"The Departments clarify that the Act's requirements apply to plans that do not cover out-of-network services. Therefore, a closed-network plan may be required to pay for out-of-network emergency or air ambulance services.... [ FAQs Part 55 ] further expand on the Federal IDR Process, including requirements for initial payment amounts, deadlines for initial payments or denial notices, and other notification requirements."   MORE >>

"The Final Rule  ... [makes] clear that IDR entities should determine the out-of-network rate during the IDR process by selecting the offer 'that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties.' The Final Rule also incorporates new requirements intended to promote transparency, consistency and predictability in the IDR process."   MORE >>

"[T]he Seventh Circuit found that denial of FMLA benefits is not required to demonstrate a violation of the FMLA based on FMLA interference. However, the court did also make clear that to recover for a violation, a plaintiff must also show they were prejudiced by the violation." [ Ziccarelli v. Dart , No. 19-3435 (7th Cir. Jun. 1, 2022)]   MORE >>

"The percentage of private-sector establishments offering health plans increased through 2016 but has since ebbed and flowed with no discernible trend.... Between 2013 and 2017, the self-insurance trend for large establishments declined. A rebound started in 2018, but the rebound did not hold in 2020. Overall, the percentage of workers in self-insured plans has been bouncing around between 58 percent and 60 percent since 2013."   MORE >>

"[A] properly designed plan with individual and aggregate stop-loss insurance protects your organization from catastrophic claims and unanticipated high utilization. For many midsize employers, the reward is worth the calculated risk."   MORE >>

"Employer-sponsored, payroll-deducted loans provide an affordable way for employees to pay for unexpected healthcare costs or to pay off accumulated medical bills or debt in collections."   MORE >>

"[The Ninth Circuit found that the] district court applied the appropriate test by asking whether the resulting death was 'substantially certain' to occur from the insured's conduct. The court found that Scott's death was an 'accident' because his death was not 'substantially certain' to occur under the circumstances. The court noted that all of the relevant cases from its sister circuits have held that a drunk driving death was a covered accident under an AD&D policy when applying de novo review." [ Wolf v. Life Ins. Co. of North America , No. 21-35485 (9th Cir. Aug. 25, 2022)]   MORE >>

"The case, based on a lawsuit filed by the churches in 2015, weighed their claims of religious discrimination against the state's position that abortion services represent basic care that should generally be covered by all health care plans offered in the state." [ Foothill Church v. Watanabe , No. 15-2165 (E.D. Cal. Aug. 25, 2022)]   MORE >>

"[As] momentous as this legislation is, it goes only so far. Negotiation of drug prices in Medicare will apply initially to a limited number of drugs ... Plus, negotiation does not take effect until well after a drug receives approval from the [FDA] (9 years for small-molecule drugs and 13 years for biological products). Also ... negotiated drug prices will not apply to private insurance plans outside Medicare."   MORE >>

"Generally speaking, employers have allowed pharmacy benefits managers and health networks to agree to any price on their behalf for years. And most of these intermediaries will agree to any price ... Will employers rise up and change their own purchasing models? Or will they continue to reinforce the opaque, rebate- and markup-driven systems prevalent in the market today? Also, will they cover any drug approved by the FDA regardless of cost?"   MORE >>

"[Q]ualified DB pension plans and other non-pension DB benefit plans would be treated for purposes of the alternative minimum tax the same way they are treated for regular federal income tax purposes ... [P]ublicly traded corporations that repurchase more than $1 million in stock will be subject to an excise tax of 1% of the stock's fair market value.... The excise tax will not apply in cases where the repurchased stock (or an amount equal to its value) is contributed to an employer-sponsored retirement plan, employee stock ownership plan or similar plan.... HSA-qualifying HDHPs will be permitted to cover insulin before the annual deductible is satisfied."   MORE >>