HHS to Start Randomly Selecting Health Plans for HIPAA Compliance – Are You Ready?

The CMS Division of National Standards, on behalf of HHS, is launching the Compliance Review Program (the “Program”) to ensure compliance among covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.  HHS will randomly select health plans and clearinghouses to assess compliance with: (1) transaction formats; (2) code sets; and (3) unique identifiers.  Participants in the Program will also have to attest whether they comply with the operating rules, which are required by the ACA and are defined as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”

If HHS finds that a health plan or clearinghouse is not compliant, HHS has indicated that it will give the covered entity the opportunity to correct issues and achieve compliance, but may impose penalties on covered entities that do not achieve compliance.  Read More ›

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Wilderness Therapy – Should We Give It Another Look?

1.     What is it?

Wilderness therapy generally is traditional therapy in an outdoor setting that seeks to treat young adults with behavioral or substance use disorders.  Some programs are licensed and accredited and the treatment they provide can be expensive.  It is not uncommon for wilderness therapy to cost $500 per day or over $40,000 in total.

2.     Why should you care?

A participant in your employer-sponsored group health plan might submit a claim for wilderness therapy or request that your plan cover it.  If the terms of your plan exclude wilderness therapy or are ambiguous with respect to its coverage, and if you choose not to cover it, the participant might argue that your plan violates the Mental Health Parity Act of 1996 (MHPA) and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (collectively, “Federal Mental Health Parity Law”). Read More ›

Posted in Employee Benefits, Health & Welfare Plans, Health Care Reform | Tagged , , , ,

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Reminder for SBCs – Yes, Please!

The Affordable Care Act’s requirement that group health plans provide summaries of benefits and coverage (“SBCs”) to applicants and enrollees at various times is not new.  Nevertheless, because of the steep penalties for noncompliance (i.e., $1,000 per failure with respect to each participant or beneficiary and an excise tax of $100 per day with respect to each individual to whom such failure relates) we think it’s worthy of another blog post.  See our July 19, 2012 Newsletter Summary of Benefits and Coverage for Group Health Plans and follow-up August 11, 2016 blog post Departments Finally Publish Updated SBC Template and Instructions for additional background information. Read More ›

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New Plan Year, New Wellness Program – Some Things to Keep in Mind

As a follow-up to our recent blog Count Down to Open Enrollment – Some Quick Thoughts, below is a little more detail on how seemingly simple wellness program design changes can have significant legal consequences.

  • HIPAA – Employers feeling extra generous this plan year may want to increase their wellness program’s financial incentive.  It is important that such employers remain mindful of the limitations under HIPAA, i.e., 30% of the total cost of health plan coverage, or 50% for programs designed to prevent or reduce tobacco use.  As noted in our previous blog “Wellness Rules Under the ADA – Will There Ever Be Certainty?
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The Family Medical Leave Act and Benefit Plans: What comes first – the Law or the Employer’s Established Policy?

An employer that employs 50 or more employees for each working day during each of 20 or more calendar workweeks in the current or preceding calendar year is subject to the Family Medical Leave Act (“FMLA”). Therefore, often when I am reviewing an employee benefits plan or policy I flag language that states something like: “You may be eligible to continue your coverage pursuant to the FMLA. Contact the company for more information.”  What does this mean?

Group Health Plan

For purposes of the FMLA, a group health plan is generally a plan that provides health care to employees, former employees, or families of such employees or former employees. Read More ›

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Wellness Rules Under the ADA – Will There Ever Be Certainty?

We previously blogged about the EEOC’s final rules, published in the Federal Register on May 17, 2016, that explain how the Americans with Disabilities Act (“ADA”) applies to employer sponsored wellness programs. These rules clarified when an employee health program, which includes a disability-related inquiry or medical examination, is considered “voluntary” under the ADA.  The EEOC’s rules stated, amongst other things, that an employer may offer incentives for employees who participate in a wellness program as long as the incentive does not exceed 30% of the total cost of self-only coverage.

We also previously blogged that this incentive provision was under scrutiny by the U.S. Read More ›

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Air Ambulance Services – What Does Your Plan Cover?

Due to the increased litigation of air ambulance claims, employers may want to review their plan language to see whether their group health plan covers air ambulance services, and if so, to better understand the terms of the coverage.

Below are three issues employers may want to consider:

  1. Expensive and Often Out-of-Network.  Air ambulance claims can be very expensive. While a 2014 report from the National Association of Insurance Commissioners (“NAIC”) indicates that the average air ambulance trip is 52 miles and costs between $12,000 to $25,000 per flight, recent litigation shows that these claims can go into the hundreds of thousands of dollars. 
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New Disability Claims Regulations Take Effect for All Plans April 1, 2018

As noted in our previous blog post, The New Disability Claims Regulations: They Don’t Only Apply to Disability Plans, the Department of Labor (“DOL”) issued regulations that revise the ERISA claims procedure regulations for all employee benefit plans that provide disability benefits (the “New Regulations”).  These rules can impact not only short-term and long-term disability plans but also qualified retirement plans (e.g., a 401(k) plan), nonqualified retirement plans, and health and welfare plans.  The New Regulations were published in the Federal Register on December 19, 2016, and are based on the Affordable Care Act’s enhanced claims and appeals regulations for group health plans.  Read More ›

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The New Disability Claims Regulations: They Don’t Only Apply to Disability Plans

Introduction

The Department of Labor (“DOL”) issued regulations that revise the ERISA claims procedure regulations for employee benefit plans that provide disability benefits (the “New Disability Claims Regulations” or “New Regulations”).  They are based on the Affordable Care Act’s (the “ACA”) enhanced claims and appeals regulations for group health plans (the “ACA Enhanced Regulations”).  The scope of the New Regulations are broader than you may  realize and apply to any plan, regardless of how it is characterized, that provides benefits or rights that are contingent on whether the plan determines an individual to be disabled.  This can include ERISA governed short-term disability plans, long-term disability plans, qualified retirement plans (e.g., a 401(k) plan), nonqualified retirement plans, and health and welfare plans.  Read More ›

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Recent Mental Health Parity Guidance — A Good Reminder to Review Your Health Plan for Compliance

The Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”) generally requires that the financial requirements and treatment limitations that apply to mental health and substance use disorder (“MH/SUD”) benefits cannot be more restrictive than the financial requirements and treatment limitations that apply to medical and surgical (“M/S”) benefits.  Financial requirements include, for example, deductibles and coinsurance.  Treatment limitations can be quantitative (e.g., limits on the number of days or visits covered under the plan) or non-quantitative (“NQTL”) (e.g., requiring participants to obtain prior authorization before treatment).

The MHPAEA and its implementing regulations also require plan administrators to provide various disclosures upon request regarding MH/SUD benefits.  Read More ›

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