There has been a recent rise in Employee Retirement Income Security Act of 1974 (ERISA) litigation against third-party administrators (TPAs) and other service providers challenging their management of self-funded health...more
In recent years, prescription drug prices have been top-of-mind for state legislators, who have responded by passing laws that seek to control that pricing in a variety of ways, including by regulating pharmacy benefit...more
In a recent article in Managed Healthcare Executive, Peter Wehrwein examines the trend of self-funding of group health benefits by smaller employers who used to depend mainly or entirely on fully insured programs....more
We are sometimes asked whether a self-funded group health plan is required to cover gender-affirming medical services. As this post explains in detail, it is generally impracticable for a self-funded ERISA-covered plan to...more
By July 31, employers that sponsor self-funded medical plans must report and pay their PCORI fee. By July 31, employers that sponsor calendar-year employee benefit plans that are subject to ERISA must file a Form 5500 (unless...more
When New York adopted a wage parity law setting minimum wage and benefit levels for home care workers, innovative home health care agency companies created a captive plan structure to meet the benefits requirements. Although...more
Earlier this year, New Jersey Governor Phil Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Law”), creating a statutory framework attempting to protect...more
On June 1, 2018, New Jersey Governor Phil Murphy signed the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Surprise Medical Bill Law”), which is intended to protect against...more
In recent weeks, the Trump Administration has been considering allowing health insurance to be purchased across state lines and expanding access to “Association Health Plans” (AHPs) that could take economic advantage of...more
Seyfarth Synopsis: The Ninth Circuit Court of Appeals recently confirmed that ERISA preempts state insurance law bans on discretionary clauses for self-funded ERISA plans....more
With its “employer mandate”—i.e., the requirement that applicable large employers make an offer of group health coverage to substantially all full-time employees or face the prospect of a penalty—the Affordable Care Act (ACA)...more
Health insurance is full of landmines for unsuspecting car crash victims, who are subject to ‘auto exclusions,’ coverage limitations, managed care, HMOs and medical pre-approval requirements and ERISA liens....more
Editor's Overview - This month, we look at the implications of the two federal district court cases from California that applied the ban on discretionary clauses typically found in ERISA plans to self-insured plans. The...more
On January 22, 2016, the court in Joseph and Gail F. v. Sinclair Services Company, D. Utah No. 2:14-cv-00505, held that a self-funded plan violated the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction...more
Over the past decade, there has been a significant increase in the number of physicians who have dropped out of Preferred Provider Organization (‘‘PPO’’) and Health Maintenance Organization (‘‘HMO’’) networks and attempted to...more
Speed Read - The Sixth Circuit, in a unanimous decision, affirmed a lower court ruling in Pipefitters Local 636 Insurance Fund v. Blue Cross and Blue Shield of Michigan, holding that an entity providing services to a...more