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…HRA vs. FSA vs. HSA: What’s the Difference?
As the price of healthcare continues to increase, employers can assist employees by providing employees the opportunity to enroll in special accounts to help pay for medical expenses. Some of these accounts enable the employer to share the cost burden with the employee while providing tax-savings to each. Generally, there are three (3) employer-sponsored vehicles that are commonly used to help pay for qualified medical expenses: (1) Health Reimbursement...
Continue reading…Is Your Denial Letter Good Enough?
Plan administrators are engaged to administer claims on the plan’s behalf, which include determinations of eligibility and denying coverage, among other services. When a claim is denied, the plan administrator is required to provide adequate notice to the participant, among other things. The Employee Retirement Income Security Act of 1974 (“ERISA”) generally requires the notice to include the specific reasons for the denial and to provide citations to the...
Continue reading…AbbVie v. Payer Matrix Pending Litigation
Introduction: In May 2023, AbbVie, a pharmaceutical manufacturing company, filed suit against Payer Matrix, a company that provides alternate funding options for their clients, usually health plans, by way of enrolling participants in the health plan into programs aimed at providing expensive specialty medication for low income and uninsured participants. After realizing Payer Matrix’s business model, AbbVie filed suit against Payer Matrix and alleged that Payer Matrix violated, and continues...
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