Health Plan Design

[Guidance Overview] Reimbursing OTC Drugs and Applying for Mini-Med Waivers
Excerpt:"On September 3, 2010, the Internal Revenue Service (IRS) and the Office of Consumer Information and Insurance Oversight (OCIIO) independently announced the release of additional Affordable Care Act guidance."(Kilpatrick Stockton LLP)

[Guidance Overview] HHS Guidance on Annual Dollar Limit Waivers for Limited Benefit Health Plans or'Mini Med'Plans
Excerpt:"The waiver process is available for group health plans and health insurance issuers if the plan or coverage was offered prior to September 23, 2010 for the plan or policy year beginning between September 23, 2010 and September 23, 2011."(Hewitt Associates)

HHS Guidance on Waivers for Health Plan Limits
Excerpt:"Under current restrictions, annual limits for plans beginning between Sept. 23 and Sept. 22, 2011 cannot be lower than $750,000 . . . ."(Henry J. Kaiser Family Foundation)

U.S. Health Care Trend Survey, Summer 2010 (PDF)
7 pages. (Aon Consulting)

[Official Guidance] Text of IRS Notice 2010-59: Most Non-Prescription Drugs Purchased After 2010 Cannot Be Reimbursed from FSAs, HRAs (PDF)
6 pages. Excerpt:"The Affordable Care Act, enacted in March, established a new uniform standard that, effective Jan. 1, 2011, applies to FSAs and health reimbursement arrangements (HRAs). Under the new standard, the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained. The change does not affect insulin, even if purchased without a prescription, or other health care expenses such as medical devices, eye glasses, contact lenses, co-pays and deductibles."(Internal Revenue Service)

Health Insurance Options for Those with a Preexisting Condition
Excerpt:"For people with preexisting medical conditions, looking for health insurance in the private market may feel like the ultimate fool's errand. A 2009 report by the Commonwealth Fund found that 36% of people who tried to buy insurance in the private market were denied coverage or charged more because of a preexisting condition or had the condition excluded from their coverage."(Los Angeles Times)

Health Law Myths: Outside the Realm of Reality
Excerpt:"[Many of the] more outlandish claims have at least some basis in truth. Here are some of the more popular myths about the law and the fact that gave rise to them."(Morning Edition via National Public Radio)

2010 New York State Legislative Update Relevant to New York Employers
The New York State Legislature enacted and the Governor signed a number of laws: the Domestic Workers Bill of Rights, Funeral Leave Benefits for Same-Sex Couples, and Health Benefits for Volunteer Firefighters and Ambulance Workers. (Jackson Lewis LLP)

[Guidance Overview] More Guidance on Claims and Appeals Requirements for 2011
Excerpt:"In general, . . . self-funded plans should know: Self-insured group health plans have been granted an interim enforcement safe harbor until further notice. In order to avoid penalty during the enforcement safe harbor, a self-insured group health plan must either (a) comply with the standard and expedited external review procedures detailed in the guidance (which are based on the new state minimum procedures), or (b) voluntarily comply with a state process (assuming that the state is willing to allow access to its external review process). The agencies intend to issue additional guidance in the future with model language for the plan's SPD, describing the plan's new internal claims and appeals and external review procedures."(Holland&Hart LLP)

Maintaining Grandfathered Status for Health Care Plans Appears to Be Exercise in Frustration, Says Expert
Excerpt:"The list of triggers that negate a health-care plan's'grandfathered'status is long and easy to trip over, including such actions as switching insurance carriers and tinkering with employees'share of healthcare costs in any substantive way."(CFO.com)

Health Benefits In 2010: Premiums Rise Modestly, Workers Pay More Toward Coverage
Excerpt:"Workers paid more toward premiums in 2010, and more workers are in consumer-directed plans and plans with high deductibles than in 2009. Thirty percent of firms reported that they reduced the scope of benefits or increased cost sharing because of the recession."(Health Affairs)

[Guidance Overview] ERISA Plan's Reimbursement Claim Enforced Against Disbursed UIM Benefits
Excerpt:"This is a very significant opinion addressing ERISA health plan subrogation. . . . U.S. Airways v. James McCutchen et al presents a set of facts typical of an ERISA health plan subrogation case."(Roy Harmon via Health Plan Law)

