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How much a health plan may change before losing grandfathered plan status was addressed in a final Affordable Care Act rule issued on Nov. 13 by the three U.S. departments that administer ACA reform. The rule (which takes effect on Jan. 1, 2017) finalizes familiar pieces of agency guidance, many of them issued in 2010. The rule also addresses […]
Large employers with 200 and more employees will not have to automatically enroll their workforces into health plans, under budget legislation signed by President Obama. This Affordable Care Act provision was repealed because it was a low government priority and because business objected to it. Rules explaining the provision were never issued and it never took […]
On Oct. 7, 2015, President Obama signed, without comment, the Protecting Affordable Coverage for Employees Act, which amends the Affordable Care Act’s definition of a “small-group,” a move intended to force mid-sized companies into providing richer coverage to workers. The PACE Act (H.R. 1624 and S. 1099) repeals the mandatory expansion of the small group […]
A third-party administrator faces California health privacy and unfair business practices charges for allegedly handing over a plan participant’s case management information to an employer, which then terminated her to avoid paying for her impending liver transplant. The TPA’s arguments for ERISA preemption failed because the plan participant’s state-law action could have been brought in […]
The IRS is asking the public for input into a rule that will determine when an employer-sponsored health plan is offering “substantial coverage” of inpatient hospital and physician services. This will be part of new rules defining minimum value in employer-sponsored health coverage. Employer-sponsored coverage must meet two tests to comply with the employer mandate: […]
By Nicole Mitchell Contractors often disclose the cost savings of self-insured plans with excitement, but buyer beware. Most contractors are surprised when I don’t immediately commend them on cost savings and instead ask them,“Did you know there are ’special‘ compliance requirements for self-insurance plans and failure to meet the compliance requirements makes the cost unallowable?” Most […]
Insurers and plan sponsors soon will have to report to the government (and list on a web page) their policies on: out-of-network liability and balance billing; enrollee claim submission; claims and denials; recoupment of overpayments; medical necessity; prior authorization; drug exception timeframes; explanations of benefits; and coordination of benefits. Guidance HHS published on Aug. 12 […]
The U.S. Supreme Court will decide whether ERISA preemption shields a self-funded health plan from state requirements to report health claims data. The court agreed June 29 to hear Gobeille v. Liberty Mutual Ins. Co. (2015 WL 2473478). The state of Vermont is appealing the 2nd U.S. Circuit Court of Appeals’ ruling in Liberty Mutual v. […]
The U.S. Supreme Court in a 6-3 vote affirmed that subsidies may go to individuals in states with exchanges established by the federal government, and the statute did not restrict subsidies to only states that themselves ran exchanges. Such a reading of the statute was not in line with the intent of the Affordable Care […]
Non-grandfathered employer-sponsored group health plans must abide by out-of-pocket maximums for every individual covered, whether they are enrolled in “self-only” or in “other than self-only” (family) coverage. And the government stayed enforcement of the Affordable Care Act’s provider nondiscrimination rules, according to a new set of frequently asked questions from the departments that administer health care reform. […]