It’s MLR Rebate Time Again!
The ACA requires insurers to submit an annual report to HHS accounting for plan costs. If the insurer does not meet the medical loss ratio standards, they must provide rebates to policyholders. Rebates must be distributed to employer plan sponsors between August 1, 2022, and September 30, 2022. 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.
For more information, please see our recent FAQ.
Medicare Part D Notice to Employees Deadline Is October 14, 2022
Employers must notify individuals who are eligible to participate in their medical plan whether the plan's prescription drug coverage is "creditable" or "non-creditable" as compared to Medicare Part D coverage.
As a reminder, the Medicare Part D notice of creditable coverage should be distributed to employees by October 14, 2022. This notice serves to inform Medicare-eligible individuals of whether or not their employer group coverage is creditable. That information is necessary to help such individuals avoid paying higher premiums (also known as late enrollment penalties) for Medicare Part D coverage.
Employers should consult with their service providers to determine whether their coverage is creditable using either the simplified determination method or actuarial analysis. Also, keep in mind that CMS provides a model notice for employers.
We are a large employer subject to the employer mandate. One of our employees just switched from full-time to part-time. When should we terminate coverage?
State Issues Further Regulations Implementing Family and Medical Leave Law
September 13, 2022
On August 26, 2022, the Department of Labor and Employment’s Division of Family and Medical Leave Insurance (the division) adopted rules on benefits and employer participation in the state’s Family and Medical Leave Insurance program (FMLI). We covered FMLI and earlier rules issued by the division in the May 24, 2022, edition of Compliance Corner.
Although the program does not start until January 1, 2024, the new rules require employers (even those who choose to use a private plan rather than the state plan) to register with the division by January 1, 2023. Employers must also submit wage reports on the same schedule that they remit their premiums. An employer with no Colorado employees will not be required to remit premiums, submit wage reports or otherwise participate in the FAMLI program.
The new rules also outline the procedure for employees to apply for the benefit. Employees must apply to the division 30 days before the expected start date of the leave, although they can have up to 30 days after the leave begins to apply if the circumstances warrant it. The division informs both the employer and the employee that the application is properly filed within five business days and determines whether the applicant qualifies for the benefit within two weeks after the application is submitted. The rules also allow employers to require their employees to let them know of the need for the leave independently of the application to the division, in the same manner as requests for other leave as required by employer policy.
The division will inform both the employer and the employee of its determination. If the division grants the benefit, it will also inform both parties of the duration of the leave. If the employer requests it, the division will also provide the employer with limited information necessary for the employer to coordinate FAMLI benefits with other benefits for which the claimant is eligible, including the wage replacement amount and the reason for leave. Such information provided by the division must be stored and maintained in accordance with all applicable federal, state, and local confidentiality laws and regulations.
The new rules give the employer and employee the right to appeal the division’s determination. An employer may file a grievance with the division if it has a good-faith belief, supported by evidence, that the division has granted benefits to an employee either in violation of the FAMLI Act or if the grant unduly disrupts the employer’s operations. Employees can appeal a denied application within 30 days of the adverse decision; the division will designate a hearing officer and hold an appeal hearing, in which both the employer and employee can participate. The hearing officer’s decision is subject to judicial review.
The new rules also impose certain obligations upon an employee on this leave, including the obligation to inform the division of any change that could affect the duration of that leave. If the division adjusts the duration of the leave as a result, then the division will inform the employer.
In addition to these procedural rules, the new regulations include some clarifications. For instance, a “covered individual” who may receive benefits is one who has earned $2,500.00 from any combination of employers, and a claimant need not earn $2,500.00 from their current employer to meet the threshold. In addition, the division will determine whether a person is considered a “family member” whose serious health condition warrants a grant of benefit to an applying employee by considering not only a significant personal bond that is or is like a family relationship, but also several other factors while looking at the totality of the circumstances surrounding the relationship.
Employers with Colorado employees should be aware of these new clarifications and procedures.
Guidance Addresses Coverage for Monkeypox Virus Testing, Diagnosis and Immunization
September 13, 2022
On August 31, 2022, the Department of Financial Services (DFS) issued Circular Letter No. 12 to advise health insurers of the coverage requirements for monkeypox virus testing, diagnosis and immunization. The memo follows Gov. Hochul’s declaration of a state disaster emergency to combat the spread of the monkeypox virus on July 29, 2022, and the issuance of Executive Order No. 20.1 (EO 20.1) on August 28, 2022. EO 20.1 was issued to ensure that health insurance coverage requirements and cost-sharing do not impede monkeypox virus immunization, testing and diagnosis.
Generally, state insurance laws require individual, small group and large group comprehensive health insurance policies, excluding grandfathered health plans, to provide coverage at no cost-sharing for immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention. However, EO 20.1 ensures that insurers cover the monkeypox virus vaccine and administration for all eligible persons, including persons covered under grandfathered plans, regardless of whether they fall within the specific ACIP recommendation. EO 20.1 temporarily modifies the state insurance laws to require coverage of the monkeypox virus immunization and administration without any cost-sharing when provided in-network or out-of-network.
With respect to monkeypox virus testing and diagnosis, EO 20.1 temporarily modifies state insurance laws governing small and large group coverage requirements to waive cost-sharing for in-network laboratory testing to diagnose the monkeypox virus; and visits to diagnose the monkeypox virus at an in-network provider’s office, an in-network urgent care center, any other in-network outpatient provider setting able to diagnose monkeypox or an emergency department of a hospital. Insurers must provide written notification to in-network providers that they shall not collect any deductible, copayment or coinsurance. However, cost-sharing may be imposed for any follow-up care or treatment for the monkeypox virus, including an inpatient hospital admission, in accordance with the applicable policy, as permitted by law. Additionally, a deductible may be applied for high deductible health plans if otherwise required by law.
The letter also reminds insurers that an otherwise covered service, including the diagnosis of the monkeypox virus, cannot be excluded due to delivery via telehealth and must be reimbursed on the same basis and at the same rate as when delivered in person. Insurers must also maintain an adequate network to meet telehealth needs. Finally, the letter emphasizes that insurers should dedicate resources to providing accurate and timely coverage information to covered individuals, including making all necessary and useful information available on websites.
Although the letter is primarily directed at insurers, employers that offer group health coverage issued in New York should be aware of the updated coverage requirements.
Bulletin Announces Increase in Annual Maximum Benefit for Behavioral Therapy Coverage
September 13, 2022
On September 6, 2022, the Department of Insurance issued Bulletin No. 2022-10 to announce the indexed increase in the annual maximum benefit for behavioral therapy coverage. The bulletin was directed at HMOs and carriers writing insurance in the state.
State law requires that an annual adjustment of the maximum benefit for behavioral therapy coverage be made to reflect any change from the previous year in the Consumer Price Index. Accordingly, the department determined that the maximum benefit for coverage for behavioral therapy shall be increased to $67,300 for the calendar year beginning January 1, 2023.
Although the guidance is directed at insurers, employers that sponsor group health plans may also want to be aware of this announcement.
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.