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2018 Employee Benefits Seminar
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Healthcare Consumerism
September 25, 2018 in TX
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Text of CMS Memo: Indication-Based Formulary Design Available to Medicare Plan D Sponsors for Contract Year 2020 (PDF)

Unnumbered document dated Aug. 29, 2018. "[This] guidance ... describes how Part D sponsors can ... include indication-based formulary design beginning in CY 2020.... [P]roviding Part D plans with the flexibility to employ the latest formulary tools would enable them to better negotiate for prescription drugs, especially high-cost drugs. The ability to exclude drugs from their formulary for specific indications will provide additional negotiating leverage with manufacturers, which can ultimately reduce beneficiary and program costs.... If a Part D sponsor intends to limit formulary inclusion of a Part D drug to only certain FDA-approved indications, the indication information must be submitted to HPMS." Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

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Text of CMS Fact Sheet: Indication-Based Formulary Design Available to Medicare Plan D Sponsors for Contract Year 2020

"This new guidance expands upon our existing policy by allowing Medicare Part D plan sponsors to tailor which drugs are on their formulary by specific indications, starting in CY 2020. This will provide Medicare Part D plan sponsors additional negotiating leverage with manufacturers, which can reduce beneficiary and program costs." Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

Two Key Requirements for Paid Leave Tax Credit

"If an employer provides paid FMLA leave to full-time employees but not to part-time employees, it is totally ineligible for the tax credit, and it cannot claim a tax credit even for paid leave it provides its full-time employees.... The number of weeks of paid FMLA leave to which part-time employees must be entitled is proportionate to the number of weeks the employer provides to full-time employees using expected hours per week as the prorating factor." ERISAfire

District Court Provides Guidance on Video Surveillance in Disability Cases

"A plan administrator is not required to ignore inconsistencies between a plaintiff's assessment of his or her level of activity and footage of the plaintiff participating in those activities. For video surveillance to be meaningful, inconsistencies between the plaintiff's assessment and the actual level of activity must be more than minor." [ Eaton v. Reliance Standard Life Ins. Co. , No. 16-2764 (W.D. Tenn. July 31, 2018)]
Robinson & Cole LLP

Another Court Scrutinizes Plan Exclusion for Wilderness Programs

"Another court has allowed mental health parity claims to proceed against an insurer that denied coverage for behavioral health care services provided in an outdoor residential treatment setting.... The insurer [had] asked the court to dismiss the case, arguing that the treatment was properly denied under the plan's 'Counseling in the Absence of Illness' exclusion, which listed wilderness programs as an example of a noncovered service." [ A.Z. v. Regence Blueshield , No. 17-1292 (W.D. Wash. Aug. 9, 2018)]
Thomson Reuters / EBIA

Employee and Employer Satisfaction with Group Benefit Marketplaces (PDF)

"Employers ... report strong satisfaction with cost control, streamlined administration, and the implementation and renewal process.... Employees ... are more likely to stay with their employer because of the marketplace.... 94% of employees were satisfied with the variety of choices available.... 97% of employees preferred to choose their own benefits (rather than have their employer choose for the ... 96% of employees are satisfied with the shopping and enrollment experience." Willis Towers Watson

House Health Subcommittee to Review Bills to Improve Patient Care, Reduce Health Care Fraud

"The Health Subcommittee ... announced a hearing for Wednesday, September 5, 2018... entitled, 'Opportunities to Improve Health Care.' ...The Majority Memorandum, witness list, and witness testimony for the hearing will be [ available online ]as they are posted."
Energy and Commerce Committee, U.S. House of Representatives

Insurers Say Small Change to FCC Regs Will Have Big Impact on Ability to Text and Call Patients

"A group of insurers is reviving a push for the Federal Communications Commission (FCC) to ... clarify now HIPAA-covered entities can use text messages or calls to communicate with patients. The group ... says two simple clarifications to the Telephone Consumer Protection Act (TCPA) would resolve ongoing confusion over a 2015 order that discourages organizations across the healthcare industry from providing patients with reminders about their health benefits or recommended screenings." FierceHealthcare

How Much Would Senator Rubio's Paid Leave Program Help New Parents?

"To expand parental leave options, Senator Marco Rubio (R-FL) introduced legislation ... that would allow new parents to trade part of their future Social Security retirement benefits for paid leave. Simulations ... show that a paid leave benefit equal to 300 percent of a monthly Social Security disability benefit would typically replace about 80 percent of pre-tax earnings for parents who leave work for two months. For each two-month paid leave, the program would raise Social Security's full retirement age by about six months, reducing average lifetime retirement benefits by 3 percent." Urban Institute

Are Pharmacy Benefit Managers the 'Good Guys' or the 'Bad Guys' of Drug Pricing?

"These companies are supposed to use their formulary power, management tools, and price concessions to benefit the insurers they serve which, in turn, are supposed to pass the savings on to their customers through more generous benefits and lower premiums.... So where did pharmacy benefit managers go wrong? In three areas: consolidation, rebate revenue, and transparency." STAT

A Six-Step Solution to the PBM Problem

"Congress can help patients by banning gag clauses.... Congress should ensure that PBMs are doing what they claim to be doing: saving patients money.... Two other proposals would directly assist pharmacies. The first would prohibit retroactive DIR fees.... Another proposal would address conflicts of interest by preventing PBMs from requiring patients to use pharmacies in which they have an ownership interest.... [T]he Department of Justice could robustly enforce the antitrust laws by challenging the pending mergers between CVS and Aetna, and Express Scripts and Cigna.... [T]he Federal Trade Commission (FTC) can use its Section 6(b) authority ... to obtain PBM rebate and fee information and to analyze PBMs' effects on drug pricing." Michael Carrier, in Health Affairs

New Jersey Lawmakers Try to Wrangle Pension Problem

"Pension and health-care costs will eat up nearly a quarter of the state's $45 billion budget by fiscal year 2023, fueling a $3 billion deficit ... One of [the] proposals shifts new state employees and those employed for less than five years of service to a hybrid pension and 401(k)-style plan. Another moves public employees to less expensive health-care plans and requires future retirees to pay more for health care." The Wall Street Journal; subscription may be required

Press Releases

BPCC Foundation is Certified for Fiduciary Excellence Centre for Fiduciary Excellence [CEFEX]

Benefitfocus Joins the MIT Initiative on the Digital Economy Benefitfocus

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Most Popular Items in the Previous Issue

Everyone Wants Telemedicine. So Why Aren't Your Employees Using It? Mercer

Text of DOL Opinion Letter FMLA2018-1-A: No-Fault Attendance Policies and FMLA (PDF) Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL]

IRS Issues Guidance for New UBTI 'Siloing' Rules, But Questions Remain Quarles & Brady LLP