" New regulations require 'downcoding' QPA disclosures, but plan and issuer 'downcoding' policies remain a subject of pending litigation.... [The new final rule] directs certified IDR entities to consider the QPA as well as certain other specific factors when resolving out-of-network rate disputes."   MORE >>

"HHS has now reproposed rules that would reinstate the 2016 definition of covered entity and then expand upon it.... [S]elf-funded plan sponsors could potentially have to revert back to providing the annual notice and work with their [TPA] to ensure the notices are included in all of the required communications. Any TPA that receives federal financial assistance in another part of its business would likely be subject to these rules, even if the plan sponsor is not directly subject to them."   MORE >>

"Applying COBRA coverage rules in the merger and acquisition (M&A) context has always been challenging. Various COBRA rules spelled out are in regulations from the [IRS] and other guidance and case law. But then there is the 'real world'; how can these rules be applied in the context of an ever-changing and evolving M&A environment?"   MORE >>

"[T]he Fifth Circuit Court of Appeals largely upheld a district court decision to reject a [DOL] advisory opinion that would have restricted a new arrangement designed to avoid major [ACA] protections and state regulation of private health insurance.... LP Management Services ... [had] requested an advisory opinion from [DOL] on whether its partnership arrangement qualified as a single-employer self-insured group health plan under [ERISA].... [I]ndividuals and small businesses could become 'partners' and buy into the health insurance plan merely by agreeing to download software and provide user data[.]" [ Data Marketing Partnership, LP v. DOL , No. 20-11179 (5th Cir. Aug. 17, 2022)]   MORE >>

"[T]he insurer asserted that the LTD policy was covered by ERISA and failed to meet the requirements of the DOL safe harbor because: [1] it was a component of the entire group health plan to which the employer contributed (through the basic life policy); and [2] it was endorsed by the employer.... [T]he court agreed with the insurer, finding that the four 'policies were jointly offered 'as part of the [employer's] employee benefits program,' which implicates ERISA regardless of the lack of employer contribution to the LTD portion of the overall plan.' " [ Duncan v. Unum Life Ins. Co. of Am. , No. 20-600 (M.D. Tenn. Jul. 18, 2022)]   MORE >>

"After experiencing no increase in actual health care cost from 2019 to 2020, employers experienced a significant return to rising costs, with a median 2021 cost increase of 8.2%.... [E]mployers expect to cover 82% of the cost of employee coverage in 2022, up from 80% the year before ... Large employers overwhelmingly (99%) said they were concerned about prescription drug trend.... Long-term mental health issues, both observed and anticipated, are the leading health-related impact of the pandemic[.]"   MORE >>