Under ERISA, “spousal consent” is needed when participant in a defined benefit (“DB”) or a defined contribution (“DC”) plan wants to make an election that would adversely affect the married participant’s rights. For example, a Participant will often need a spouse’s consent to waive an annuity form of payment and instead receive a lump-sum payment. To give “consent” the non-participant spouse must execute a waiver that satisfies IRS rules...
Continue reading…New Roth Catch-up Rules for High Earners Set to Take Effect
Defined Contribution plans can allow employees age 50 or older to make “catch-up contributions,” which are additional elective deferrals beyond the annual limit. The purpose is to allow those close to retirement to stash away extra money just before they cease working. Like all other elective deferrals, these extra contributions are made on a pre-tax basis. However, the SECURE Act 2.0 made two major changes to these rules. First, participants...
Continue reading…Searching for Missing Participants: Duties and Best Practices
Under the Employee Retirement Income Security Act of 1974 (“ERISA”) multiemployer retirement plan fiduciaries must make reasonable efforts - under the duties of prudence and loyalty - to locate missing participants entitled to benefits from Defined Benefit (“DB”) and Defined Contribution (“DC”) retirement plans. Multiemployer plans often face challenges due to increased participant mobility. To assist plan fiduciaries in meeting their obligations, the Department of Labor (“DOL”) and the...
Continue reading…ACA Preventive Care List – Updated Coverage Requirement and Surviving a Supreme Court Challenge
It was an eventful month for a portion of the Affordable Care Act’s (“ACA”) that is rarely in the news. However, the ACA’s preventive care list was a recent news topic for two separate reasons. First, the agencies responsible for overseeing and updating the preventive care list added four new types of screenings to the list. Second, on June 27, 2025, the U.S. Supreme Court issued an opinion upholding...
Continue reading…Navigating COBRA Notice Requirements for Multiemployer Health Plans: Key Content and Timing Essentials
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...
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