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FAQs Describe 2014 Safe Harbor Limit on Out-of-Pocket Maximums for Health Plans

A set of Frequently Asked Questions (?Ç£FAQs?Ç¥) posted on the U.S. Department of Labor?ÇÖs website describes a safe harbor provided under the Affordable Care Act (the ?Ç£Act?Ç¥) regarding compliance with the Act?ÇÖs annual limit on out-of-pocket maximums (?Ç£OOPMs?Ç¥).?á Under the Act, an OOPM under a non-grandfathered group health plan must (i) be applied on an overall basis to essential health benefits under the plan, and (ii) not exceed the Act?ÇÖs dollar limit, starting with the first plan year beginning on or after January 1, 2014. The safe harbor provides, for the 2014 plan year only, that if multiple service providers administer the benefits which are subject to the OOPM, the plan will be deemed to comply with the Act?ÇÖs limit if (a) the major medical coverage under the plan complies with the Act?ÇÖs limit, and (b) to the extent there is already an OOPM on the other coverage, the OOPM… Continue Reading

Court Overrules Self-Funded Benefit Plan?ÇÖs Claim Denial of ?Ç£Experimental?Ç¥ Procedure

A federal district court recently overruled a self-funded, group health plan?ÇÖs denial of benefits for a procedure that the plan determined to be ?Ç£experimental,?Ç¥ and thus not covered by the plan.?á The court reviewed the plan?ÇÖs benefit determination de novo, rather than applying the deferential standard of review that is available under ERISA, because the plan administrator, which had discretionary authority under the plan to interpret its terms, did not expressly delegate its discretionary authority to the employer?ÇÖs Benefits Appeal Committee that conducted the final claim review.?á Accordingly, the court gave no deference to the plan?ÇÖs final benefit determination, reviewed additional evidence related to the procedure in question that had not been considered by the committee, and concluded that the procedure was covered under the plan. Dubaich v. Conn. Gen. Life. Ins. Co., 2:11-cv-10570-DMG-AJW (C.D. Cal. July 31, 2013).

IRS Erroneously Issues Penalty Notices on Form 8955-SSA

It has come to our attention that a significant number of plan sponsors have recently received notices from the IRS that erroneously assess a penalty for filing a late or incomplete IRS Form 8955-SSA (Annual Registration Statement Identifying Separated Participants with Deferred Vested Benefits). We understand the IRS intends to inform those employers, within the next several weeks, that they can ignore the notices.

August 2013
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