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New Federal Reporting Requirements for Prescription Drug and Health Care Spending

The Consolidated Appropriations Act of 2021 (“CAA”) requires employer-sponsored group health plans to submit certain information about prescription drug and health care spending, premiums, and enrollment to HHS, the DOL, and the Treasury on an annual basis. Interim final rules were issued implementing this requirement, with enforcement delayed so that reporting for 2020 and 2021 is not due until December 27, 2022. However, employers are advised to contact their third party administrators and pharmacy benefit managers soon to determine if they will submit these reports on behalf of the group health plan and will be ready to do so by the deadline.  Although an employer with a self-funded group health plan may contract with a third party administrator and/or pharmacy benefit manager to handle these reporting requirements, the employer remains liable if there is a compliance failure.  The interim final rules are available here. 

HIPAA Breach by Express Scripts Vendor Triggers Plan Sponsor Actions

Many employers that sponsor a group health plan which is a “covered entity” subject to the HIPAA privacy and security rules have recently received notice from Express Scripts, Inc., a pharmacy benefit manager (“ESI”), regarding a cyberattack on the computer network of its subcontractor, Medical Review Institute of America (“MRIA”). This cyberattack apparently resulted in a HIPAA breach of current or former participants’ protected health information (“PHI”) under the plans. The breach notices were sent to the employers by ESI in its capacity as a HIPAA business associate of the plans.  A breach of unsecured PHI triggers notification obligations on the part of covered entities under HIPAA’s breach notification regulations (the “Breach Rules”), including (i) notifications to the individuals whose PHI was involved in the breach (the “Impacted Individuals”), and (ii) notification to HHS. Such notifications are subject to specific requirements of the Breach Rules, including content and timing requirements.   ESI’s… Continue Reading

Illinois State Law Imposes Group Health Coverage Disclosure Requirements

The Illinois Consumer Coverage Disclosure Act (the “CCDA”), which went into effect on August 27, 2021, requires an employer to notify employees in Illinois who are eligible for its group health plan whether such plan does or does not cover each of the essential health benefits identified by the Illinois Department of Labor (the “Illinois DOL”). The list of essential health benefits is available here. Because this is a disclosure requirement and not a benefits mandate, the Illinois DOL maintains that this requirement also applies to self-funded group health plans regulated by ERISA.  Employers must provide this disclosure to eligible employees (i) upon hire, (ii) annually thereafter, and (iii) upon request. The disclosure can be provided by emailing employees or by posting the information on a website that employees can regularly access. The Illinois DOL has the power to conduct inspections in connection with the CCDA’s disclosure requirements, and upon… Continue Reading

Are Your Employee Health and Other Welfare Benefits Fully Wrapped?

Many employers utilize “wrap plan” documents to consolidate their health and other employee welfare benefit programs into a single plan for ERISA purposes. Basically, a wrap plan document incorporates by reference the insurance policies and benefits booklets that comprise the entire plan. By consolidating employee welfare benefit programs into a single plan, a wrap plan document, when properly drafted, will ease the plan sponsor’s compliance obligations under ERISA’s plan document, reporting, and disclosure requirements. If welfare benefits are properly consolidated under a wrap plan, employers may be able to file a single Form 5500 for all their employee welfare benefit programs. Problems may arise if not all of the benefits programs that are considered ERISA “employee welfare benefit plans” are covered by the wrap document. It is thus critical that employers review all their welfare benefit programs to ensure they are properly covered under the wrap plan and included with the… Continue Reading

Reminder About Key 2021 Year-End Amendments

As the end of the calendar year approaches, plan sponsors are reminded to adopt certain amendments that may be required for their benefit plans to conform to regulations or reflect certain legal and/or plan design changes. Retirement Plans 2019 Required Amendments List In Notice 2019-64, the IRS published the 2019 Required Amendments List (the “List”), which lists the amendments required to be adopted by December 31, 2021. Pursuant to the List, plans offering hardship distributions must be amended in accordance with the final regulations issued under the Bipartisan Budget Act of 2018. In addition, the List provides that collectively bargained cash balance/hybrid defined benefit plans maintained pursuant to collective bargaining agreements ratified on or before November 13, 2015 must be amended to comply with the final cash balance/hybrid plan regulations. The List also includes certain periodic changes that took effect in 2019, such as adjustments to various dollar limits for… Continue Reading

