed laws affecting pharmacy benefit managers (PBMs) and prescription drugs. States passing health insurance coverage mandates included California, Illinois, New Jersey and Oregon.... A new commuter benefit mandate will apply to many Chicago-area employers next year."  MORE >>


[Guidance Overview]

Florida Requires Pharmacy Benefit Managers to Be Licensed Starting January 1

"The [Office of Insurance Regulation] recently ... published additional information about the application process, including the application forms and instructions ... The Florida Administrator application requirements are some of the most challenging and robust of any state that licenses TPAs."  MORE >>

Polsinelli PC

Lawsuit Accuses UnitedHealth Group of Using Faulty AI to Deny Claims

"A class-action lawsuit ... [alleges] UnitedHealth Group is using a faulty artificial intelligence algorithm to wrongly deny coverage for Medicare patients who need rehabilitation care following hospitalizations.... The litigation comes amid signs of growing consumer and government suspicion that health insurers are frequently denying payment for medically necessary services." [Estate of Lokeken v. UnitedHealth Group, Inc., No. 23-03514 (D. Minn. complaint filed Nov. 14, 2023)]  MORE >>


Some Employers Are Now Covering Ketamine-Assisted Therapy

"Ketamine is an anesthetic that is perhaps better known as a party drug. But some studies have indicated that it can be effective as a treatment for some types of clinical depression ... and is starting to be offered as an employee benefit by a handful of companies ... A full course of ketamine treatment typically costs $6,000 to $8,000, and depending on the benefit design, companies may spend between $35 to $200 per employee annually to cover it."  MORE >>

HR Brew

FDA Approves a New GLP-1 Weight Loss Drug

"Zepbound is expected to be commercially available in the U.S. after the Thanksgiving holiday in six different doses. Its projected list price is approximately $1,060, which is roughly 20% lower than Wegovy."  MORE >>


In an Era of Premium and Provider Price Increases, State Employee Health Plans Target Key Cost Drivers

"[T]he agencies that purchase health insurance for [the more than 15 million] public employees ... are often the largest commercial purchaser of health care services in their state and therefore have market power to exert pressure on insurance companies and providers.... [T]heir efforts to shift health plan and provider behaviors and encourage greater efficiencies can have ripple effects for other commercial purchasers."  MORE >>

Health Affairs Forefront

Benefits in General

HSA Impact on Retirement Income Adequacy for Future Retirees

"[I]ncreasing access to HSAs and encouraging investment among HSA account holders can help reduce the cumulative retirement savings shortfall, particularly for demographic cohorts projected to face the largest deficits.... Maximizing HSA enrollment accounts for more than half of the difference in the retirement saving shortfall relative to the baseline with HSA. Maximizing contribution and limiting distribution behavior have minor impacts."  MORE >>


GAO Report on EBSA: Systematic Process Needed to Better Manage Priorities and Increased Responsibilities

"[EBSA] resources have generally remained unchanged while oversight responsibilities have increased over the last decade.... Although EBSA officials said they use several strategies to manage declining resources, the agency does not have a clear or systematic decision-making process for doing so.... Without [such a] process, EBSA officials may not have adequate information for making informed decisions about how to manage resource reallocations to meet its increased responsibilities." [GAO-24-105667 Published Oct 24, 2023; Released: Nov 16, 2023.]  MORE >>

U.S. Government Accountability Office [GAO]

Employee Benefits Jobs

View job as Defined Contribution Consultant
            for AimPoint Pension Group

Defined Contribution Consultant

AimPoint Pension Group


View job as Defined Contribution Consultant for AimPoint Pension Group

View job as Document Specialist
            for Definiti

Document Specialist


Remote / The Woodlands TX

View job as Document Specialist for Definiti

Press Releases

Prime Pensions Acquires Pension Benefits Unlimited

Prime Pensions

Webcasts and Conferences
(Health & Welfare Plans)

Employee Benefits Briefing, Fall 2023


Nixon Peabody LLP

Harnessing Price Transparency for Providers and PSHPs

November 30, 2023 WEBINAR

HFMA [Healthcare Financial Management Association]

Last Issue's Most Popular Items

The Proposed MHPAEA Regs: A Comment on the Comments

McDermott Will & Emery

Where Are the Section 1411 Notices to Employers?

MZQ Consulting, LLC

Transportation Plans Offer Valued Benefits But Pose Challenges for Compliance (PDF)


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BenefitsLink® Health & Welfare Plans Newsletter, ISSN no. 1536-9595.

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