"Employers with fully insured plans should ensure that they have their carrier's NQTL analysis, that they review it, and that they acknowledge, agree, and sign-off on their carrier's work. Employers with self-funded plans will need to engage further on this topic.... The MHPAEA requirements are inherently complex and could potentially cause much consternation for employers so beginning the process as early as possible is recommended."  MORE >>

"[T]hree aspects of the Final Rule are noteworthy for employers: [1] Elimination of quantitative testing for Non-Quantitative Treatment Limits ... [2] Application of MHPAEA to intellectual and developmental disabilities, including autism spectrum disorder ... [3] Fiduciary liability."  MORE >>

"[HHS] published a proposed rule containing the 2026 HHS Notice of Benefit Payment Parameters and certain proposals related to the Basic Health Program. This article summarizes the proposed rule's provisions related to the individual and small group market risk adjustment programs ... In brief, HHS largely proposes to continue its existing risk adjustment policies. However, it does break some notable new ground[.]"  MORE >>

"The Third Circuit found that the plaintiffs, who were former MetLife employees, had failed to allege the necessary financial harm to establish standing ... The plan document terms expressly stated that the rebates would be applied to plan expenses ... The plaintiffs alleged that MetLife's misappropriation of plan funds caused participants to pay higher out-of-pocket (OOP) costs, primarily in the form of premiums[.]" [Knudsen v. MetLife Grp., Inc., No. 23-2420 (3d Cir. Sep. 25, 2024)]  MORE >>

"[T]he court emphasized that ERISA requires a full and fair review of benefit denials, including a 'meaningful dialogue' between the administrator and the beneficiary. Here, the court found that UHC's denial letters fell short of these requirements by failing to explain how ED's medical condition was evaluated under the plan's provisions.... [G]iven that UHC was provided with extensive information, its conclusory responses without citing the medical record did not afford a full and fair review." [Dwyer v. United Healthcare Ins. Co., No. 23-50439 (5th Cir. Sept. 19, 2024)]  MORE >>

"Another year of health and welfare litigation, another year of mixed results for both plaintiffs and defendants, but lessons for all. This column summarizes case law developments in 2023 and early 2024 involving health and welfare plans, including fee disclosure issues, use of artificial intelligence in claim denials, privacy issues, pleading standards and court deference in mental health parity cases."  MORE >>

"The traditional [prior authorization (PA)] process is plagued by delays, manual errors, and inefficiencies, which negatively impact patient engagement and create administrative challenges for Healthcare Providers.... [T]he industry is embracing innovative solutions to overcome these challenges."  MORE >>

"The infographic includes actual cost trend data from 2019 to 2023 for: [1] Medical plans; [2] Prescription drug trend; [3] Trends for generic, brand and specialty drugs; [4] How trend differs for plans that cover anti-obesity medications (AOMs) compared to those that do not cover AOMs; [5] Cancer-related medical and prescription drug trends; [6] How the cost trend for mental health compares to overall medical cost trend."  MORE >>

"Certain pre-tax wellness arrangements that promise large tax savings for employers and employees with little employer investment ... frequently lack a legitimate basis in tax law ... [M]arketing and other promotional materials regarding these cafeteria plan wellness arrangements can be vague and misleading ... The IRC rules on permissible employee benefit tax exclusions are well-established. Programs promoting innovative designs with substantial tax savings may instead set up improper withholdings and underpayment of employment taxes."  MORE >>

"Highlight the importance of preventive care ... Teach employees how using in-network providers can save them money ... Highlight the cost differences between pharmacies, even within the same network, and how to perform price checks.... Compare the various care options available ... [R]emove the benefits jargon and use clear, concise, simple language that employees will understand"  MORE >>

"[The IRS] approved an employee benefits program design (outside of a cafeteria plan) that would offer employees flexibility in allocating an employer contribution among certain employer-sponsored benefit plans.... Employer Considerations: [1] When to implement.... [2] Educational assistance program limit.... [3] Administrative complexity.... [4] Nondiscrimination testing.... [5] Program costs."  MORE >>

"In the October 7, 2024 memo, the [NLRB] general counsel ... [stated] her intent to prosecute employers who require their employees to sign non-compete and 'stay-or-pay' provisions, including those that take the form of training repayment agreement provisions, educational repayment contracts, quit fees, damages clauses, sign-on bonuses or other types of cash payments tied to mandatory stay periods and other contracts under which employees must pay their employer in the event that they separate from employment."  MORE >>

"The memorandum is not the official legal position of the NLRB; however, if it is adopted and broadly applied by the NLRB, it could have significant impacts on the business operations of many employers -- with one important limitation. The NLRA does not apply to managerial or supervisory employees. Given that noncompetes and stay-or-pay provisions tend to be directed at these higher-level employees, the memorandum could be of limited application."  MORE >>