Director, Client Relationship Management
Healthcare Association of New York State
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Empower Retirement
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First Financial Bank
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Preferred Pension Planning Corporation
in NJ

Director, Marketing Strategy
Ascensus
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TPS Group
in CT, MA, ME

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45th Annual TIPS Midwinter Symposium on Insurance and Employee Benefits
January 17, 2019 in FL
American Bar Association [ABA]

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New Comments and Topics

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Employers, Why Don't You Require That Employees Call Two Phone Numbers to Request FMLA Leave?

"[T]his approach is perfectly legal and makes complete sense if you have the resources to pull it off. If an employee calls off work, they already are required to call their supervisor so that the shift can be covered. However, if they also want the FMLA to apply to this absence, they are required to call a second number. This second call can be required to another employer intake line or a third-party administrator handling calls on the employer's behalf." FMLA Insights

Health Savings Accounts (HSAs): Compliance Obligations Under the Internal Revenue Code and ERISA

Nov. 28 webinar. Although HSAs have numerous tax advantages, it is easy to inadvertently fail to satisfy the requirements. This webinar will help health plan administrators navigate this sometimes treacherous terrain. BenefitsLink discount .

Medicare Part D Notice Action Items for Employers

"The Notice is due before October 15, 2018. There have been no changes in the Model Part D Coverage Notice since last year -- thus you can use your 2017 Notice (although you will need to update your 2017 notice with corresponding 2018 dates).... Rather than try to identify Medicare-eligible individuals for targeted distribution, many employers simply provide the Notice to all their plan participants." Findley

Major PBMs Release 2019 Formulary Exclusions, Some Drugs Cut

"For 2019, Express Scripts Holding Co. will exclude 48 drugs from its national preferred formulary, including hepatitis C drug Mavyret and HIV drug Atripla. Meanwhile, CVS Health and OptumRx cut 23 and 36 medications from their 2019 formularies, respectively.... [T]he changes are likely to negatively impact 0.2% to 1.24% of members, as estimated by two of the three largest national PBMs." AISHealth

Health FSA Limit Projected to Increase in 2019

"The 2019 indexing is based on the 12-month average CPI-U through August 2018. With the release of the August 2018 CPI-U data, [the authors] are projecting that the health FSA limit will increase to $2,700 for 2019. The IRS is not expected to formally release the 2019 FSA limit until late October." Buck

Employees Spending More on Medical Services, Less on Drugs

"Spending on medical services for people enrolled in employer-sponsored health plans increased 44% between 2007 and 2016 ... Out-of-pocket spending among people enrolled in employer-sponsored coverage increased approximately the same amount, rising 43% over the study period.... The distribution of overall spending by service didn't change significantly over time, with one exception: Spending on outpatient services outpaced all others, growing an average of 5.7% per year." FierceHealthcare

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Life Insurance Purchased in Welfare Benefit Fund Taxed Under Split-Dollar Rules

"The Tax Court rejected the taxpayers' argument that neither the welfare benefit plan nor its contractual death benefit constituted life insurance, and instead looked through the trust to the life insurance policy in reliance on the attribution rule cited above. The Tax Court also found that the insurance was not group-term life insurance, in part because of the nature of the insurance product and in part because the amount of insurance was not determined under 'a formula that precludes individual selection' as required by the section 79 regulations." [ De Los Santos v. Comm'r , T.C. Memo. 2018?155 (Sept. 18, 2018)]
Eversheds Sutherland

Agreement Required District Court to Consider Information from Post-Complaint Internal Review Process

"During the litigation process, the parties agreed that the plaintiff would be allowed to complete another internal administrative review of her claim, and that the information generated during that review would become part of the record before the district court.... The First Circuit noted that HPHC 'explicitly agreed -- twice in a two-page document' that information submitted or generated as part of the plaintiff's pending administrative review would be included in the record before the court." [ Doe v. Harvard Pilgrim Health Care , No. 17-2078 (1st Cir. Sept. 6, 2018)]
The Wagner Law Group

