The federal government recently delivered back-to-back measures forcing pharmacy benefit managers (PBMs) to be more transparent about their business models. However, with this heightened transparency comes a host of new fiduciary obligations for sponsors of health and welfare benefit plans. New Requirements Reforming the PBM industry has been a frequent talking point for the past [&hellip… Continue Reading »
The Health Insurance Portability and Accountability Act (HIPAA) regulations require updates to the Notice of Privacy Practices that health plan sponsors furnish to plan participants and health care providers furnish to patients. The updates must be made by February 16, 2026. The Upshot The regulations require changes to the Notice of Privacy Practices for information [&hellip… Continue Reading »
The Internal Revenue Service (IRS) has provided guidance on the changes made to the rules governing health savings accounts (HSAs) in the One Big Beautiful Bill, which was enacted this summer. The Upshot The guidance addresses: The Bottom Line The guidance generally addresses narrow points affecting the HSA changes in the legislation. Comments to the [&hellip… Continue Reading »
Employers now may have an opportunity to save money and time by posting a Notice of Availability with respect to the reporting required by the Affordable Care Act (ACA) and Forms 1095-B and 1095-C. The Upshot The Bottom Line Health plan sponsors can save time and money by posting a Notice of Availability with respect [&hellip… Continue Reading »
Although much of our attention this fall was focused on the government shutdown, health plan sponsors may be interested in several less-publicized developments affecting group health plans. The Upshot The Bottom Line The two lawsuits and the administrative guidance, along with factors affecting the cost of health coverage, bear watching as each of these matters [&hellip… Continue Reading »
A recent federal district court decision has upheld an Arkansas Insurance Department rule that requires health benefit plans to submit certain pharmacy compensation information to the Department. The court ruled that this reporting requirement is not preempted by ERISA, finding that the rule does not apply exclusively to ERISA plans and that the reporting required by the rule [&hellip… Continue Reading »
The Fifth Circuit and the Federal District Court of Connecticut have issued conflicting decisions on whether service providers may sue to enforce arbitration awards under the No Surprises Rules in the Consolidated Appropriations Act, 2021. While the Connecticut court found that a service provider may request a court to order an insurance company to pay [&hellip… Continue Reading »
H.R.1—the One Big Beautiful Bill Act (OBBBA)—contains several provisions that directly affect employer-provided benefit programs, primarily health and welfare programs. The Upshot The new budget law’s changes to health and welfare benefits include: Beginning with tax years starting after 2026, the OBBBA also changed the method used to determine the amount of compensation paid to [&hellip… Continue Reading »
Two recent U.S. Supreme Court rulings support provisions of the Affordable Care Act, one directly and one indirectly. The Upshot The Bottom Line Plans will need to continue to provide 100 percent coverage for preventive health services with an A or B recommendation from the USPSTF. Based on the Court’s ruling, federal district courts will [&hellip… Continue Reading »
A federal district court has vacated a federal regulation under HIPAA that provided special restrictions on the disclosure of reproductive health information. The Upshot The Bottom Line Employers will need to watch for relevant developments and consider how they affect their HIPAA compliance measures. They will, in any event, need to consider certain amendments to [&hellip… Continue Reading »
A recent court filing offers a reprieve to health plan sponsors in their efforts to comply with final regulations issued last year under the Mental Health Parity and Addiction Equity Act (MHPAEA). In a motion to stay proceedings in a lawsuit challenging those regulations, the U.S. Departments of the Treasury, Labor, and Health and Human Services notified the court [&hellip… Continue Reading »
Section 1557 of the Affordable Care Act mandates nondiscrimination in health care programs managed or funded by the Department of Health and Human Services (HHS), with upcoming deadlines for compliance set for May and July 2025. However, uncertainties remain regarding enforcement and future regulatory guidance, especially concerning provisions related to transgender discrimination and foreign language [&hellip… Continue Reading »
Summary The Fifth Circuit Court of Appeals recently upheld regulations defining the qualifying payment amount (QPA). The QPA is a key factor in determining how much individuals and health plans must pay out-of-network providers in certain situations, where the individual does not have a choice to receive services in-network. The Upshot The Bottom Line The [&hellip… Continue Reading »
Summary The IRS recently issued Notices 2024-71 and 2024-75, which expand the list of “preventive care” benefits permitted to be provided by a high deductible health plan (HDHP) without a deductible and the list of benefits considered “medical care expenses” under group health plans. The Upshot The Bottom Line Employers that offer health benefits, and particularly those that [&hellip… Continue Reading »
Summary The Departments of the Treasury, Labor, and Health and Human Services have published final regulations under the Mental Health Parity and Addiction Equity Act that prohibit group health plans and health insurers from imposing nonquantitative treatment limitations that place greater restrictions on benefits for mental health and substance use disorders than for medical and [&hellip… Continue Reading »
Summary The U.S. Department of Labor (DOL) updated its 2021 cybersecurity guidance to clarify that it applies to all employee benefit plans. The DOL guidance confirms that plan fiduciaries, including health and welfare plan fiduciaries, have an obligation to evaluate the cybersecurity procedures of plan record-keepers and other service providers. The Bottom Line While the updates to [&hellip… Continue Reading »
Summary Following the U.S. Supreme Court’s decision to overturn its Chevron decision three district courts have struck down provisions in nondiscrimination regulations under the Affordable Care Act that prohibit discrimination based on gender identity. in what constitutes unlawful discrimination. The Upshot The Bottom Line The full impact of the Loper Bright and Corner Post decisions [&hellip… Continue Reading »
Over the course of the past few months, the Office of Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC), both of which are divisions of the U.S. Department of Health and Human Services (HHS), have issued a series of new regulations and guidance related to the Health Insurance [&hellip… Continue Reading »
Summary The U.S. Department of Health and Human Services (HHS) has issued final regulations on the nondiscrimination rules set forth in Section 1557 of the Affordable Care Act. The new rules apply to certain group health plans, as well as many health care providers. The Upshot The Bottom Line Plan sponsors need to evaluate whether the new [&hellip… Continue Reading »
Summary The Biden administration has issued two sets of final regulations that overturn rules adopted during the Trump administration pertaining to association health plans and short-term, limited-duration insurance (STLDI). The regulations go into effect June 17, 2024. The Upshot The Bottom Line The new rules come as no surprise, but employers considering entering into an association health [&hellip… Continue Reading »
Summary Providing notice of a vendor’s HIPAA breach is often difficult, but it can be particularly hard when information is delayed. Sometimes an investigation takes months to complete, and the HIPAA deadline for providing notice may have passed before a health plan or health care provider even knows who was affected by the breach and [&hellip… Continue Reading »
Summary The United States Department of Health and Human Services (HHS) has filed court pleadings stating that it does not intend to initiate enforcement actions against plans that maintain copay accumulator programs. The Upshot The Bottom Line The non-enforcement policy provides welcome—albeit temporary—relief for employers weighing their options following the court’s decision. In court papers [&hellip… Continue Reading »
Summary The rules in the Consolidated Appropriations Act that aim to eliminate much of the surprise from billings by out-of-network providers in particular situations are the subject of continued controversy. The Upshot The Bottom Line If upheld, the district court’s decisions will likely result in higher costs for plans and patients, but there remains much [&hellip… Continue Reading »
Summary Employers taking advantage of copay accumulator programs now face unexpected administrative complications following a recent federal court decision. The Upshot The Bottom Line Plan sponsors should consult with their advisers to determine how this recent federal court decision affects their employee prescription drug benefit design. Some employers may not even know that their benefit [&hellip… Continue Reading »