Employer Health Benefits 2010 Annual Survey
Excerpt:"This annual survey of employers provides a detailed look at trends in employer-sponsored health coverage, including premiums, employee contributions, cost-sharing provisions, and other relevant information."(Henry J. Kaiser Family Foundation)

National Results: 2010 UBA Health Plan Survey
Excerpt:"While other surveys primarily target large employers, this survey focuses on reporting results that are applicable to the small to midsize companies who represent the overwhelming majority of the nation's 5 million-plus employers, with a mix of larger companies in rough proportion to their prevalence nationally."(United Benefit Advisors)

[Opinion] Plan Sponsors Not Focused on Same Issues As Advisers&Regulators
Interview with PlanSponsor's Nevin Adams. Excerpt:"Adams: Like their workers, I find most plan sponsors are more worried about the here-and-now aspects of health care reform than they are retirement plans, per se. People are people, after all, and there is a strong sense that we have more time to deal with retirement than with health care, and there is agreat concern about what the new law will require, and how that will impact existing programs, and what that will mean."(Fiduciary News)

[Opinion] First Obamacare Casualty: Health Insurance Agents, Rest In Peace
Excerpt:"The first casualties of ObamaCare -- not counting truth and the trust the public had placed in President Obama to keep his promises -- will be health insurance agents. That proud army of tens of thousands of Americans whose calling was to help individuals and employers work through the maze of available health insurance policies to find one that met their clients'needs."(Merrill Matthews on Forbes.com)

[Opinion] Pro&Con: Will Health Overhaul Provide Better Care for U.S. Workers?
Excerpt:"YES: Entrepreneurs will better afford coverage and options will increase. . . . NO: Businesses will drop health plans and hire fewer workers because of the costs."(The Atlanta Journal-Constitution)

HHS Pushes Competition With Health Insurance Site
Excerpt:"HealthCare.gov hopes transparency on health policy costs, claim denials drives down costs and helps consumers and businesses make better decisions."(Information Week)

Most Large Employers Will Change Health Plan Designs in Spite Of, Or Because Of, Health Reform
Excerpt:"More than half (53%) of large employers plan to proceed with health plan design changes for 2011, in spite of the threat of losing grandfathered plan status under health reform, according to a survey from the National Business Group on Health (NBGH)."(Wolters Kluwer Law&Business)

[Opinion] Comments to HHS by Employers Council on Flexible Compensation, on Application of Patient?Protection?and?Affordable?Care?Act?to Health Reimbursement Arrangements (PDF) (PDF)
4 pages. Excerpt:"Given that HRAs are not set up with a bright line annual limit and that they are most often used in conjunction with primary overage as a supplemental benefit, ECFC urges the agencies to exempt all HRAs from the prohibition on annual limits. The exemption should apply regardless of whether or not primary coverage is offered through the individual's employer or is obtained through another avenue, such as a spouse's employer."(Employers Council on Flexible Compensation)

[Opinion] Comments to HHS by Employers Council on Flexible Compensation, on Application of Healthcare Reform to Healthcare Reimbursement Arrangements (PDF)
4 pages. Excerpt:"Given that HRAs are not set up with a bright line annual limit and that they are most often used in conjunction with primary overage as a supplemental benefit, ECFC urges the agencies to exempt all HRAs from the prohibition on annual limits. The exemption should apply regardless of whether or not primary coverage is offered through the individual's employer or is obtained through another avenue, such as a spouse's employer."(Employers Council on Flexible Compensation)

[Opinion] Comments to HHS by Employers Council on Flexible Compensation, on Application of PPA to Health Reimbursement Arrangements (PDF)
4 pages. Excerpt:"Given?that?HRAs?are?not?set?up?with?a?bright?line?annual?limit?and?that?they?are?most?often?used?in?conjunction?with?primary?overage?as?a?supplemental?benefit,?ECFC?urges?the?agencies?to?exempt?all?HRAs?from?the?prohibition?on?annual?limits.??The?exemption?should?apply?regardless?of?whether?or?not?primary?coverage?is?offered?through?the?individual's?employer?or?is?obtained?through?another?avenue,?such?as?a?spouse's?employer."(Employers Council on Flexible Compensation)

