Healthcare Reform
Federal Updates
Retirement Update
Reminders
Public Disclosure of Provider Reimbursement Rates Begins July 1, 2022
On July 1, 2022, enforcement of the machine-readable file requirement of the Transparency in Coverage (TiC) final rule begins. Under the rule, non-grandfathered group health plans and insurers must publicly post machine-readable files that disclose in-network provider negotiated rates and historical out-of-network allowed amounts and billed charges for plan years beginning on or after January 1, 2022. (Enforcement of the prescription drug rate file requirement is postponed pending regulatory review.)
The files must be in a specified format, updated monthly and posted on a public website accessible to any person free of charge. No conditions can be imposed to access the files, such as establishing a user account or password or submitting personally identifiable information.
Group health plan sponsors should be in consultation with their insurers or third-party administrators to ensure timely compliance with the July 1 deadline.
For fully insured plans, the legal obligation can be contractually transferred to the insurer. For self-insured plans, the sponsor remains liable for TiC compliance even if a TPA contractually agrees to assist with the creation and implementation of the files.
For further information, please see:
Transparency in Coverage Final Rule »
FAQs on ACA and CAA, 2021 Implementation »
FAQ
If an employee is injured on the job and goes out on workers’ compensation, must we continue their group health insurance coverage?
State Updates
Arizona
Extended Relief for Non-ACA-Compliant Small Group and Individual Policies and Plans
May 24, 2022
The Department of Insurance and Financial Institutions recently extended the ability of health insurance carriers in the individual and small group market to continue transitional health insurance plans indefinitely until such time as CMS issues an announcement ending the nonenforcement of certain market reforms.
On March 23, 2022, CMS provided guidance for a transition policy extension that allows insurers the option to renew non-grandfathered non-ACA-compliant plans if the state allows for such an extension. Such transition policies are not required to comply with certain ACA mandates, including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions and the annual out-of-pocket maximum limit. This bulletin applies this most recent federal extension to Arizona and allows the issuer to renew these non-ACA-compliant plans.
Small employers that are interested in renewing their non-ACA-compliant plan should work with their advisors and insurers.
Arizona Announces Extension of Major Medical Transitional Policies Until Further Notice »
Colorado
State Issues New Regulations for the Paid Family Leave Insurance Program
May 24, 2022
In January 2022, the Department of Labor and Employment promulgated new rules relating to the state’s paid family and medical leave insurance (FAMLI) program. The regulations further define key terms relating to the collection and remittance of premiums into the program, as well as provide procedures for local governments to opt out of the program. In addition, the department posted FAQs on its website providing much of this information in a condensed format.
In 2020, voters passed the statute that created FAMLI. Starting on January 1, 2024, the program provides employees who work in the state and earn at least $2,500 at their jobs with up to sixteen weeks of paid leave for the following reasons:
- Caring for their own serious health condition.
- Caring for a new child during the first year after the birth or adoption or for foster care of a new child.
- Caring for a family member with a serious health condition.
- When a family member is on active-duty military service or is called for active-duty military service.
- When the individual or the individual’s family member is a victim of domestic violence, stalking or sexual assault.
This leave is designed to run concurrently with federal FMLA. Note that FAMLI allows employers to use a private plan rather than the state’s plan. To do this, the private plan must provide the same rights, protections and benefits as the public plan. Employers may require employees to contribute to the private plan, but no more than what they would have contributed to the state plan.
The leave is paid for through a fund to which employers with at least one employee in the state and employees working in the state contribute premiums. Starting on January 1, 2023, FAMLI requires employers to remit those premiums to the fund. The premiums take the form of a .9% payroll tax, split 50/50 between employer and employee. The new regulations define the wages that are subject to the payroll tax to include salary or hourly wages, commissions, payments on a piecework basis, bonuses or other forms of compensation (such as board, lodging or payments in kind). The department’s employer FAQs provide formulas for calculating premiums. Note that employers with fewer than 10 employees are not required to pay the employer share of the premiums (although they are still required to remit the employee share to the fund). Employers that report ten or more employees in the first quarter of 2023 will be required to pay the employer share of the premium for all calendar quarters in calendar year 2023.
The new regulations also require employers to remit the premiums on a quarterly basis. Self-employed workers can also participate in the program, and the new regulations outline the process they must use to do so, including a quarterly earnings report as well as quarterly remittance of premiums.
The fund sends payments directly to employees on FAMLI leave, and those payments are capped at $1,100 per week. Employers are not responsible for paying salary while an employee is on FAMLI leave. According to the department’s employer FAQs, employees are not required to use PTO before using FAMLI leave, but employers can allow employees to use PTO to “top off” the remaining balance of their weekly wage.
