28 pages; Sep. 6, 2024. "(CMS) has created two versions of software and software instructions for issuers to use with their enrollment data to simulate their enrollee populations' 2024 benefit year risk scores within the HHS-HCC risk adjustment models. This software is being issued only as a supplemental tool for issuers of risk adjustment covered plans to better understand and simulate the calculation of plan liability risk scores for their enrollees." [Also available: Technical Details (XLSX) and 2024 Benefit Year Risk Adjustment SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP)]  MORE >>

13 pages. "[A] final rule from the departments of Labor, Treasury, and [HHS] ... requires fixed-indemnity plans to supply a new consumer notice beginning in 2025 but omits more sweeping proposals that would have required many employers to redesign their fixed-indemnity coverage.... [This article] provides background information about group fixed-indemnity plans, details about the new consumer notice, an overview of proposals left out of the final rule, and a summary of IRS guidance identifying a variety of fixed-indemnity designs (often paired with a wellness program) as improper 'double dipping' schemes. This article also summarizes provisions in the rule addressing individual fixed-indemnity plans and short-term limited duration insurance (STLDI)."  MORE >>

"Despite the acceptance and prevalence of domestic partner benefits, they pose complex legal, tax, administration and other compliance issues. Employers need to understand and effectively communicate these issues to employees with domestic partners. This GRIST summarizes the major issues, provides a tax-dependent flowchart and a domestic partner checklist for employers, and includes two charts summarizing applicable state laws."  MORE >>

"[Prescription drug affordability boards (PDABs)] are independent, state-level boards that review prescription drug costs, and some states have authorized their PDABs to take additional actions to lower the prices of certain drugs. As of April 2024, at least eleven states have enacted some form of a PDAB, and several others are considering such legislation.... This Sidebar analyzes some of the legal arguments in [a recent case challenging Colorado's PDAB law], and offers several considerations for Congress in light of the new state PDAB law trend." [LSB11221 Sep. 4, 2024]  MORE >>

"A California federal court 'lost the letter' in remanded proceedings over allegations that United Behavioral Health improperly denied nearly 70,000 claims for mental health coverage, the Ninth Circuit has said ... According to the seven-page order issued on [September 4]  ...  the district court wrongly allowed for relitigation of a claim under [ERISA] addressed by a ruling from the appellate court last year." [United Behavioral Health v. U.S. District Court, N.D. Calif., No. 24-0242 (9th Cir. Sep. 4, 2024; unpub.)]  MORE >>

"The district court held that OCR exceeded its authority in certain respects in a bulletin concerning HIPAA's application to cookies and other online tracking technologies on HIPAA-regulated entities' unauthenticated webpages (i.e., webpages that are publicly available and do not require users to log in before they are able to access the webpage)." [Am. Hosp. Assoc. v. Becerra, No. 23-1110 (N.D. Tex. June 20, 2024; appeal dismissed Sep. 4, 2024)]  MORE >>

"Acknowledging that the evidence suggested that Ray's initial request for vacation indicated that his wife's condition was not the true motivation for his leave request [ya think?], the court concluded that the evidence also showed his employer may have interfered with Ray's FMLA entitlement by refusing to treat his absences as covered by the FMLA." [Black v. Swift Pork Co., No. 23-1502 (8th Cir. Aug. 28, 2024)]  MORE >>

"[This update] discusses cases addressing the effect of continuing to receive benefits during the period of alleged disability, reliance on an employer’s records in making a disability determination, the admissibility of expert and lay testimony from a physician in a trial over LTD benefits, the effect of failing to comply with governing claims regulations and whether the risk of COVID-19 can qualify a claimant as disabled."  MORE >>

"Among non-elderly adults with ESI (estimated to be 116.8 million from NHIS), 42%, or 49.3 million people, are clinically eligible for GLP-1 drugs; 36.2 million people with ESI are potentially eligible for GLP-1 drugs based on an obesity diagnosis alone."  MORE >>

"[W]hile employers may want to support their workforces by providing access to GLP-1 medications to treat obesity and weight loss, the high cost of coverage can certainly impact the overall sustainability of their plans.... Potential actions for employers to consider [include]: [1] Restricting coverage to a subset of plan members.... [2] Implementing prior authorization ... [2] Restricting providers ... [3] Implementing lifetime maximums ... [4] Implementing a separate copay/cost share structure for specific drugs."  MORE >>

"This paper delves into contracting strategies to eliminate ambiguity, methods to accelerate the assessment timeline, and techniques to better understand the risks facing all parties involved in value-based care management programs. Through detailed examples and practical solutions, [the authors] aim to provide a roadmap for more effective and efficient contract negotiations and value demonstration exercises."  MORE >>

"The IRS has previously issued two similar PLRs that permitted the choice between a defined contribution plan contribution and a retiree health reimbursement arrangement (HRA) contribution. [PLR 202434006] expands on that approach and permits a choice [among] a DC plan contribution, a retiree HRA contribution, a health savings account (HSA) contribution, and a student loan payment under a qualified educational assistance program."  MORE >>

"[PLR 202434006] may be helpful to employers that have or are considering benefit arrangements that allow employees to choose among benefits they want funded. One key requirement seems to be that employees cannot choose to receive amounts in cash or taxable benefits."  MORE >>