Health & Welfare

Wagner Law Group

Agencies Issue Regulations Restricting Surprise Billing

The Biden administration, through HHS, DOL, IRS and the Office of Personnel Management (collectively, the “Agencies”), issued an interim final rule that aims to restrict excessive out-of-pocket costs from “surprise billing” and balance billing. Beginning in 2022, the interim final rule bans surprise out-of-network and balance billing for individuals enrolled in employer-sponsored or marketplace ...

Court Rejects Health TPA’s Cross-Plan Offsetting Practice

The U.S. District Court for the District of New Jersey, in Lutz Surgical Partners PLLC v. Aetna, Inc., has ruled that a group health plan administrator (“TPA”) cannot offset overpayments made to a provider by one health plan it administers by reducing the amount paid to that provider by a different health plan.

DOL Says Claimant May Request Phone Call Recordings Relevant to Benefits Claim

The DOL has stated in a June 14, 2021 Information Letter, that under ERISA claims procedures, a participant must be given audio recordings of telephone conversations that are relevant to his claim for benefits.

Court Confirms Participant Must Exhaust Administrative Remedies Before Filing a Suit

The U.S. District Court for the Southern District of New York, in Benson vs. Tiffany and Company SPD, has ruled that a participant in an ERISA-governed group health plan may not proceed with her claim for denial of benefits because she failed to exhaust the administrative remedies available to her under the plan in a timely manner.

Court Reviews Requirements for Providing Adequate Notice of COBRA Rights

The U.S. District Court for the Eastern District of Michigan, in Green vs. FCA US, LLC, has ruled that a terminated employee could proceed with his claim against his former employer based on its failure to provide adequate notice of his right to health care continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”).  

IRS Finally Releases Guidance Implementing COBRA Subsidies but Leaves Important Questions Unanswered

By Dannae Delano, Barry Salkin and Roberta Casper Watson

IRS Explains Tax Treatment of Dependent Care Benefits Under New Rules

The IRS has issued Notice 2021-26 to explain the tax treatment of dependent care flexible spending account plan (“DCAP”) benefits under the Consolidated Appropriations Act (“CAA”) and the American Rescue Plan Act (“ARP”).

OOP Limits and Marketplace Special Enrollment Period

The U.S. Department of Health and Human Services (HHS) has announced the inflation-adjusted maximum out-of-pocket (OOP) limits that will apply to non-grandfathered plans for plan years beginning in 2022.  The OOP limit includes the plan’s deductible and cost sharing for essential health benefits (EHBs) under the Affordable Care Act (ACA). HHS has also clarified the duration of the special open ...

Ninth Circuit Confirms ERISA Preempts State-Law Claims Against Health Plan’s Insurer

The Ninth Circuit Court of Appeals has ruled, in Meyer vs. United Healthcare, that a health plan participant’s lawsuit alleging that the plan’s insurer violated state law by improperly handling his claim for medical benefits is preempted by ERISA.   

Will Federal Rules on Mental Health Parity Work This Time?

Agencies Issue Guidance Regarding Consolidated Appropriations Act, 2021 (“CAA”) Amendments to Mental Health Parity and Addiction Equity Act (“MHPAEA”)