Federal District Court Rules that Cross-Plan Offsetting Violates ERISA

Cross-plan offsetting is a practice that is used by third-party administrators (“TPAs”) of employer-sponsored group health plans as a means of recouping a benefit payment that was purportedly overpaid to an out-of-network health care provider under one plan by reducing the benefit payment owed to the same provider under another entirely separate plan. This practice has raised fiduciary compliance issues under ERISA and has frequently been the subject of litigation. Recently, in Lutz Surgical Partners, PLLC, et al. v. Aetna, Inc., et al.¸ a federal district court in New Jersey held that Aetna’s use of cross-plan offsetting violated ERISA. Under ERISA, a plan fiduciary may not, “in his individual or in any other capacity act in any transaction involving the plan on behalf of a party (or represent a party) whose interests are adverse to the interests of the plan or the interests of its participants or beneficiaries.” In addition, ERISA… Continue Reading

As Plan Administrator, the Employer is Liable – Not the Service Provider (i.e., What Kind of Indemnification Are You Getting?)

The plan administrator of an employee benefit plan (employee welfare or retirement) has the general fiduciary responsibility under ERISA to ensure the operational and documentary compliance of the plan. Under ERISA, the sponsoring employer is the plan administrator unless another person or entity is named in the plan. This generally means the employer retains ultimate responsibility and liability for legal compliance even though the employer may rely heavily on the plan’s third-party service providers. One way to mitigate this liability is to obtain indemnification from a service provider for the service provider’s errors, for which the employer (as plan administrator) would still be legally liable. The default language in third-party service provider contracts often provides indemnification only for the service provider’s “gross negligence”, but not its “ordinary negligence”, thus leaving the employer responsible for correcting (and paying for) errors caused by the service provider that do not amount to “gross negligence” or “intentional… Continue Reading

Keeping Your Wellness Program Healthy

For years, employers have used wellness programs with the hope they would help improve employees’ overall health while simultaneously reducing group health plan costs. The pandemic has presented challenges for wellness programs though, as employees have found it more difficult to meet the requirements for discounts because of lockdowns and fears of COVID-19. To address these challenges, some employers are considering modifications to their programs to allow employees to qualify for discounts if they obtain a flu or COVID-19 vaccine. Before adopting any changes, employers should use caution, as wellness programs are subject to numerous legal requirements, including requirements under the ACA, ERISA, HIPAA, and the Americans with Disabilities Act. By carefully evaluating changes and considering the myriad of legal requirements applicable to wellness programs prior to implementing any changes, plan sponsors can avoid jeopardizing the legal health of their wellness programs.  Our prior blog posts regarding wellness program compliance… Continue Reading

New COBRA Subsidy Guidance Addresses Outstanding Issues

The IRS recently issued Notice 2021-46 (the “Notice”), which provides new guidance in the form of FAQs regarding the application of the COBRA premium assistance provisions of the American Rescue Plan Act of 2021 (the “COBRA Subsidy”). The Notice supplements the IRS’s prior Notice 2021-31 regarding the COBRA Subsidy and addresses additional matters. Issues addressed in the Notice include, among others, (i) the availability of the COBRA Subsidy in situations where an individual is entitled to notify the plan administrator, but has not yet done so, of his or her eligibility for an extended COBRA coverage period due to a disability determination or the occurrence of a second COBRA qualifying event, (ii) the loss of an individual’s entitlement to the COBRA Subsidy with respect to dental and vision coverage when he or she becomes eligible to enroll in other group health plan coverage or Medicare that does not provide dental… Continue Reading

ERISA Lawsuit Alleging Worker Misclassification Is A Reminder to Employers to Monitor Their Employee Classifications

A plaintiff recently filed suit against Yum! Brands, Inc. (“Yum”), Taco Bell Corp. (“Taco Bell,” together with Yum referred to herein as, the “Employers”), and various other defendants under ERISA over the alleged misclassification of his employment status. The complaint states that common law employees were eligible to participate in certain retirement plans maintained by the Employers (collectively, the “Plans”) pursuant to the Plans’ governing documents. The plaintiff alleges he met the common law test for employee status but was classified as an independent contractor, instead of an employee, during his 25 years of employment. Specifically, the plaintiff alleges that during the relevant employment periods, the Employers controlled the work he performed and the manner and means by which he performed his work, such as by directing the specific order and sequence of his work and requiring him to attend employee-only events and meetings. The plaintiff further alleges that other… Continue Reading

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