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Paul Zimmerman

Showing 6 posts from April 2018.

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Ersler Dmitry ©

CMS Increasingly Turns to Civil Monetary Penalties to Police Federally-Funded Health Programs

The federal government has upped the use of civil monetary penalties to enforce its regulations on subsidized health programs. In 2017, the Centers for Medicare & Medicaid Services (CMS) announced civil monetary penalties totaling $5.7 million against 27 Medicare Advantage and Part D prescription drug plans. CMS has been exceeding this pace in 2018, and through February has already announced $1.7 million in penalties against eight plans, slapping one with a $1.4 million fine. (Read More)

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Evgeny Atamanenko ©

Courts Read Network Adequacy Requirements into Federal Lactation Counseling Mandates

The ACA and federal regulations require health insurers and plans to cover lactation counseling without cost-sharing (deductibles and co-pays). Under the regulations, an insurer or plan can meet this obligation by either including “a provider” in its network who can provide the service, or by permitting its members to use an out-of-network provider free of any cost. In two recent cases, courts appear to be reading some level of network adequacy and disclosure requirements into the mandates for insurers and plans that take the in-network route. (Read More)

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Andriy Popov ©

The Payroll Audit Independent Determination (PAID) Program: Wage and Hour Amnesty for Employers

Attention employers: the Department of Labor has your back – at least on a six-month trial basis. The DOL has launched the Payroll Audit Independent Determination (PAID) program, a new nationwide initiative that seeks to facilitate the resolution of potential overtime and minimum wage violations under the Fair Labor Standards Act (FLSA). (Read More)

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morganka ©

New Essential Health Benefits Rules Give Obamacare Plans More Flexibility As They Face Rising Competition

The Department of Health and Human Services (HHS) just issued its annual revision of the rules for Obamacare plans that are sold on the state Exchanges (Marketplaces). The rules give states and insurers more flexibility in determining what benefits these plans should offer. Likewise, they fix some nonsensical prior guidance from HHS that discouraged plans from providing special benefits to children, elders, women and the disabled. This flexibility is needed as Obamacare plans begin to compete with association and short-term health plans. (Read More)

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asnida marwani ©

Is a New Federal Standard for Breach Notification on the Horizon?

In the wake of the recent announcement by Equifax that an additional 2.4 million consumers had personal information stolen as part of the company’s massive data breach in 2017, a light is being shined on related legislation currently pending in the United States House of Representatives. Indeed, lawmakers are once again trying to codify nationwide standards on breach notifications and how data is handled and stored. It appears to be an uphill battle. (Read More)

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belchonock ©

Two Courts Reject § 1557 and Title VII Healthcare Discrimination Claims Against Insurance Companies Acting as Third-Party Administrators

In two recent decisions, courts have refused to hold insurers acting as third-party administrators (TPAs) liable under ACA § 1557 or Title VII for carrying out allegedly discriminatory terms of self-funded employer health plans. In both cases, the TPAs did not appear to have any role in setting the terms of the employer-sponsored plans, but only in approving and denying claims under their terms. (Read More)