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446 Matching News Items
1.
Out-of-Network Provider's Claim for Underpaid 'Gap Exceptions' Preempted by ERISA (PDF)
Thomson Reuters / EBIA
May 16, 2024
Thomson Reuters / EBIA
May 16, 2024
"For plans and insurers relying on out-of-network providers squeezed by the surprise billing protections and seeking ad hoc arrangements regarding payment for services, this case rather clearly demonstrates that ERISA preemption prevails when the payment amount is determined by referencing the terms of a plan." [Peer Grp. for Plastic Surgery, PA v. United Healthcare Servs., Inc., No. 23-2073 (D.N.J. Mar. 28, 2024)]
2.
Fourth Circuit: Exclusion of Gender Affirming Care Violates ACA Section 1557
Thomson Reuters / EBIA
May 9, 2024
Thomson Reuters / EBIA
May 9, 2024
"[T]he Fourth Circuit has affirmed trial court rulings that the exclusion of coverage for gender affirming care by state health plans in West Virginia and North Carolina violated the nondiscrimination protections of [ACA] Section 1557. Current and former state employees (and a Medicaid program participant) sued because the states' health plans and programs denied coverage for medically necessary gender affirming care for themselves or their dependents." [Kadel v. Folwell, No. 22-1721 (4th Cir. Apr. 29, 2024)]
3.
Agency FAQ Part 67 Extends Nonenforcement for Surprise Billing QPA Calculations (PDF)
Thomson Reuters / EBIA
May 9, 2024
Thomson Reuters / EBIA
May 9, 2024
"The FAQ is in response to feedback that plans and insurers need additional time to complete the 'significant efforts' associated with recalculating QPAs consistent with the guidance that remains in effect after TMA III.... [U]pdates regarding IDR portal availability and process changes continue to be posted on the CMS website, including a recent announcement of a new process for resubmitting IDR disputes that were originally improperly batched or bundled."
4.
District Court Holds That HRA Is Not Commensurate with Promised Lifetime Retiree Health Benefits (PDF)
Thomson Reuters / EBIA
May 9, 2024
Thomson Reuters / EBIA
May 9, 2024
"The employer argued that it met its obligation to provide lifetime benefits by providing the HRA, which it said was 'reasonably commensurate' with the old plan. But the court pointed out three reasons why this was not the case." [Kaiser v. Alcoa U.S. Corp., No. 20-0278 (N.D. Ind. Mar. 25, 2024)]
5.
HHS FAQs Address Change Healthcare Cybersecurity Incident (PDF)
Thomson Reuters / EBIA
May 2, 2024
Thomson Reuters / EBIA
May 2, 2024
"The FAQs specifically point to OCR's ransomware guidance, which has information on actions for regulated entities to take to determine if a ransomware incident is a breach (which is a fact-specific determination). OCR highlights that if covered entities are aware of a potential breach by a business associate, there is an obligation to proactively investigate whether a breach occurred, and report the breach to HHS, impacted individuals, and in certain cases, the media."
6.
Can an Employee Drop a DCAP Election Midyear If Free Childcare Becomes Available? (PDF)
Thomson Reuters / EBIA
May 2, 2024
Thomson Reuters / EBIA
May 2, 2024
"Yes, provided that your plan document has been drafted as expansively as IRS rules allow regarding midyear election changes due to changes in cost or coverage. The rules apply broadly to dependent care assistance programs (DCAPs), permitting midyear election changes in a variety of circumstances involving changes in care providers or in the cost of care."
7.
Can Our Company Let Employees Use Our Services Tax-Free? (PDF)
Thomson Reuters / EBIA
Apr. 25, 2024
Thomson Reuters / EBIA
Apr. 25, 2024
"The [income] exclusion for no-additional-cost services applies to services provided in-kind, and to partial or total cash rebates of any amount the employee paid for the service....IRS regulations provide that eligible services may include excess-capacity services such as hotel accommodations, transportation (by aircraft, train, bus, subway, or cruise line), and telephone services.... The regulations suggest that some tangible items (e.g., in-flight meals) can be provided without loss of the exclusion, so long as the goods are incidental to the primary service."
8.
HHS Provides Update on Progress of Advanced Explanation of Benefits Guidance
Thomson Reuters / EBIA
Apr. 24, 2024
Thomson Reuters / EBIA
Apr. 24, 2024
"This update is a very high-level summary of HHS's progress with the AEOB. It does not include any discussion of the timeframe for implementation of this requirement for group health plans, although the need to develop new technical standards suggests further delay."
9.
Ninth Circuit Refuses to Dismiss Class Action Challenging Insurer's Use of Algorithms to Process Mental Health/Substance Use Disorder Claims (PDF)
Thomson Reuters / EBIA
Apr. 18, 2024
Thomson Reuters / EBIA
Apr. 18, 2024
"The court determined that by alleging a systematic denial of his MH/SUD benefit claims and citing the state report's conclusion that the insurer was applying a more stringent algorithmic review process to such claims, the participant had plausibly alleged that the insurer had applied an improper internal process to his claims in violation of the MHPAEA." [Ryan S. v. UnitedHealth Group, Inc., No. 22-55761 (9th Cir. Apr. 11, 2024)]
10.
Is Our Self-Insured Health Plan Subject to the Section 1557 Nondiscrimination Rules? (PDF)
Thomson Reuters / EBIA
Apr. 18, 2024
Thomson Reuters / EBIA
Apr. 18, 2024
"Most likely, neither your company nor your self-insured health plan is currently subject to the Section 1557 nondiscrimination rules simply because the plan's third-party administrator (TPA) also sells policies through the Exchanges -- but the law in this area continues to evolve. "
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