"Given the upcoming deadline and the heightened litigation risk associated with pharmacy benefit managers (PBMs).... [this post] provides action steps for group health plans to consider. RxDC reporting is no small task, and plan sponsors would be well advised to craft an approach specific to their needs and capabilities to mitigate compliance and litigation risks."   MORE >>

"[Q]ualified high deductible health plans (HDHPs) and some drug plans will have difficulty demonstrating that the prescription drug benefit they offer will provide at least as good a benefit as the newly improved Medicare Part D prescription drug benefit.... Early and clear communication will aide ... the working aged, who may believe they can enroll in Medicare when they stop working in 2026 (and later) but find out they are subject to late enrollment penalties because their employer plan was not creditable in 2025."   MORE >>

"The new final rules primarily address the [short-term limited-duration insurance (STLDI)] portion of the proposed rules, and generally adopt them as proposed. Aside from a new notice requirement, the agencies delayed finalizing the rules on fixed indemnity insurance, but warned that the delay should not be an endorsement of the abusive practices that have emerged in this space."   MORE >>

"New York has become the first state in the nation to mandate paid prenatal leave for pregnant employees.... [E]ligible pregnant employees are entitled to 20 hours of paid leave within a 52-week calendar period to attend appointments for prenatal care, including physical exams, monitoring and testing, and discussions with health care providers. This benefit is in addition to state sick leave or paid leave under the NY PFL."   MORE >>

"[E]mployers with operations in Puerto Rico must report in box 5 of the local Form W-2 the aggregate cost of their healthcare benefits to Puerto Rico employees.... [L]ocal tax laws do not provide for, or grant favorable tax treatment on, health Flexible Spending Arrangements (FSAs).... Thus, Puerto Rico employees should not be allowed to participate in FSAs ... In fact, the local tax rules require that the employee share of healthcare premiums be paid with after-tax dollars."   MORE >>

13 pages. "While most state legislatures stayed busy in the first quarter of 2024, comparatively few leave- and insurance-related bills became law. Instead, much of that activity took place on the regulatory front."   MORE >>

"Relying heavily on the findings and conclusions of the California state agency, the Ninth Circuit concluded that ... it is enough for such a plaintiff to allege the existence of a procedure used in assessing MH/SUD benefit claims that is more restrictive than those used in assessing medical/surgical claims under the same classification if the allegation is adequately pled in the complaint. A plaintiff doesn't have to allege that they had claims of both types." [ Ryan S. v. UnitedHealth Group, Inc. , No. 22-55761 (9th Cir. Apr. 11, 2024)]   MORE >>

"Employers will typically define the plan's eligibility terms in one of the following types of documents: [1] The wrap SPD; [2] The insurance carrier and TPA documents; [3] New hire and open enrollment materials; [4] Employer's benefit guide/booklet; [5] Employee handbook. While there are advantages and disadvantages to each, as well as additional nuances for particular types of eligibility to consider, the wrap SPD generally provides the best option."   MORE >>

"Due to the absence of statutory guidance in defining employee under ERISA, plan sponsors have often defaulted to the definition of employee under the Internal Revenue Code ... The use of the new economic realities test to determine the existence of an employee-employer relationship may simplify the analysis for plan sponsors and provide a more definitive classification."   MORE >>