"The Final Rule helpfully clarified that plans and issuers are not prohibited from performing and documenting a comparative analysis at the issuer or TPA level. However, to the extent that relevant data exists at the plan level and measures access to MH/SUD benefits in a different manner from data at the issuer or TPA level, the comparative analysis must account for that data."  MORE >>

"[T]he final rules detail the required content of the documented comparative analysis, including a fiduciary certification requirement. In a departure from the proposed regulation, under the final rules the fiduciary certification focuses on the prudent selection and monitoring of service providers involved in the development of documented comparative analysis."  MORE >>

"[U]nder the MSP reporting requirements, only a [responsible reporting entity (RRE)] is obligated to make the MSP reports to CMS on behalf of the plan. For group health plans, an RRE is: the insurer; a plan's third party administrator if it pays or adjudicates claims for the plan; or, the plan administrator in the case of a plan that is self-insured and self-administered."  MORE >>

"SB 188 applies to nearly all insurance carriers, HMOs, and plan sponsors of self-insured plans ... who offer prescription drug coverage in Kentucky.... The Kentucky law ... states it will apply to the extent of applicable law. This protects the entire law from being upended, but does not expressly include or exclude a preemption challenge. Self-insured employers will want to work with their PBM vendors and legal counsel to determine what, if any, impact this may have on their adherence to this new regulation."  MORE >>

"The Third Circuit found that the plaintiffs’ allegations that their purported financial injury—higher out-of-pocket costs for prescription drug coverage—was caused by the employer’s retention of rebates was speculative and, as a result, the plaintiffs failed to adequately allege Article III standing. The decision ... is a major victory for employers and is a significant roadblock for plaintiffs attempting to plead ERISA claims predicated on allegedly excessive health plan fees." [Knudsen v. MetLife Grp., Inc., No. 23-2420 (3d Cir. Sep. 25, 2024)]  MORE >>

"According to the complaint, the named plaintiff and other similarly situated enrollees, all diagnosed by their treating physicians with obesity and prescribed medically necessary prescription drugs to treat their obesity, are 'qualified individuals with disabilities' under First Circuit precedent.... The plaintiff contends that Anthem excludes all coverage of prescription medication for the treatment of obesity, even though it covers similar prescriptions for other medical conditions, such as diabetes." [Holland v. Elevance Health, Inc., No. 24-0332 (D. Me. complaint filed Sep. 20, 2024)]  MORE >>

"A federal judge has ruled that two former associates at Jones Day can go to trial on seven claims against the law firm, including allegations that its family-leave policy discriminates against male attorneys.... [The judge] temporarily sealed a decision with his reasoning to allow for proposed redactions to protect confidential business information and privacy interests of third parties." [Savignac v. Jones Day, No. 19-2443 (D.D.C. Sep. 25, 2024)]  MORE >>

"[D]espite the continued consolidation and vertical integration of PBMs, health plans may minimize any adverse impact by contractually limiting the rights and responsibilities of PBM-affiliated organizations.... To protect against PBMs steering prescription drugs toward their affiliated pharmacies via formulary changes, health plans may maintain leverage over their formularies by exercising final approval rights over the content, form, format, and/or frequency of their formularies and formulary changes under their PBM contracts."  MORE >>

"The employer should select a potential TPA well before the implementation date so that there is time for legal counsel and the broker/consultant to negotiate the services agreement and fees and, if necessary, select an alternate TPA if the negotiations fall apart. Key contractual provisions include: [1] Indemnification provisions.... [2] Accepting fiduciary responsibility.... [3] Audit rights.... [4] Termination provisions.... [5] Claims litigation."  MORE >>

"Long-run medical cost increases are estimated at 5.0% per year eventually declining to match the rate of increases in per capita incomes. The component assumptions of long-run medical cost increases are unchanged from last year. The Society of Actuaries Research Institute's Getzen Model Project Oversight Group (POG) expects that there will be greater budgetary resistance and more regulation in the future which will limit the share of total incomes/GDP devoted to medical care."  MORE >>

"While the Inflation Reduction Act of 2022 included policies designed to reduce specialty drug costs, relatively few policies have been enacted during the past decade. In 2022-2023, [the authors] conducted a scoping literature review to identify a range of policy options ... Based on these results [they] offer four recommendations to policymakers considering ways to reduce specialty drug costs."  MORE >>

"Missouri voters will vote this year on whether employers will be required to provide earned paid sick time (PST) to eligible employees. PST would accrue at a rate of one hour for every thirty hours worked; it would begin accruing for existing employees on May 1, 2025, or the first day of employment for employees hired after that date. Employers with fifteen or more employees may limit an employee's use of PST to fifty-six hours per year; employers with fewer than fifteen employees may limit an employee's use of PST to forty hours per year."  MORE >>

"In a year where insurers have expanded coverage for multiple medical treatments, federal employees will see their Federal Employees Health Benefits Program premiums increase by an average of 13.5% in 2025."  MORE >>