[Opinion] It's Time for Washington State Workers to Help Pay More for Healthplan Coverage
Excerpt:"Labor negotiators for Gov. Chris Gregoire told state and higher-education employees last week that state workers must increase their contribution to health-care premiums from the current 12 percent to as much as 26 percent or reshape their health-care benefits package. The governor, at long last, has it right."(Seattle Times)

High-Deductible Plans Grow, but Not Everyone Should Get on Board
Excerpt:"In exchange for picking up a larger share of their own health care costs, employees pay lower insurance premiums and are allowed to use pretax dollars to pay out-of-pocket costs. But many consumers embracing the plans have discovered there are pitfalls aplenty, including out-of-pocket expenses they cannot afford."(New York Times; free registration required)

[Opinion] Hewitt Comments on Interim Final Rules Related to Lifetime and Annual Limits, Rescissions
Excerpt:"Hewitt's comment letter . . . addresses several issues as they relate to employer-sponsored health plans, including: Lifetime and Annual Limits; Definition of Essential Health Benefits; Rescissions; Mini-Med Waiver Program[.]"(Hewitt Associates)

Dallas-Fort Worth Business Group on Health Starts Health Strategy Program to Help Employers Ensure Their Health Benefits Improve the Health of Their Employees
Excerpt:"The Texas Health Strategy Project is part of the American Health Strategy Project, a national initiative sponsored by the Washington-based National Business Coalition on Health, which was designed to improve the health of employees and their families, promote wellness and prevention, and better manage health care costs."(Business Insurance)

Employers Packaging Next Year's Benefits Plans Confront Health Insurance Overhaul
Excerpt:"While not every employer blames the new law, one executive said the carriers she's dealing with say the rate hikes are attributable to new requirements such as coverage of preventive services, and extending benefits to adult children . . . ."(Henry J. Kaiser Family Foundation)

Employers Plan to Increase Health Coverage Cost Sharing Next Year, According to Survey
Excerpt:"An Aon news release said the poll also found that 57% of companies will ask employees to contribute more for the overall cost of health care in 2011."(PLANSPONSOR.com)

[Guidance Overview] ERISA Plan Wins Recovery from Settlement; Auto Insurer Must Reimburse Member
Excerpt:"This is the first time we've seen a case where a federal district court ruled that a Michigan no-fault auto insurer now has to pay more than its maximum plan liability when a health plan subject to ERISA recovered a substantial portion of the tort settlement proceeds it paid."(Passion for Subro)

Employers Urge Regulators to Ease Rules for Keeping Health Plan'Grandfathered'Status Under Reform
Excerpt:"Extensive comments from employer groups urge more flexible rules giving employers greater ability to control costs and make other plan changes without losing grandfathered status. Specific recommendations include easing cost-sharing and contribution restrictions and allowing plans to switch from insured to self-insured status and to make network provider or formulary changes."(Mercer LLC)

HHS Website Is One-Stop Shop for Details about New Preventive Services Mandate
Excerpt:"The U.S. Department of Health and Human Services has established a Web site - www.healthcare.gov - that includes a comprehensive, detailed list of all the mandated preventive services along with other information about the health reform law."(Deloitte via BenefitsLink.com)

Health Law Requires Continued Insurance Coverage for Patients in Clinical Trials
Excerpt:"The law requires health plans to pay the routine care costs of patients who participate in clinical trials for the prevention, detection and treatment of cancer and other life-threatening conditions."(Henry J. Kaiser Family Foundation)

[Opinion] Why Are Large Employers Unable to Control Their Health Benefit Costs?
Excerpt:"The reason is quite simple. Our fragmented, dysfunctional, multi-payer system permeates the entire health care delivery system, and these employers are unable to function in an isolated delivery system that has not been damaged by the financing perversities."(Physicians for a National Health Program)

Employer Reaction to Health Care Reform: Grandfathered Status (PDF)
3 pages. Excerpt:"[The Hewitt] survey shows that almost three-quarters of respondents (73%) have already determined whether their group health plans will be grandfathered in 2011."(Hewitt Associates)

[Guidance Overview] Can Preexisting Condition Insurance Plans Help Employers Control Health Care Costs?
Excerpt:"An employer could be subject to sanctions if it offers financial incentives to enrolled individuals who end up in the [Preexisting Condition Insurance Plan]. Would the comparisons of eligibility periods and coverage costs be sufficient to constitute'disincentives'? The PCIP rules do not appear to preclude the employer from steering new employees to the program. Any reasons why it should not?"(Tax Management Inc.)

