Posted By cmonfils on December 2, 2011
Applying the traditional equitable principle of unjust enrichment, we conclude that the judgment requiring McCutchen to provide full reimbursement to US Airways constitutes inappropriate and inequitable relief. Because the amount of the judgment exceeds the net amount of McCutchen’s third-party recovery, it leaves him with less than full payment for his emergency medical bills, thus undermining the entire purpose of the Plan. At the same time, it amounts to a windfall for US Airways, which did not exercise its subrogation rights or contribute to the cost of obtaining the third-party recovery. Equity abhors a windfall. See Prudential Ins. Co. of America v. S.S. American Lancer, 870 F.2d 867, 871 (2d Cir. 1989).
Category: 3rd, Subrogation |
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Posted By cmonfils on December 2, 2011
In the summer of 2011, the Departments of Labor, Treasury and Health and Human Services (HHS) released a long-awaited proposed rule and draft template of a new uniform Summary of Benefits and Coverage (SBC) required by the Affordable Care Act.1 The purpose of the new SBC is to allow individuals to easily compare health coverage options when shopping for or enrolling in group or individual health coverage. The proposed rule2 incorporated the Affordable Care Act’s requirement that health plans and health insurance issuers would start using the template beginning March 23, 2012, but requested comments on the feasibility of that time frame.3
Category: Health Care Legislation, Health Insurance, HHS |
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Posted By cmonfils on December 2, 2011
November 21, 2011 (PLANSPONSOR.com) – A new survey from Aon Hewitt, The Futures Company and the National Business Group on Health, reveals consumers want their employers to do more to help them improve their health and get the most from their employer-provided health and wellness plans.
Under continued pressure to mitigate costs and adjust to new regulations, employers are continuing to carefully consider the future of their employer-provided health plans. However, as they adjust their plan design and wellness strategies, the survey finds many employers aren’t aligning these strategies with the goals, needs and concerns of their employees.
Category: Wellness |
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Posted By cmonfils on December 2, 2011
The Hill writes that letting the 2010 health law stand without the individual mandate is the worst possible outcome for insurers. Meanwhile, CQ looks into the Medicaid expansion issue and demands for Kagan and Thomas to recuse themselves.
The Hill: Insurers ‘Terrified’ Of Supreme Court Ruling On Health Care Reform Law
The insurance industry is terrified that the Supreme Court will strike down the individual mandate to buy insurance next year while leaving the rest of the healthcare reform law intact. For insurers, the death of the mandate alone — one of many plausible outcomes in the blockbuster case — is the nightmare scenario, one Republican healthcare lobbyist told The Hill. ”They’re terrified they’re going to be left holding the bag,” the lobbyist said (Pecquet, 11/22).
Category: Health Care Legislation, Health Insurance |
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Posted By cmonfils on November 30, 2011
In a Frequently Asked Question (“FAQ”), the Departments of Health & Human Services, Labor, and the Treasury (the “Departments”) stated that group health plans are not required to comply with the Summary of Benefits and Coverage and Uniform Glossary requirement until final regulations are issued.
On August 22, 2011, the Departments issued proposed regulations that require group health plans subject to the Patient Protection and Affordable Care Act to furnish a Summary of Benefits and Coverage and Uniform Glossary to plan participants and beneficiaries (the “Summary Requirement”). At that time, the Departments also issued a proposed template for compliance with the Summary Requirement and proposed an effective date of March 23, 2012.
http://www.reedsmith.com/publications/search_publications.cfm?widCall1=customWidgets.content_view_1&cit_id=32734
Category: Health Care Legislation, HHS, PPACA |
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Posted By cmonfils on November 30, 2011
The US Court of Appeals for the Third Circuit held that, under ERISA Section 502(a)(3), an employee benefit plan was not entitled to full reimbursement for medical expenses it incurred on behalf of a participant and was limited by equitable principles and defenses to “appropriate” relief, despite plan language specifying full reimbursement. In its decision in US Airways v. McCutchen, the court held that the plan could not recover the full cost of the participant’s medical expenses when the participant recovered less from a third party.
