The Internal Revenue Service, Department of Labor, and Department of Health and Human Services (the “Agencies”) have issued a revised, mandatory notice for fixed indemnity insurance coverage....
Health & Welfare
Employee Must Provide Adequate Notice of Need for FMLA Leave
The U.S. Court of Appeals for the Fifth Circuit has ruled, in Cerda v. Blue Cube Operations, that an employee was not protected by the Family and Medical Leave Act (“FMLA”) when she never gave the...
Agencies Revise Short-Term Health Insurance Regulations
HHS, DOL and IRS (the “Agencies”) have jointly issued revised final regulations reducing the maximum duration of short-term, limited-duration health insurance (“STLDHI”) coverage. Background. ...
COBRA Compliance: Employer Tips From Audit Guidelines and Class Action Litigation
COBRA Compliance: Employer Tips From Audit Guidelines and Class Action Litigation - Dannae Delano and Linda Stuessi, panelists, Lorman Education Services live CLE webinar, May 15, 2024, 1:00 - 2:05...
Insurer May Be Liable Under ERISA for Unauthorized Premium Increases
The U.S. Court of Appeals for the First Circuit, in Parameter v. Prudential Insurance and Tufts University, has ruled that an insurer may have breached its fiduciary duty through unauthorized...
IRS Warns Companies are Making False Statements About Health Plan Reimbursements
In IR-2024-65 (the “IR”), the IRS warns taxpayers that some companies are misrepresenting the circumstances under which food and wellness expenses can be paid or reimbursed under health flexible...
LTD Plan Must Consider Future Harm from Stress
In Aisenberg v. Reliance Standard Life Ins. Co., the United States District Court for the Eastern District of Virginia has ruled that a long term disability (“LTD”) plan must take into account...
Court Finds Health Plan Not Required to Furnish Administrative Service Agreements in Response to ERISA Document Request
In Zavislak v. Netflix, Inc., the U.S. District Court for the Northern District of California has largely rejected a plaintiff’s assertion that an employer/plan administrator for an ERISA...
IRS Announces Decreased 2025 Employer Shared Responsibility Penalties
In Revenue Procedure 2024-14, the IRS has announced the 2025 penalty rates for violations of the employer shared responsibility provisions of the Affordable Care Act (“ACA”). Background. Under the...
ICHRAs: The New Health Care Benefit for Advisors to Learn in 2024
ICHRAs: The New Health Care Benefit for Advisors to Learn in 2024 - Thomas Clark, Jr., 401(k) Specialist Magazine, February 5, 2024 (PDF)
DOL Updates FMLA Fact Sheets
To assist in employer and employee compliance, the Department of Labor (“DOL”) has issued several revised Family and Medical Leave Act (“FMLA”) Fact Sheets, including Fact Sheet 28D: Employer...
Johnson & Johnson Case Signals Employee Drug Price Suits to Come
Johnson & Johnson Case Signals Employee Drug Price Suits to Come - Roberta Casper Watson, Bloomberg Law, February 9, 2024 (PDF)
Agencies Update Non-English Language Requirements
The Departments of Labor and Health and Human Services, and the IRS (“the Agencies”) have issued Frequently Asked Questions About Affordable Care Act (“ACA”) and Consolidated Appropriations Act,...
DOL Announces Indexed Penalties for Health and Welfare Plans
The Department of Labor released a final rule that provides new figures reflecting the adjusted civil penalty amounts for 2024, for certain health and welfare plan violations. The DOL is required...
Workers Poised to Get Benefits as Rule Creates ‘Employees’
Workers Poised to Get Benefits as Rule Creates ‘Employees’ - Roberta Casper Watson, Bloomberg Law, January 29, 2024 (PDF)
Plan Insurer Held Liable for Failure to Follow Claims Procedures
The U.S. District Court for the District of Utah, in R.E. v. Blue Cross Blue Shield, has ruled that the failure to properly follow ERISA’s claims procedures may result in a reversal of a claims...
State Law Claims Preempted By ERISA
In Steigleman v. Symetra Life, the U.S. District Court for the District of Arizona has ruled that a small business owner could not sue an insurance company under state law for long term disability...
