"[1] Adjust to a lower affordability threshold ... [2] Be aware of the affordability safe harbors ... [3] Recognize that ESRP penalty amounts continue to rise ... [4] Calendar the Form 1094-C/1095-C deadlines ... [5] Use current draft ACA reporting forms."   MORE >>

"The interim final rules require plans and issuers to disclose the QPA for each item or service to providers and facilities with each initial claim payment or notice of denial of payment in any case where the QPA set the relevant cost-sharing amount. Additionally, when a plan or issuer changes a provider or facility's service code to one of lesser value, the plan or issuer must now provide additional information for this 'downcode' process."   MORE >>

"Share the following list with your employees to make sure they are fully equipped to benefit from their plan elections: [1] Be on the lookout for new ID cards ... [2] Set up your user account ... [3] Schedule your annual exams ... [4] Double-check your first paystub ... [5] Lastly, track all health-related expenses."   MORE >>

"[An] employee's health plan enrollment information does not become protected health information (PHI) subject to HIPAA until it is in the hands of the health insurer (or, if the plan is self-funded, the staff or service provider responsible for plan administration). The enrollment information entered on an employee portal would likely be considered an employment record (rather than PHI) ... Assuming then that HIPAA does not apply, the response to an accidental disclosure of personal information will depend on state law[.]"   MORE >>

"The decision to introduce alternative work arrangements needs to also consider the significant implications to total rewards.... Covering health and retirement benefits for part-time workers increases overall labor costs.... [O]rganizations with a vision to enable their new work strategies with a holistic view on total rewards design will outperform competitors in the long run."   MORE >>

"The percentage of the population under age 65 with employment-based health coverage diagnosed with a mental health disorder increased from 14.2 percent in 2013 to 18.5 percent in 2020.... [T]he percentage of enrollees using outpatient services increased from 12 percent to 16 percent ... Overall spending on mental health care services as a percentage of total spending increased from 6.8 percent in 2013 to 8.2 percent in 2020."   MORE >>

"A growing number of hospitals are outsourcing often-unprofitable outpatient services for their poorest patients by setting up independent, nonprofit organizations to provide primary care. Medicare and Medicaid pay these clinics ... significantly more than they would if the sites were owned by hospitals."   MORE >>

"It is critical for the personal injury lawyer to obtain the benefit plan and not just rely on the summary plan description (SPD).... It is just as important for personal injury lawyers to attempt to negotiate with the benefit plans as early as possible.... Any leverage to negotiate a lower reimbursement is lost if the attorney waits too long."   MORE >>

"Provident had learned that Messing had done part-time legal work, but it could not prove that it would have terminated his claim if it had known about that work. The evidence only showed that Provident would have reevaluated Messing's claim, and 'a review of Messing's claim does not necessarily mean it would have terminated his benefits earlier.' Because Provident had not introduced satisfactory evidence of inducement, it could not prevail on its restitution theory." [ Messing v. Provident Life and Accident Ins. Co. , No. 21-2780 (6th Cir. Sep. 9, 2022)]   MORE >>

"As plan sponsor for the group health plan, the plaintiff subsequently filed an ERISA action in federal district court seeking an equitable lien by agreement over the wrongful death settlement funds in the possession of the decedent's estate, in order to recoup the funds the plan paid for the beneficiary's accident-related medical treatment.... [T]he district court concluded that the relief the plaintiff's ERISA claim sought would interfere with the distribution process approved by the probate court for the settlement funds, thus triggering the probate exception." [ American Electric Power Service Corporation v. Fitch , No. 22-3005 (6th Cir. Aug. 30, 2022; unpub.)]   MORE >>