Category: 3rd, ERISA, Reimbursement |
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Posted By cmonfils on November 30, 2011
The U.S. Department of Health and Human Services’ Office for Civil Rights released plans to audit 150 covered entities under its pilot HIPAA audit program. Covered entities should review HIPAA compliance policies and complete a security risk assessment to ready themselves for potential audit.
On November 8, 2011, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) published on its
website the details of its pilot program to perform up to 150 audits of compliance with the privacy, security and breach notification standards (collectively, the Standards) adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act) between November 2011 and December 2012 (the Pilot Audit Program).
Category: HHS, HIPAA |
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Posted By cmonfils on November 30, 2011
On November 17, 2011, the Department of Labor (DOL) issued responses to frequently asked questions (FAQs) on health care reform and the Mental Health Parity and Addiction Equity Act of 2008. The FAQs provide guidance on the health plan benefits summary requirement under health care reform, and they also clarify the permissible nonquantitative limitations that health plans may apply to mental health and substance abuse benefits.
Category: DOL, Health Care Legislation, Mental Health Parity |
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Posted By cmonfils on November 30, 2011
WASHINGTON — The Supreme Court on Friday made two prominent Washington lawyers very happy and very busy, appointing them to argue on behalf of positions that neither side in the challenges to the 2010 health care law has chosen to embrace.
Category: Health Care Legislation, Supreme Court |
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Posted By cmonfils on November 30, 2011
St. Louis – August 2011 – How can employers and governments encourage individuals to practice healthier behaviors? How can companies get their workers to stop smoking, watch what they eat, consume less alcohol, take their medicine and change their diet? One of the most promising methods is to offer incentives within corporate sponsored wellness programs, according to a new study from the Incentive Research Foundation (IRF). The study affirms the role and success of wellness incentive programs – important findings in light of the forthcoming 2014 implementation of the Patient Protection and Affordable Care Act’s provisions that increases the potential funding of wellness incentives to equal as much as 50 percent of the per worker total health care premium.
Category: Health Insurance, Wellness |
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Posted By cmonfils on November 30, 2011
WASHINGTON — A dispute has erupted between President Obama and Democrats in Congress over a proposal to broaden the exemption from new rules that require health insurance plans to cover contraceptives for women free of charge.
Category: Health Care Legislation |
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Posted By cmonfils on November 30, 2011
In a case of significant importance for plan sponsors and fiduciaries, the U.S. Court of Appeals for the Third Circuit held in US Airways, Inc. v. McCutchen, No. 10-3836 (3d Cir. Nov. 16, 2011), that an employee benefit plan was not entitled to full reimbursement of medical expenses it paid to a participant even though the plan provided that the participant was required to reimburse the plan for all amounts paid “out of any monies recovered from a third party.” The Court found that, because the participant had not received a complete recovery for his injuries in collateral litigation, full reimbursement to the plan would not be consistent with the terms of Section 502(a)(3) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132(a)(3), which limits recovery to “appropriate equitable relief.”
Category: 3rd, ERISA, Reimbursement |
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Posted By cmonfils on November 30, 2011
Jonathan Gruber, an M.I.T. professor and a key intellectual architect of President Obama’s overhaul of the American health care system, said, “You know, I think basically, what they’ve constructed, the Affordable Health Act, is the best possible private-sector
Category: Health Care Legislation, Supreme Court |
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Posted By cmonfils on November 30, 2011
The U.S. Department of Health and Human Services Office for Civil Rights (“OCR”) announced last week that it has begun formal auditing of covered entities under HIPAA. The action is not unexpected; the American Recovery and Reinvestment Act of 2009 (“ARRA”) required OCR to conduct the audits. However, the announcement, along with ARRA’s increased penalties for not complying with HIPAA, may cause covered entities and business associates to refocus on HIPAA’s requirements.
Category: HHS, HIPAA |
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Posted By cmonfils on November 30, 2011
from Spencer’s Benefits Reports: The Equal Employment Opportunity Commission’s (EEOC) Age Discrimination in Employment Act (ADEA) exemption for coordination with Medicare applies only to retiree benefits, not the benefits of current employees, the EEOC Office of Legal Counsel staff confirmed in an informal discussion letter in response to an inquiry from a member of the public.
Category: Medicare |
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