"Plaintiff's main argument on appeal was that United disregarded A.C.'s substance abuse as an independent ground for coverage.... [T]he reviewing doctor on the second appeal ... only cited to the Mental Health Guidelines.... The court explained that where an administrator ignores an independent ground for coverage, and there is little evidence to refute the claimant's theory, the decision fails arbitrary-and-capricious review. " [C. v. UnitedHealthcare Ins. Co., No. 22-4082 (10th Cir. Dec. 5, 2023)]  MORE >>

"The resolution agreement ... resolves the first HIPAA charges OCR has classified officially as arising from a phishing attack [and] warns health plans, health care providers, health care clearinghouses and their business associates to ensure the adequacy of their risk analysis, safeguards, training and other processes for guarding electronic protected health information against phishing or other impermissible access."  MORE >>

"Areas of focus will be increased transparency (particularly at the federal level) and restrictions on several standard PBM practices like spread pricing, rebate allocation, preferred networks, mail-order steerage and copay accumulator programs. On the federal front, the continuing resolution stopping a November government shutdown pushes any reforms to the first quarter of next year at the earliest. The upcoming election year may provide limited opportunities to pass meaningful legislation."  MORE >>

"This report provides information related to several topics of recent congressional interest with respect to the implementation of the IRA, including litigation surrounding the Program; concerns about its impact on future drug innovation, research, and development; and questions about its interaction with patents and other federal marketing protections for pharmaceuticals." [R47872 Dec. 8, 2023]  MORE >>

"The Cigna Group appears to have given up on a big acquisition like the health insurance giant Humana ... [T]he company will now 'consider bolt-on acquisitions.' This could mean Cigna will look into purchases of smaller health insurers where the company isn't a dominant player ... or look to add health plans where the company is strong such as commercial health insurance like individual plans sold under the [ACA] as well as employer coverage."  MORE >>

"The Lower Costs, More Transparency Act (HR 5378) includes provisions that would require 'site-neutral' payments for drug administration in off-campus hospital outpatient departments.... Although the measure only applies to Medicare, employers say site-neutral payments could spill over to reduce costs for commercial plans."  MORE >>

"The IRS, [PBGC], Social Security Administration, and [CMS] have issued 2024 cost-of-living adjustments for retirement, health and fringe benefit plans; Medicare; and Social Security and Supplemental Security income. Puerto Rico's Treasury Department has not yet announced 2024 limits for retirement plans qualified in Puerto Rico, but those figures are tied to US limits."  MORE >>