[Guidance Overview] Regulations Regarding Internal Claims and Appeals and External Review Processes
Excerpt:"The new claims and appeals requirements under health care reform will impose more time-consuming and expensive rules on plan administrators. Plan sponsors considering the benefits of retaining grandfathered status will want to carefully consider these costs. These additional costs may encourage employers to retain grandfathered status. However, in many cases, if an employer has multiple benefit options, only some of which may be grandfathered, it may make more sense to apply all of the new claims procedures to all applicable group health plans in order to make the process consistent for everyone."(Sherman&Howard)

[Opinion] National Association of Insurance Commissioners Defers the Worst Insurance Industry Demands for Weakening the Implementation of Health Care Reform
Excerpt:"'Today the NAIC took a step toward ending the health insurance companies'stranglehold on our health care. The top state insurance regulators from across the nation voted to put patient care above insurance company profits.'"(Consumer Watchdog)

New York State Requires Discussion on Options Before Breast Removal Surgery
Excerpt:"[A] state law signed on Sunday by Gov. David A. Paterson will require New York hospitals and doctors to discuss the options for breast reconstruction with their patients before performing cancer surgery, to give them information about insurance coverage and to refer them to another hospital, if necessary, for the reconstructive surgery."(The New York Times; free registration required)

[Opinion] U.S. Chamber Comments on Grandfathered Health Plan Status Regulations (PDF)
14 pages. Comments to DOL regard the Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan under the Patient Protection and Affordable Care Act. (U.S. Chamber of Commerce)

Majority of Large Employers Revising Health Benefit Programs for 2011, According to Survey Results (PDF)
22 pages. (National Business Group on Health)

Small Businesses Wrestle with What Health Reform Will Mean for Them
Excerpt:"As a result of the federal health overhaul, businesses'with under 50 full-time equivalent employees will be under no obligation to offer health insurance, but those with over 50 must offer it or pay a fine. This will require counting employee hours; 30 hours is considered full time by the federal government. . . .'"(Henry J. Kaiser Family Foundation)

GAO Report on Consumer-Directed Health Plans: Health Status, Spending, and Utilization of Enrollees in Plans Based on Health Reimbursement Arrangements
Excerpt:"On average, enrollees in the HRA groups [that] GAO reviewed spent less and generally used fewer health care services before they switched into the HRA in 2003 than those who remained in the PPO, suggesting that the HRA groups were healthier. Average annual spending per enrollee for the . . . HRA group was $1,505 lower than the PPO group . . . ."(U.S. Government Accountability Office)

Federal Appeals Court Puts California Gay Marriages on Hold
Excerpt:"California's ban on same-sex marriages will remain in place until at least December, an appeals court ruled Monday . . . ."(Washington Post; free registration required)

Groups Seek Swift Clarification on Health Care Reform's Adult Child Coverage Mandate
Excerpt:"The American Benefits Council and the HR Policy Association urged regulators to define'adult child'consistent with current tax law, to give employers flexibility to cover additional classes of dependents, such as grandchildren, without adhering to the mandates that apply to adult children. The groups also want plans to be able to charge higher premiums to cover adult children."(Mercer)

Health Plans Predict Only Slight Rate Increases with Inclusion of Preventive Services Under Reform Mandate
Excerpt:"A survey of 10 health insurers conducted by [Health Plan Week] found that most of them expect premiums for products that don't now include preventive services to increase by 3% to 4%, while premiums for plans that now require a copayment for preventive services will likely rise by 1% to 2%."(AISHealth.com)

Most Health Plans to Lose Grandfathered Status, Survey Says
Excerpt:"Ninety percent of employers expect their health care plans to lose their grandfathered status by 2014 under the health care reform law because of changes they expect to make, according to a survey . . . ."(Workforce Management (free registration required))

