Health & Welfare

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.

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”)

Court Finds Cost of Heart Transplant Could Be Appropriate Equitable Remedy

A federal district court has ruled, in Rose vs. PSA Airlines, Inc. Group Insurance Plan, that a decedent’s estate may be entitled to recover the cost of a heart transplant as equitable relief under ERISA. 

Court Says Group Health Plan May Not Exclude Specified Autism Treatments

The District Court for the Northern District of California has ruled, in Doe v. United Behavioral Health, that the exclusion of certain specified procedures related to the treatment of autism violates the Mental Health Parity and Addiction Equity Act (“MHPAEA”).

CMS Creates Additional Marketplace Special Enrollment Period

The Centers for Medicare & Medicaid Services (“CMS”) has determined that the COVID-19 emergency presents exceptional circumstances for consumers in accessing health insurance, and will be providing a new Special Enrollment Period (“SEP”) allowing individuals and families to enroll in individual coverage through the ACA Marketplace.

FAQs Discuss Expiration of Paid Sick and Family Leave Requirements

The Department of Labor has issued additional FAQs regarding the expiration of the requirement that employers provide paid sick and family leave under the Families First Coronavirus Response Act (“FFCRA”).

Arkansas Pharmacy Law Not Preempted by ERISA

In Pharmaceutical Care Management Association v. Rutledge, the U.S. Supreme Court has held that ERISA does not preempt an Arkansas statute that imposes rules on pharmacy benefits managers (“PBMs”).