DOL Sues Blue Cross Blue Shield Minnesota for Collecting $66.8M in Provider Tax
DOL Sues Blue Cross Blue Shield Minnesota for Collecting $66.8M in Provider Tax - Andrew Oringer, PLANSPONSOR, January 17, 2024 (PDF)
LTD Insurer May Subsequently Reverse Disability Determination
The U.S. District Court for the Southern District of Florida has ruled, in Delucca v. The Guardian Life Insurance Company of America, that a long term disability (“LTD”) plan was not bound by prior...
Compliance Issues for Employer Health and Welfare Plans: Fees, Services, Plan Contracts, Reporting, Audits
Compliance Issues for Employer Health and Welfare Plans: Fees, Services, Plan Contracts, Reporting, Audits - Dannae Delano, panelist, Strafford live CLE webinar, January 4. 2024 - Click here for...
DOL Proposes Rescission of Association Health Plan Rules
The Department of Labor (“DOL”) has proposed that the Association Health Plan (“AHP”) regulations be revoked and replaced with stricter standards that provide additional employee protections....
Eleventh Circuit Adopts Strict Standard for FMLA Claims
The Eleventh Circuit Court of Appeals, in Lapham v. Walgreen Co., has ruled that the “but for” legal standard applies to Family and Medical Leave Act (“FMLA”) retaliation claims. Law. The FMLA...
DOL Proposes to Rescind 2018 Association Health Plan Rule
DOL Proposes to Rescind 2018 Association Health Plan Rule - Roberta Casper Watson, PLANSPONSOR, December 22, 2023 (PDF)
Plan Must Consider All “Independent Grounds” for Claims Coverage
The U.S. Court of Appeals for the Tenth Circuit, in Ian C. v. UnitedHealthcare Ins. Co., has ruled that a group health plan violated ERISA’s claims procedures by failing to separately evaluate each...
2025 ACA Out-of-Pocket Limits
The U.S. Department of Health and Human Services (“HHS”) has announced the proposed maximum out-of-pocket (“OOP”) limits that will apply to non-grandfathered plans for plan years beginning in...
Participant May Sue Plan for Facial Feminization Surgery Coverage
The United States District Court for the Eastern District of Pennsylvania, in Doe v. Independence Blue Cross, declined to dismiss a participant’s lawsuit claiming that a group health plan covered...
IRS Announces PCORI Fee
IRS has released Notice 2023-70, which provides the “applicable dollar amount” for the Patient-Centered Outcomes Research Institute (“ PCORI” ) fee for plan years ending before October 1, 2024....
CMS Announces Medicare Part A Deductibles and Part B Premiums for 2024
The Centers for Medicare & Medicaid Services (“CMS”) has announced the 2024 premiums, deductibles and coinsurance amounts for the Medicare Part A and Part B programs. Medicare Part A covers...
IRS Notice on Treatment of Leave-Based Donation Programs
In response to an extreme need for charitable relief by victims of the Hawaiian wildfires that began on August 8, 2023, the IRS has issued Notice 2023-69 (the “Notice”) to provide guidance under the...
Participant May Receive Monetary Damages for Plan’s Failure to Approve Procedure
In Rose v. PSA Airlines, Inc., the Fourth Circuit Court of Appeals ruled that a self-funded group health plan may be sued for monetary damages for failure to approve a medical procedure for a plan...
Court Rules ERISA Preempts Oklahoma Law Regulating PBMs
The U.S. Court of Appeals for the Tenth Circuit, in Pharmaceutical Care Management v. Mulready, has ruled that a state law regulating pharmacy benefit managers (“PBMs”) is preempted by the Employee...
Guidelines for Mental Health and Medical/Surgical Claims Need Not Be Identical
The U S District Court for the District of Utah has ruled, in L.D. v. United HealthCare, that a group health plan does not violate the Mental Health Parity and Addiction Equity Act (“MHPAEA”) if it...
COBRA Notice Need Not Be Single Notification
In deciding Bryant v. Walgreen Co., the U.S. District Court for the Northern District of Illinois addressed several important aspects of the COBRA notification requirements. Law. Employers must...
Claims Denial Overturned for Failure to Follow Claims Procedures
The U.S. Court of Appeals for the Tenth Circuit, in David P. v. United Healthcare Ins. Co., has reversed a group health plan’s benefits claim denial because the plan’s claims administrator failed to...
