The Consolidated Omnibus Budget Reconciliation Act (COBRA) requires that group health plans (GHPs) offer continued coverage to covered employees, former employees, spouses, former spouses, and dependent children when coverage would otherwise be lost due to “qualifying events.” These events include the death of a covered employee, job loss (except due to gross misconduct), reduced hours worked, divorce, legal separation, entitlement to Medicare under Title XVIII of the Social Security...
Continue reading…Departments of Labor, Health and Human Services, and Treasury Update the Gag Clause Attestation Rules – Part 2
On January 14, 2025, the Departments of Labor, Treasury, and Health and Human Services (collectively, the “Departments”) issued new guidance (i.e., FAQ 69) on two important provisions within the No Surprises Act, which was signed into law on December 27, 2020. The second part provides plans with additional guidance on what constitutes an impermissible “gag” clause. Gag Clause Prohibition and Attestation The No Surprises Act also prohibits health plans from entering...
Continue reading…Departments of Labor, Health and Human Services, and Treasury Update the Gag Clause Attestation Rules – Part 1
On January 14, 2025, the Departments of Labor, Treasury, and Health and Human Services (collectively, the “Departments”) issued new guidance (i.e., FAQ 69) on two important provisions within the No Surprises Act, which was signed into law on December 27, 2020. This first part offers insight into how plans and providers should calculate the “Qualifying Payment Amount” (“QPA”) when faced with out-of-network emergency medical and air ambulance bills. Calculating the...
Continue reading…Supreme Court Overturns Chevron: Implications for ERISA Plan Administration
Introduction The Chevron doctrine, established in the 1984 Supreme Court case Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., instructed courts to defer to agency interpretations of ambiguous statutes due to the agencies' specialized expertise. Chevron promoted consistency and predictability in regulatory interpretation but faced criticism for allowing excessive agency power and reducing judicial oversight. These concerns led to its overturning in the 2024 Supreme Court decision in Loper...
Continue reading…What Should a Claims Denial Letter for Health Benefits Include?
One of the many jobs in administering a health plan is determining whether a claim should be paid. This requires looking at the plan and determining whether the claim meets the criterium established under the plan. As one would imagine, this may lead to claims being denied. Section 503 of the Employee Retirement Income Security Act of 1974 (“ERISA”) requires the plan to provide any participant or beneficiary...
Continue reading…FTC Takes Aim at Pharmacy Benefit Managers Over High Drug Costs
On July 9, 2024, the Federal Trade Commission (FTC) released a critical interim staff report shedding light on the role of pharmacy benefit managers (PBMs) in driving up prescription drug costs. The report outlines how these PBMs profit at the expense of patients and independent pharmacies by inflating drug prices and imposing unfair practices. Just a day later, news broke that the FTC is preparing to sue the nation’s...
Continue reading…HHS Doubling Down on Health Plan Cybersecurity and HIPAA Compliance
Recently, health entities have experienced cybersecurity attacks at an alarming rate, causing concern for the integrity of the healthcare system. The information compromised during these attacks may include personally identifiable information (“PII”), which includes names, dates of birth, and social security numbers. In response, the Department of Health and Human Services’ Office of Civil Rights (“OCR”), which oversees compliance with the Health Insurance Portability and Accountability Act of 1996...
Continue reading…IRS Issues Extends Previously Granted Relief for Missed Required Minimum Distributions issued in 2024 and 2025
Introduction Recently, the IRS issued Notice 2024-35 providing additional guidance on Required Minimum Distributions (“RMDs”) due for the 2024 and 2025 calendar years. The purpose of the new guidance was to remind taxpayers of the new 10-year rule introduced under the SECURE Act of 2019 and extend relief to those who failed to take an RMD. These rules impact both the participant and beneficiary of a defined contribution retirement plan...
Continue reading…Benefit Statements for Defined Benefit Plans – When to Send and What to Say
Section 105 of the Employee Retirement Income Savings Act of 1974 (“ERISA”) (29 U.S.C. §1025) requires the plan administrator for defined benefit plans, such as pension plans, to provide benefit statements to the participants and beneficiaries of the plan. The benefit statement is essentially a notice that contains information about the plan, including the rights of the participants and the benefits available to the participant or beneficiaries, among...
Continue reading…District Court Decision Reminds Plan Administrators About the ERISA Disclosure Rules
A recent district court decision from California serves as helpful reminder to ERISA plans about their obligation to disclose certain documents upon request. In Zavislak v. Netflix, a California District Court reviewed whether an ERISA health plan adequately complied with ERISA’s disclosure rules and, if not, whether it should be subject to the daily penalty under ERISA Section 502(c)(1). Background The Plaintiff was a Netflix employee who was a covered participant...
Continue reading…