It’s MLR Rebate Time Again!
The ACA requires insurers to submit an annual report to HHS to account for plan costs. If the insurer does not meet the medical loss ratio standards, this means too large a portion of the premiums charged in the previous year went towards the insurer’s administration, marketing, and profit, rather than going toward paying claims and quality improvement initiatives. In such case, the insurer must provide rebates to policyholders. For 2023, insurers must distribute rebates to employer plan sponsors between August 1, 2023, and September 30, 2023.
Employers should keep in mind that if they receive a rebate, there are strict guidelines as to how the rebate may be used or distributed. Generally, any portion of the rebate that is considered ERISA plan assets (e.g., the portion attributable to participant contributions) must be returned to participants in some form within 90 days of receipt.
For more information, download a copy of our publication, Medical Loss Ratio Rebates: A Guide for Employers.
COVID-19 National Emergency Outbreak Period Has Ended
Based on DOL FAQ guidance and subsequent commentary, the COVID-19 National Emergency Outbreak Period ended on July 10, 2023. This means that the tolling of certain ERISA plan deadlines (e.g., COBRA elections, payments and certain notices, HIPAA special enrollments, and claims and appeals filings) will no longer be required.
Accordingly, employers should work with legal counsel, TPAs, COBRA vendors and other service providers to ensure related plan documents, procedures and systems have been updated to accommodate the Outbreak Period end and subsequent reversion to pre-pandemic election, notice and payment timelines after July 10, 2023. Additionally, employers should ensure appropriate communications are provided to plan participants and COBRA beneficiaries regarding the applicable deadlines.
For further information, download a copy of End of COVID-19 Emergency Declarations: A Guide for Employers.
12-Month Contraception Coverage Mandate Goes into EffectAugust 17, 2023
Effective August 7, 2023, carriers and PBMs must provide coverage for the single dispensing or furnishing of contraception intended to last for a duration of 12 months (as permitted by the covered person's prescription) and dispensed or furnished at one time unless requested otherwise by a covered person.
Carriers and PBMs are also:
- Prohibited from implementing utilization management practices that prevent compliance with the 12-month mandate.
- Required to allow for alternate prescribed contraception, if medically necessary.
- Required to provide coverage for over-the-counter contraception without a prescription and without prior authorization, step therapy, utilization management, or cost-sharing.
Employers should contact their carriers or PBMs for further information.
District of ColumbiaAugust 17, 2023
On July 26, 2023, Mayor Muriel Bowser signed the Short-Term Disability Insurance Benefit Protection Clarification Emergency Amendment Act of 2023 (DC Act 25-204) into law.
The Emergency Act extends the prohibition of short-term disability policies reducing benefits (also known as offsetting benefits) based on an insured’s receipt of DC Paid Family and Medical Leave benefits. The prohibition applies to fully insured policies regardless of where the policy is issued but does not apply to self-insured plans.
As previously reported, this prohibition was initially effective in May 2021 on a temporary basis and has been extended multiple times since. Under the new Emergency Act, the prohibition will remain in place for at least 90 more days until October 24, 2023.
We will continue to report on any additional extensions.
KentuckyAugust 17, 2023
Recently, Gov. Beshear signed several healthcare bills into law.
HB 148 allows an insured to make a written assignment of substance abuse or mental health treatment benefits to a facility providing such services. Insurers may require the facility to, amongst other items, furnish information to an insured, including a statement if the facility is an out-of-network provider and that the facility may charge the insured for services not covered under the insurance contract, a schedule of applicable charges, and submit claims within ninety days of providing the service. The effective date of this Act is June 29, 2023, and applies to health insurance policies issued, delivered, or renewed on or after that date.
HB 170 creates a new health coverage mandate for insured plans in the state, requiring coverage for oocyte and sperm preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. Coverage shall include evaluation, laboratory assessments, medication and treatment, including obtaining, freezing, and storage for up to one year. The effective date of this Act is January 1, 2025, and applies to health insurance policies issued or renewed on or after that date.
HB 180 requires insured plans in Kentucky to cover testing for biomarkers, such as gene mutations or known gene-drug interactions, if supported by medical and scientific evidence to diagnose or treat an insured’s disease or condition. The effective date of this Act is January 1, 2024, and applies to health insurance policies issued, amended, or renewed on or after that date.
Employers that sponsor insured plans should be aware of these new laws and may want to contact their carrier for further information.
This material was created by PPI Benefit Solutions to provide accurate and reliable information on the subjects covered but should not be regarded as a complete analysis of these subjects. It is not intended to provide specific legal, tax or other professional advice. The service of an appropriate professional should be sought regarding your individual situation. PPI does not offer tax or legal advice. "PPI®" is a service mark of Professional Pensions, Inc., a subsidiary of NFP Corp. (NFP). All rights reserved.