HHS Issues Warning About Online Tracking
The Office of Civil Rights (“OCR”) at the U.S. Department of Health and Human Services (“HHS”) and the Federal Trade Commission (“FTC”) have issued a letter, dated July 20, 2023 (the “Letter”),...
DOL Revises Medicaid/CHIP Model Notice
The Department of Labor (“DOL”) has released a revised Model Notice for employers to use to inform employees about the potential for them to receive state-provided premium assistance subsidies to...
Failure to Follow Claims Regulations Results in De Novo Review
The U.S. District Court for the Southern District of New York, in Rhodes v. First Reliance, has ruled that an insurer’s denial of a long-term disability (“LTD”) claim must be reviewed under the de...
Departments Consider Potential Safe Harbor for Nonquantitative Treatment Limitations under the Mental Health Parity and Addiction Equity Act Regarding Network Adequacy
By Dannae Delano, Roberta Casper Watson and Barry Salkin On July 25, the Departments of Treasury, Labor, and Health and Human Services (the “Departments”) issued proposed regulations and other...
Agencies Issue Proposed Regulations on Mental Health Parity Implementation
HHS, DOL and IRS (collectively, the “Agencies”) have jointly issued proposed regulations to provide guidance on the implementation of the requirements of the Mental Health Parity and Addiction...
CMS Recommends Extension of Special Enrollment for Individuals Losing Medicaid and CHIP
By Roberta Watson, Dannae Delano and Barry Salkin Employers frequently provide group health plan coverage for their employees through pre-tax contributions to a cafeteria plan. Elections under a...
Departments Issue Guidance on No Surprises Act and Limitations on Cost Sharing Under the Affordable Care Act
By Dannae Delano, Roberta Watson and Barry Salkin In FAQ Part 60, the Departments of Health and Human Service, Treasury, and Labor (the “Departments”) addressed limitations on cost sharing under the...
Plan Penalized for Failure to Follow Its Own Provisions
In Laake v. Benefits Committee, Western & Southern Financial Group Co., the U.S. Court of Appeals for the Sixth Circuit determined that the de novo standard of review applies where an employer’s...
Reservists Must Receive Paid Administrative Leave Benefits
In Myrick v City of Hoover, the U.S. Court of Appeals for the 11th Circuit has ruled that military reservists must be treated as if they were on paid leave for purposes of the Uniformed Services...
Plan May Exclude Certain Specified Emergency Services
The U.S. Court of Appeals for the Eighth Circuit has ruled, in Shafer v. Zimmerman Transfer, that a group health plan does not have to pay for emergency services specifically excluded by the plan...
FAQ Clarifies Status of In-Network Providers, Facility Fees
FAQ Clarifies Status of In-Network Providers, Facility Fees - Roberta Casper Watson, PLANSPONSOR, July 10, 2023 (PDF)
EBSA Publishes Regulatory Update on Health Facility Fees, Provider Networks
EBSA Publishes Regulatory Update on Health Facility Fees, Provider Networks - Roberta Casper Watson, planadviser, July 7, 2023 (PDF)
IRS Issues HDHP Guidance for End of COVID Emergency Period
In response to the ending of the COVID-19 public health emergency and national emergency, the IRS has issued Notice 2023-37, which modifies its prior guidance on benefits relating to the testing and...
IRS Releases Guidance Denying Favorable Tax Treatment to Certain Wellness Program Incentive Payments
IRS has released guidance, in the form of Chief Counsel Memorandum Number: 202323006 (the “Memorandum”), denying favorable tax treatment to wellness incentive program payments provided through...
DOL Provides Guidance About Holidays During FMLA Leave
The Department of Labor (“DOL”) has issued Opinion Letter FMLA 2023-2-A (the “Letter”) to clarify how the amount of leave used is calculated when an employee takes Family and Medical Leave Act...
Massachusetts Division of Insurance Provides Special Enrollment Period for Loss of COBRA Coverage
By Dannae Delano, Barry Salkin and Roberta Casper Watson As we have previously described in client alerts, the end of the National Emergency and the cessation of the outbreak period on July 10,...