"[T]he DOL issued an FAQ stating that it intends to propose rulemaking that would require large group market and self-funded group health plans to treat prescription drugs covered by the plan, including those in excess of the state benchmark plan, as EHB and, therefore, subject to the annual out-of-pocket limit."  MORE >>

"The final rule revises the consumer notice that is currently required for fixed indemnity excepted benefits coverage in the individual market and establishes a new requirement to provide a consumer notice in the group market. The notice is designed to highlight the differences between fixed indemnity excepted benefits coverage and comprehensive health insurance coverage."  MORE >>

"[In] 2019, the federal government required first hospitals and then insurers to publish their negotiated prices.... [F]ederal price transparency rules specifically make state departments of insurance responsible for enforcing these rules against the insurers they regulate.... In this article, we examine state efforts to promote price transparency both before the enactment of federal price transparency rules as well as after it."  MORE >>

"The participant in this case alleged that the insurer applied a more rigorous review process (involving a system of algorithms) to benefits for outpatient, out-of-network (OON) mental health and substance use disorder (MH/SUD) treatments than to otherwise comparable medical/surgical (M/S) treatments. In reviewing the participant's claims at the motion to dismiss stage, the Ninth Circuit also addressed standards for MHPAEA plaintiffs in pleading claims involving a plan's internal claims administration processes." [Ryan S. v. UnitedHealth Group, Inc., No. 22-55761 (9th Cir. Apr. 11, 2024)]   MORE >>

"[T]he Court noted that while Unum's medical consultants did address and distinguish Plaintiff's award of SSDI, it found that Unum did not offer any explanation for the inconsistency of Unum's award of FMLA leave during the same time frame as the LTD decision, which suggested that Unum's decision was arbitrary. The Court denied the parties motions for summary judgment and directed Unum to produce an amended final determination letter[.]" [ Rogers v. Unum Life Ins. Co. of Am., No. 22-11399 (D. Mass. Mar. 31, 2024)]  MORE >>

"The growing tension between state law and federal preemption over regulating drug benefits will be high on lawmakers' agenda at an upcoming House hearing on strengthening [ERISA] as the law turns 50.... States see the new laws as an effort to help community pharmacists who may be harmed by PBM practices, but employer groups say the laws could block them from designing their health plan benefits in ways that reduce pharmacy costs."  MORE >>

"Prescription drug spending by private health plans climbed to nearly $152 billion in 2021, an 18 percent increase from 2016. Health plans generally rely on PBMs to process claims, develop pharmacy networks, and negotiate rebates from drug manufacturers.... GAO was asked to review states' regulation of PBMs serving private health plans. Among other things, this report describes actions selected states have taken to regulate PBMs, and lessons learned that state regulators identified for PBM regulation." [AO-24-106898 pub. Mar 18, 2024, rel. Apr 15, 2024]  MORE >>

"The strategies available to employers who want to help employees with IVF treatment are similar to those that many considered after the Dobbs decision, including: [1] Travel benefits  ... [2] Leave of absence  ... [3] Embryo transport, storage, or destruction[.]"  MORE >>

"Plan sponsors who maintain only fully insured welfare benefit plans may think that they don't have to focus on fiduciary compliance, as the insurance carrier handles the payment of claims and the plan sponsor's only financial obligation is to timely remit premium payments. However, even a fully insured plan has multiple obligations that cannot be fully outsourced to the insurer ... An employer with a self-funded plan must comply with all of [these] obligations and has additional challenges, including monitoring claims and placing stop-loss insurance."  MORE >>

"The use of AI-assisted chat engagement allows participants to receive support for new hire onboarding, open enrollment, and life event inquiries when they are ready, 365/24/7.... AI analyzes participant responses to utilization and risk tolerance questions alongside key underwriting demographics like age, location, and gender. This personalized approach 'right-sizes' benefits coverage and tailors recommendations to each participant's unique needs and preferences ... AI unlocks radical data transparency. HR professionals can gain insights into data status across the population by benefit, carrier, and other vital filters, such as division, location, and plan."  MORE >>

"A marked feature of health insurance plan choice is inconsistent choices through the overweighting of premiums relative to out-of-pocket spending. We show that this source of inconsistency disappears when both types of spending come from the same source of designated funds."  MORE >>

"The Fourth Circuit's decision in Rose is significant. The opinion contains one of the most detailed analyses of the types of relief that were typically available in equity courts of any circuit or district court decision since Mertens. It is certainly the most detailed analysis since Montanile.... Ultimately, Rose provides a strong basis for pushing back on claims for monetary relief that do not include situations where there is an identifiable fund." [Rose v. PSA Airlines, Inc., No. 21-2207 (4th Cir. Sep. 11, 2023; cert. pet. denied Apr. 15, 2024)]  MORE >>