Senators Draft Legislation to End Surprise Medical Bills

"[T]he draft bill would bar a health plan or out-of-network provider from billing a patient more than their in-network cost-sharing. The excess amounts ... would instead be paid by the health plan in accordance with an applicable state law, an amount based on the greater of the median in-network amount negotiated by health plans, or 125% of the average allowed amount for the service provided by a provider in the same or similar specialty and provided in the same geographical area." American Journal of Managed Care

Health Plan TPA Faces Mental Health Parity Claim

"Another court has addressed a participant's claim for wilderness therapy benefits--this time against a self-insured health plan's claims administrator.... This is one of several recent cases seeking benefits for mental health services delivered in a wilderness setting ... Although still in the early stages, this case is interesting because it extends the potential for liability to claim administrators." [ Gallagher v. Empire HealthChoice Assurance, Inc. , No. 16-9105 (S.D.N.Y. Sept. 11, 2018)]
Thomson Reuters / EBIA

How CBO Is Updating Its Health Insurance Simulation Model

"CBO's health insurance simulation model (HISIM) generates estimates of health insurance coverage and premiums for the population under age 65. HISIM is used to help develop baseline projections ... and also to model proposed changes in policies that affect health insurance coverage. Currently, CBO is developing and testing a new version of HISIM to respond to continued Congressional interest in understanding the effects of legislative proposals that significantly affect health insurance coverage. The new model will be used to help develop CBO's spring 2019 baseline projections and subsequent cost estimates." Congressional Budget Office [CBO]

Pharmacy Spread Pricing Exposed

"[L]ower-volume PBMs ... can easily compete in the market just by accepting a more reasonable profit margin. Many of these new PBMs offer pass-through pricing arrangements in which the PBM negotiates discounts from pharmacy manufacturers and makes its profits off pre-established dispensing fees rather than pricing spreads.... Many can't understand why the cash price would be so much less than the cost using their health insurance card... [T]his explains it -- it's done by cutting out the spread pricing profit." Frenkel Benefits

Sixth Circuit Provides 'Guideposts' for Consideration of Plan Reformation

"[T]he Sixth Circuit Court of Appeals ... rejected the lower court's analysis based on the absence of intentional fraud on Chrysler's part ... Where there is a conflict, especially where the participant relied on the language in the SPD for a critical decision, courts are likely to have some sympathy for the participant's claim. Risk is highest where a large number of participants are affected by a decision for which the terms of the plan (and the SPD) are critical." [ Pearce v. Chrysler Group LLC Pension Plan , No. 17-1431 (6th Cir. June 20, 2018)]
October Three Consulting

A Closer Look at Health Savings Accounts: An Overlooked Retirement Savings Vehicle

"Legislation has been proposed to enhance HSA accounts ... [1] An HSA could be used to pay for over-the-counter medications. [2] HSA contribution limits would be raised to $6,650 for individuals and $13,000 for families ... [3] Individuals who are actively employed but participating in Medicare Part A and covered by a qualifying HDHP would be able to contribute to and HSA. [4] Flexible spending account (FSA) and health reimbursement account (HRA) balances could be transferred to an HSA.... [5] Individuals would no longer be barred from contributing to an HSA if his/her spouse is enrolled in a medical FSA." Cammack Retirement Group

How to Gain Employee Compliance on Cybersecurity Procedures

"[1] Start With Employee Awareness ... [2] Provide Regular Training Programs ... [3] Make It Personal And Relatable ... [4] Be Transparent About Security Procedures ... [5] Use Entertaining Videos To Convey Your Points ... [6] Tie Training To Their Personal Lives ... [7] Keep It Simple And Easy." Forbes Technology Council

Press Releases

John Hancock Leaves Traditional Life Insurance Model Behind to Incentivize Longer, Healthier Lives John Hancock

E*TRADE Launches New Planning Center That Helps Participants Integrate Their Stock Plan Benefits into an Investment Plan E*TRADE Financial

View All Press Releases

Most Popular Items in the Previous Issue

The Changing Landscape of Out-of-Network Reimbursement (PDF) Milliman

Proposed Legislation Would Expand HSAs DataPath

Health Care Spending Under Employer-Sponsored Insurance: A 10-Year Retrospective Health Affairs