GAO Study Finds CDHP Enrollees Healthier Than Those in Other Health Plans
Excerpt:"A new Government Accountability Office . . . study of two large employers, one public and one private, finds that enrollees in consumer-driven health plans . . . with a health reimbursement arrangement (HRA) are healthier than employees who remain in traditional health plans."(PLANSPONSOR.com)

Filling in the Insurance Gap for Adult Children
Excerpt:"[M]any health plans limit coverage of college-age children for a variety of reasons, including age, whether they live at home and whether they are financially dependent. For families with those plans, the choices are more difficult. And the health care law has added wrinkles to an already complicated decision."(The New York Times; free registration required)

[Guidance Overview] Being a Grandfathered Health Insurance Plan Brings Certain Advantages (PDF)
3 pages. (The National Law Journal via Proskauer Rose LLP)

[Guidance Overview] Implementing Parity: The Safe Harbor for Outpatient Benefits (PDF)
2 pages. Excerpt:"A new reform briefing paper looks at the safe harbor for outpatient benefits and augments an earlier discussion about the steps group health plans face as they respond to the new rules."(Milliman)

[Guidance Overview] New Health Care Claims and Appeal Rules Will Include an Excise Tax
Excerpt:"In contrast to current rules, failure to comply with the Section 503 Regulations as modified by the new internal claims and appeals and external review processes requirements may subject a health plan sponsor or health insurance issuer to a $100 per day per violation excise tax imposed under the Internal Revenue Code, in addition to giving the claimant a green light to file suit."(Littler Mendelson P.C.)

Insurers Defend Limited-Benefit Health Policies in Fight Over Proposed Restrictions
Excerpt:"Insurers can seek a waiver from the government to keep their current limited plans if they can prove that offering better benefits would cause significant premium increases or force employers to drop or severely limit coverage."(Henry J. Kaiser Family Foundation)

[Guidance Overview] The Implications of Losing'Grandfathered Plan'Status
Excerpt:"What many employers may not know . . . is that under new interim final regulations, if a fully insured health plan loses its grandfathered plan status, it will have to comply with the requirements of the tax code's'nondiscrimination'provisions, which prohibit a plan's more favorable treatment of highly compensated individuals. Prior to these regulations, these nondiscrimination requirements only applied to self-insured plans."(Fox Rothschild LLP)

[Guidance Overview] Internal and External Claims Review Guidance for Non-Grandfathered Health Plans (PDF)
6 pages. (Buck Consultants)

DOL Helping Make Sense of Health Care Reform
Excerpt:"[Phyllis Borzi talks about how] new regulations will affect employees and employers. Here, in an edited version, are her comments (supplemented with information from her department's website, www.dol.gov/ebsa)."(San Francisco Chronicle)

[Guidance Overview] Agency Regulations on Preventive Care under the Affordable Care Act
Excerpt:"Plan sponsors that have lost their grandfathered status -- or that are contemplating plan design changes that might have that impact -- should work with their insurers and plan administrators to determine what additional services will have to be covered."(The Segal Group, Inc.)

Employee Benefits in the United States, March 2009: Tables Organized by Ownership
Types of Ownership: Civilian (includes private industry and State and local government establishments); Private industry (excludes agricultural establishments, private households, and the self-employed); and, State and local government (excludes federal employees). (U.S. Bureau of Labor Statistics)

Employee Benefits in the United States, March 2009: Tables Organized by Benefit
Types of Benefits: Retirement Benefits; Health Care Benefits; Life, Short-term Disability, and Long-term Disability Insurance Benefits; Holiday, Vacation, Sick, and Other Leave Benefits; Other Benefits; and, Establishment Data. (U.S. Bureau of Labor Statistics)

Local Employer Pay-or-Play Laws: ERISA Preemption a Moot Issue?
Excerpt:"Following the enactment of the Patient Protection and Affordable Care Act (PPACA) and the sweeping changes it is making to the healthcare landscape, it appears the issue of whether existing non-Federal employer'pay-or-play'healthcare mandates are preempted by ERISA has been put on hold."(Deloitte)

How Will the Patient Protection and Affordable Care Act Affect Small, Medium, and Large Businesses?
Excerpt:"Larger firms are unlikely to experience significant changes in the coverage they provide but may face higher costs associated with increased take-up of the policies that they offer."(Urban Institute)