Kentucky Department of Insurance issues penalty against CaremarkPCS Health, LLC

The Kentucky Department of Insurance issued an Order of Civil Penalty and Probation against pharmacy benefit manager (PBM) CaremarkPCS Health, LLC (Caremark) for multiple violations of the Kentucky Insurance Code. As a result, Caremark’s pharmacy benefit manager license has been placed on probation for 12 months and Caremark has been assessed a fine of $1,551,500. […]

CMS announces funding opportunity for the Navigator program

The Centers for Medicare and Medicaid Services (CMS) has announced a funding opportunity for the federally-facilitated exchange (FFE) Navigator program for plan year 2019. Under the 2018 FOA, CMS expects to award up to $10 million for a one-year period of performance. A minimum of $100,000 will be awarded in each of the 34 FFE […]

Survey reveals ‘managing high cost claimants’ is employers’ top health benefits strategy

“Managing and monitoring high cost claimants” is the top health benefits strategy that U.S. employers will be focusing on for the next five years, according to a recent analysis of Mercer’s National Survey of Employer-Sponsored Health Plans, 2017. More than three quarters (77 percent) of U.S. employers with 500 or more employees said this strategy […]

Guidance addresses CMS actions related to court’s invalidation of the risk adjustment program

CMS’ Center for Consumer Information & Insurance Oversight (CCIIO) has issued guidance to address the implications of a ruling issued by the U.S District Court for the District of New Mexico’s on February 28, 2018, that prevents CMS from making further collections or payments under the risk adjustment program, including amounts for the 2017 benefit […]

Part D preempts Arkansas law regulating pharmacy benefits managers

The Eighth Circuit has ruled that both ERISA and Medicare Part D preempted an Arkansas law that sought to govern the conduct of pharmacy benefits managers by mandating that pharmacies be reimbursed for generic drugs at a price equal to or higher than the pharmacies’ cost for the drug. In ruling in favor of Pharmaceutical […]

ERISA preempts widow’s state law claims for supplemental life insurance benefits

ERISA preempts state-law claims in a suit contending that an Applebee’s franchise failed to procure life insurance coverage for an employee despite withholding premiums from his pay—only for his widow to be denied an additional $160,000 in supplemental benefits after his death. The Eighth Circuit held the court below properly found that ERISA preemption applied, […]

Texas cancer center ordered to pay $4.3 million in penalties for HIPAA violations

A Department of Health and Human Services Administrative Law Judge (ALJ) has ruled that The University of Texas MD Anderson Cancer Center (MD Anderson) violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules and granted summary judgment to the Office for Civil Rights (OCR) on all issues, requiring MD […]

Manager whose pay change followed on heels of leave is unable to revive FMLA, contract claims

A district court’s dismissal of the FMLA claims of an O’Reilly Automotive manager against his former employer were upheld by a divided Sixth Circuit in an unpublished opinion. The crux of the suit brought by the employee was that his former employer had pulled the plug on assurance pay that he was receiving in lieu […]

CMS puts risk adjustment payments on hold awaiting resolution of litigation

A ruling issued by the U.S District Court for the District of New Mexico invalidating CMS’ use of the statewide average premium in the risk adjustment transfer formula established under Sec. 1343 of the Patient Protection and Affordable Care Act (ACA) for the 2014 to 2018 benefit years, prevents CMS from making further collections or […]

Mental health patient’s room, board covered under mental health parity law

A federal district court erred in ruling that an employer-sponsored health insurance plan was not required to cover room and board costs incurred by an insured while receiving treatment at a residential mental health facility, the U.S. Court of Appeals for the Ninth Circuit ruled. Under the Paul Wellstone and Pete Domenici Mental Health Parity […]