"As is common in any transition, the new administration issued a regulatory freeze memo ... The two most immediate effects are on the proposed HIPAA Security Rule revisions and the proposed Medicare Part D updated simplified creditable coverage determination for 2026.... [T]reatment to facilitate gender transitions, at least for minors, will likely not be a focus under Section 1557 of the [ACA] during this Administration.... EO 14192 [directs] agencies to eliminate 10 pieces of guidance for every regulation that is issued.... [W]hile some regulations may get repealed, an effort to get to 10 will likely require the elimination of additional subregulatory documents (like notices, memos, guidance documents, etc.)."  MORE >>

"The court found equitable estoppel does not apply since Lubin's claims sought to enforce his own statutory rights to adequate COBRA notice and were not brought under his wife's employment agreement. The court also rejected Starbucks' argument that the third-party beneficiary doctrine compels Lubin to arbitrate his claims ... Finally, the court rejected the argument that Lubin's claim is derivative of his wife's claim[.]" [Lubin v. Starbucks Corp., No. 21-11215 (11th Cir. Dec. 16, 2024)]  MORE >>

"[The Seventh Circuit] made clear that disability insurers and district courts within the Seventh Circuit must adequately consider [functional capacity evaluations (FCEs)] within the context of contemporaneous medical evidence ... [D]istrict courts within the Seventh Circuit will need to thoroughly address loss of earnings provisions within the definition of disability.... District courts must also meaningfully consider an occupation's cognitive demands when weighing a claimant's inability to perform their occupation as it is normally performed, not just the physical demands." [Scanlon v. Life Ins. Co. of N. Am., No. 22-1121 (7th Cir. Aug. 31, 2023)]  MORE >>

"[T]he District Court examined whether the DOL's exemption of certain payroll practices from coverage under ERISA exceeded its rulemaking authority. The argument arose in the context of a lawsuit filed by Plaintiff alleging that Defendant, her employer, violated state law when it denied her claim for benefits under its short-term disability (STD) policy.... The District Court rejected Labcorp's broad reading of Loper noting that the holding in Loper set aside Chevron deference previously accorded to federal agencies but did not stand for the proposition that all federal regulations must be disregarded." [Hansen v. Laboratory Corp. of Am., No. 24-0807 (E.D. Wis. Oct. 24, 2024)]  MORE >>

"The medication had been covered by Cole’s employer-provided health insurance under a United Health-OptumRx Plan, at an out-of-pocket cost ranging from $35 to $66.86. However, plaintiffs said, Cole was abruptly informed by a Walgreens pharmacist in January 2024, when he attempted to refill his prescription, that the medication’s cost rose to $539.19." [Schmidtknecht v. OptumRx, Inc., No. 25-0093 (E.D. Wis. complaint filed Jan. 21, 2025)]  MORE >>

"While this outcome is certainly positive for J&J, it is likely not the end of similar potential lawsuits. Attorneys who represent plaintiffs in such cases will likely continue to pursue these claims in hopes of overcoming the standing issue Lewandowski faced. As a result, plan fiduciaries should use this as an opportunity to review their applicable fiduciary duties."  MORE >>

"According to Medicare data filed in federal court, Pain MD and Mid-South Pain Management billed Medicare for more than 290,000 'tendon origin injections' from January 2010 to May 2018, which is about seven times that of any other Medicare biller in the U.S. over the same period.... These kinds of enormous billing allegations are not uncommon in health care fraud cases, in which fraudsters sometimes find a legitimate treatment that insurance will pay for and then overuse it to the point of absurdity[.]"  MORE >>

"On Feb. 14, the administration announced that funding for the ACA Navigator program was dropping from $97.7 million for plan year 2024 to $10 million annually going forward.... CMS also has drafted a proposed rule, which has yet to be published, implementing new program-integrity standards for the marketplaces."  MORE >>

"There appears to be a widespread perception that the delay and denial of necessary care is a basic business strategy of the commercial insurance industry. Despite being forced to accept all kinds of compromises, from larger deductibles and coinsurance to limitations on provider choice, consumers continue to face spiraling premium cost increases that far outpace inflation.... [The authors describe a] proposed 'Sustainable Pricing Framework' policy and explain how it can address consumers' growing resentment and frustration with commercial health insurance."  MORE >>