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Reporting and Disclosure Under ERISA: Management Tools for Administrators of Employee Benefit Plans
August 14, 2018 WEBCAST
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Text of CMS Memo: Implications of the Decision by U.S. District Court for the District of New Mexico on the Risk Adjustment and Related Programs (PDF)

"CMS will not collect or pay the specified amounts [for the 2017 benefit year] at this time. CMS will inform stakeholders of any update to the status of collections or payments at an appropriate future date.... CMS will not collect or pay any specified amounts remaining for the 2014-2016 benefit years at this time.... CMS will collect 2017 benefit year risk adjustment user fees in the August 2018 payment cycle ... Issuers must continue archiving and maintaining 2014, 2015, 2016, and 2017 EDGE data consistent with normal operations.... CMS will cease issuing any further discrepancy resolution decisions at this time." [Unnumbered document, July 12, 2018] Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

Recent New Jersey Legislation Affects Out-of-Network Health Services

"If a [self-insured plan subject to ERISA] opts in, its members would not be balance billed for out-of-network charges for emergency care in excess of the deductible, copayment, or coinsurance amount applicable to in-network services, and the plan can take advantage of the act's binding arbitration provisions. The opt-in plan must provide each primary insured with a health insurance identification card indicating that the plan has elected to be subject to the act." Morgan Lewis

New York Legislature Approves Paid Family Leave Expansion for Bereavement and Organ Tissue Donation

"If the Governor signs the bill, employees may start utilizing the program for bereavement starting January 1, 2020. The legislature also passed 'The Living Donor Protection Act', which would grant Paid Family Leave Benefits to employees for transplant preparation and recovery from surgery related to organ or tissue donation. If signed into law by the Governor, employees may utilize the paid family leave program for such serious health conditions immediately." Jackson Lewis P.C.

IRS Releases Draft Forms 1094-C and 1095-C for 2018 But Not Much Has Changed

"The only thing that appears to have changed on the Form 1094-C is the year switched from 2017 to 2018.... After reviewing the draft Form 1094-C there are no other obvious differences compared to prior years. However, this could change upon the release of the draft instructions." Accord

Ways and Means Reports Out Eleven Health Care Bills After a Two-Day Markup

"The bills reported out of the Ways and Means Committee ... deal with the following topics. [1] Delay of the implementation of the Cadillac Tax.... [2] Broadening of Qualified Medical Expense definition.... [3] Increase HSA contribution limits.... [4] Expand eligibility for HSAs ... [5] HSA 'housekeeping' issues.... [6] Modification of the ACA premium tax credit." Employers Council on Flexible Compensation [ECFC]

Ninth Circuit: Health Plan Must Cover Room and Board During Residential Treatment for Mental Illness

"The court ruled that if a plan provides benefits for MH/SUD but excludes some types of coverage that it provides for medical and surgical benefits, the exclusion is an impermissible treatment limitation under the MHPAEA." [ Danny P. v. Catholic Health Initiatives , No. 16-35609 (9th Cir. June 6, 2018)]
The Wagner Law Group

Life Insurance Denial Overturned Due to 'Procedural Unreasonableness'

"The appellate court reversed the trial court's decision and overturned the benefit denial, citing the insurer's failure to mention its toxicologist's report in its denials or provide the report to the wife in response to her attorney's written request for documents that the insurer 'may rely on' in making its decision. The court concluded that the failure to acknowledge the toxicology report indicated that the insurer did not consider all relevant evidence, amounting to procedural unreasonableness." [ White v. Life Ins. Co. of North America (LINA) , No. 17-30356 (5th Cir. June 13, 2018)]
Thomson Reuters / EBIA

Court Rules on Coverage of Lactation Services

"Plans and insurers should keep in mind that coverage of comprehensive lactation support and equipment rentals extends for the duration of breastfeeding. In addition, coverage for lactation-counseling services is required to be covered (without cost-sharing) from providers acting within the scope of their state licenses or certifications (e.g., registered nurses)." [ Condry v. UnitedHealth Group, Inc. , No. 17-183 (N.D. Cal. June 27, 2018)]
Thomson Reuters / EBIA

Health Care Cost Control: Where Do We Go From Here?

"Markets could be improved with stronger financial incentives for individuals to select higher-value providers and services and by making more information available to patients about the value of alternative treatments and sites of care.... Options for limited price regulation could take the form of price ceilings on commercial plan services based on a percentage of Medicare rates -- say 175 percent.... [E]mployers must take a far more aggressive role. This could include increasing the use of benefit design that rewards consumers for selecting cost-effective providers and therapies." Health Affairs

Medicare Billing Overhaul to Transform Documentation, Expand Telehealth

"Rather than continuing to comply with documentation guidelines from the 1990s, practitioners would be able to choose to document [Evaluation and Management ('E&M')] visits based on time spent with the patient or on their own medical decision-making.... Rather than having to re-document information from past visits, practitioners would have more options to simply review and update existing documentation. Physicians would further be allowed to simply review and verify certain medical records that staff members or the patient entered." HealthLeaders Media

Telemedicine: Does It Measure Up to the Hype?

"Along comes the idea of a face-to-face online appointment with a real doctor who can diagnose and prescribe medications or refer to an appropriate care level.... [At] around $49 per visit I thought uptake would be rapid. I was wrong again as I look at 1-5% employee utilization rates. So what happened?" Frenkel Benefits

Freezing Risk-Adjustment Payments Will Cause More Instability in the Individual and Small-Group Insurance Markets

"The court ruled in February that the formula is arbitrary and capricious because CMS did not adequately justify key assumptions. The court left open that the formula may be allowed, if justified through notice and comment rulemaking.... CMS could have waited for the court to issue an opinion on a motion to reconsider the decision ... then appeal and request a stay to keep the formula in place through the appeals process. Reversal on appeal may not be a long shot given that a court in Massachusetts upheld the formula in a similar case." The Commonwealth Fund

Bullet Proofing Your Claims Procedures

"When there is a request for documents related to a claim or appeal pay close attention to what is requested ... and carefully assess what is relevant in light of the applicable court decisions. Given the change in the disability claim and appeal procedure requirements that became effective ... on April 1, 2018, and the regular litigation over disability claims, it may be prudent to carefully review the forms being used, the process being followed, how document requests are addressed, and how those match with the current requirements." Winstead PC

Fight the ACA ESRP '(b)' Penalty?

Even when the ALE offered affordable coverage, some full-time employees were able to get PTC/CSR subsidies and it's causing the IRS to propose the 4980H(b) ESRP against the ALE. If we "prove" to IRS that our employee was not entitled to any subsidy because we offered affordable coverage, will the IRS go back against the employee to recoup the subsidies? If so, the employer may decide to not fight the "(b)" penalty in order to avoid antagonizing the employee. BenefitsLink Message Boards

Intranet Posting of 5500 Information

To satisfy the requirement to post 5500 information to the plan sponsor's intranet, must the Form 5500 AND SAR be posted, or just the 5500, or just the SAR? BenefitsLink Message Boards

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