Health Plan Compliance

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Family building benefits continue to be top of mind as employers and plan sponsors implement new benefit programs to support family building journeys for their employees.  At the same time, there have been a few recent lawsuits challenging health plan eligibility criteria for infertility treatment coverage.  This post summarizes the recent litigation and challenges for…

As discussed in our prior blog post, on April 26, 2024, the Office for Civil Rights (“OCR”) at the Department of Health and Human Services (“HHS”) issued final regulations (“Reproductive Health Care Rule”) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) limiting the uses and disclosures of protected health information (“PHI”) in…

At the end of June, the U.S. Court of Appeals for the Fifth Circuit affirmed a district court order invalidating the Affordable Care Act preventive services mandate for “A” or “B” items and services recommended by the United States Preventive Services Task Force (USPSTF) on or after March 23, 2010, on the basis that the…

Today, the U.S. Supreme Court rejected a challenge to the U.S. Food and Drug Administration (FDA) approval of the drug mifepristone, which is used as part of a two-drug protocol to induce abortion.  The Court ruled that the providers seeking to overturn the FDA approval did not have standing, because the providers were not directly…

The Office for Civil Rights (“OCR”) at the Department of Health and Human Services (“HHS”) recently issued final regulations (“Reproductive Health Care Rule”) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) that narrow the permitted uses and disclosures of protected health information (“PHI”) in the context of an individual seeking, obtaining, providing…

The Departments of Labor, Treasury, and Health and Human Services (the “Departments”) recently issued guidance for group health plans outlining a “therapeutic equivalence” medical management technique for required preventive services coverage of contraceptives. The guidance, which was issued in the form of FAQs that can be downloaded here, builds on previous FAQs addressing required…

Last week, the Departments of Labor, Treasury and Health and Human Services (“the Departments”) issued an FAQ about the final Transparency in Coverage rules (“TiC Rules”). This FAQ addresses compliance with cost‑sharing disclosure requirements where a plan is providing cost estimates based on claims data but there is extremely low utilization of the item or…

As we approach December, the impending arrival of Santa Claus is no doubt dominating discussions in many households.  However, there is another, perhaps lesser known, “clause”-related item that health plan sponsors need to keep top of mind in the coming month. 

Specifically, as discussed in our blog found here, health plan sponsors must remember…

On November 9th, the IRS announced additional inflation adjustments for 2024, including to the annual contribution and carryover limits for healthcare flexible spending accounts and the monthly limit for qualified transportation fringe benefits. The IRS did not increase the annual contribution limit for dependent care flexible spending accounts because that limit is not indexed to…

Last week, the Departments of Labor, Treasury and Health and Human Services rolled back two non-enforcement policies related to the machine-readable file requirements included in the transparency in coverage (TIC) final rules: (1) deferred enforcement of the requirement that health plans post a machine-readable file listing negotiated rates and historical net prices for covered prescription drugs, and (2) an enforcement safe harbor with respect to the requirement that dollar amounts be listed in the in-network rate machine-readable file for items and services for which it is difficult to ascertain dollar amounts in advance. The guidance was released in the form of FAQs, which can be viewed here.

By way of brief background, for plan years starting on or after July 1, 2022, non-grandfathered health plans are required to post three machine-readable files (updated monthly) covering the following: (1) in-network rates (expressed as a dollar amount) for covered items and services, (2) allowed amounts for covered items and services furnished by out-of-network providers, and (3) negotiated rates and historical net prices for covered prescription drugs.