"This Carrier Letter clarifies Pharmacy Benefit Manager (PBM) Transparency Standards for fee-for-service (FFS) and experience-rated (ER) HMO Carriers.... OPM will decline any arrangements which may manipulate the prescription drug benefit design or incorporate any programs such as copay maximizers, copay optimizers, or other similar programs ... Carriers must exercise due diligence, implement these standards, and use transparent pass-through pricing and manufacturer payments when contracting with PBMs. Carriers are required to apply [these] transparency standards ... with current PBM contractors and subcontractors."  MORE >>

"A common fact pattern that frequently results in ACA reporting errors is the employee who moves from a full-time position to a part-time position mid-year. Must plan sponsors continue to offer this part-time employee health coverage? Doesn't the ACA only require employers to offer health coverage to their full-time employees? The answers to these questions depend on which measurement methodology the employer uses to calculate full-time employee/full-time equivalent (FTE) status."  MORE >>

"In November 2023, the Massachusetts Department of Family and Medical Leave (DFML) announced changes to its Paid Family and Medical Leave (PFML) program. With these changes, Massachusetts employers may need to revise their policies and practices regarding supplementing or 'topping off' PFML benefits with employer-provided, accrued paid leave. Additionally, employers should expect their PFML contribution rates to increase in 2024."  MORE >>

"Among other things, plaintiff alleges that prudent fiduciaries ... [1] continually supervise their PBM's actions to ensure that the plan is minimizing costs and maximizing outcomes for beneficiaries; [2] retain sufficient control over their plans' formularies to prevent the PBM from making formulary decisions that serve the PBM's interests but not the plan's interests; ... [3] will replace brand name drugs on the formulary when lower-cost, FDA-approved generics become available; and [4] are aware of the conflicts of interest that PBMs have in making formulary decisions." [Lewandowski v. Johnson & Johnson, No. 23-0671 (D.N.J. complaint filed Feb. 5, 2024)]  MORE >>

"The J&J lawsuit highlights that plan participants (or more likely their lawyers) not only scrutinize the reasonability of their own out-of-pocket costs, but how much the plan is paying for a drug as compared to other plans or pharmacies in the market.... Even though the claims are paid by the plan sponsor, plaintiffs will allege that a participant's premiums, co pays, and deductible will all be higher if the fiduciary is not ensuring the lowest cost drugs possible. If the plaintiffs are successful, this will turn the health and welfare plan industry upside down." [Lewandowski v. Johnson & Johnson, No. 23-0671 (D.N.J. complaint filed Feb. 5, 2024)]  MORE >>

"Historically, less attention has been paid to the service providers that serve group health plans, but the new Transparency Rules and fee disclosure requirements necessitate a fresh review of group health plan fiduciary governance and administration.... In particular, plan sponsors should engage in [listed] action items."  MORE >>

"Health plan fiduciaries should ensure they have the proper processes in place to comply with ERISA's fiduciary duties, including monitoring fees and expenses. Because health plan structures and benefits change more frequently than on the retirement side, developing these proper processes may be more challenging and may involve stakeholders different than the usual retirement plan fiduciaries."  MORE >>

"While many self-insured groups do see savings, it is important to make sure you are seeing the full picture through a proper and thorough reserving process.... Typically, this process follows four steps: [1] Access your data ... [2] Add margin for claim volatility ... [3] Consider stop loss and other variables ... [4] Add in fixed fees."  MORE >>

"It is estimated that in 2022 about 41% of healthcare payments in the United States were based on some form of value-based contracting linked to the cost of care. This white paper looks at some of the key dynamics that are driving the shift to value-based care."  MORE >>

"The first step ... was getting rid of [the] overcharging health insurance carrier and pharmacy benefit manager. They were blocking access to billing claims data we needed to understand which providers were overbilling ... [The] health plan has made contracts with ambulatory surgical centers, centers of excellence and imaging centers at fractions of what big hospitals charged under the previous plan.... [E]mployees now enjoy primary and ancillary care for free and prescriptions for $1."  MORE >>

"$844.7 million recovered in investigations.... EBSA investigations led to the indictment of 60 people for crimes related to employee benefit plans.... Compliance assistance programs yielded tremendous results.... $444.1 million restored to workers through informal complaint resolution.... Over 2,150 education and outreach events held in FY 2023."  MORE >>