The new regulations also provide a process through which local governments can opt out of the FAMLI program. To do so, the rules require local governments to hold a vote after providing written notice that they will hold such a vote. If the local government votes not to participate, then it must provide its employees with written notice of the decision within 30 days, along with notice that employees can still opt into the program (participating in much the same way as self-employed workers do).
Employers in the state or with at least one worker in the state should be aware of the law and the new regulations. Further guidance and additional regulation are expected in the next year to clarify and administer the FAMLI program.
Colorado Paid Family and Medical Leave Insurance Act »
Regulations Concerning Paid Family Medical Leave Program (Premiums) »
Regulations Concerning Paid Family Medical Leave Program (Local Governments) »
Employer FAQs »
Delaware
Delaware Enacted Paid Family and Medical Leave Law
May 24, 2022
On May 10, 2022, Gov. John Carney signed into law the Family and Medical Leave Insurance (FMLI) program called the “Healthy Delaware Families Act.” The payroll withholding of the employees’ contributions is scheduled to begin on January 1, 2025, and the benefits will be available to eligible employees starting January 1, 2026.
There are several key differences from other states’ PFML programs. For example, the minimum employer size that needs to comply with the Delaware FMLI program is an employer who employs 10 or more employees working in Delaware, in contrast to employers with at least one employee working in the state for other states’ PFML programs. Moreover, the Delaware FMLI program allows employers to include their employees who work outside of Delaware to participate in Delaware’s FMLI program voluntarily. Another major difference is employers, rather than the state, are responsible for approving or denying a claim application within five business days of receipt of a completed application with the required documentation. Once approved, the state’s Department of Labor will make the benefits payment to the eligible employees.
Overall, Delaware aligns many of the program’s details and terms with the federal FMLA, such as the definitions of the family members. Therefore, the eligible family members under the FMLI program are much narrower than other states’ PFML programs.
Below are the key highlights of the Delaware FMLI program:
Timeline
- January 1, 2025: Contributions to Family and Medical Leave Insurance Fund begin
- January 1, 2026: Benefits will be available to employees
Covered Employers
- Employers with 10-24 covered employees during the previous 12 months must comply with the parental leave requirements only. Covered employees are those who primarily report to work at a Delaware worksite unless otherwise excluded. However, employers can reclassify an employee as a covered employee even when the EE works at a worksite in another state.
- Employers with 25+ covered employees must comply with all the parental, family caregiving and medical leave requirements.
Funding of the Program
Employers can require covered employees to pay up to 50% of the total premium. Employers are responsible for the remaining premium amount. The contribution amounts in 2025 and 2026 are:
- Parental leave: 0.32% of employee’s wages
- Family caregiving leave: 0.08% of employee’s wages
- Medical leave: 0.4% of employee’s wages
Employers are required to remit the total premium to the state at least quarterly as regulated by the department.
Eligibility to Take Leave
Covered employees are eligible when they have worked at least 1,250 hours over the 12-month period immediately preceding the date on which leave is to begin.
Qualified Reasons for Leave
- EE’s own serious health condition (medical leave)
- For an eligible EE to:
- Care for a family member with a serious health condition (family leave)
- Bond with a new child (by birth, adoption or fostering) during the first 12 months after the child’s birth or placement (parental leave)
- Attend to a qualifying exigency arising out of a family member’s military deployment (family leave)
Maximum Benefits Duration
- Aggregate of all combined leave: 12 weeks total in an application year
- Parental leave: 12 weeks in an application year
- Total family caregiver leave and medical leave: 6 weeks in 24-month period
- Leave can be taken continuously or intermittently or reduced schedule basis only when medically necessary.
Maximum Benefits Amount
Covered employees are entitled to 80% of their average weekly wage up to $900 in 2026 and 2027. (After 2027, revisited annually and adjusted by the state as appropriate.)
Next Steps
Because the contributions do not begin until 2025, and the benefits will be available to eligible employees in 2026, employers have time to review the law closely against their existing leave policies and benefits eligibility, and consider how the new Delaware FMLI will coordinate with other leaves including the federal FMLA and STD. Moreover, employers should monitor any future guidance and developments as it is expected that the state will release more detailed guidance.
Georgia
Governor Signs New Healthcare Bills into Law
May 24, 2022
Recently, Gov. Kemp signed two new healthcare bills into law.
HB 733 (Part II) requires insurers that cover diagnostic examinations for breast cancer to treat cost-sharing requirements the same as annual mammograms. Such diagnostic examinations include medically necessary and clinically appropriate examinations using breast MRI or ultrasound to evaluate an abnormality detected by a breast cancer screening or other examination.
For HSA qualified HDHPs, these cost-sharing requirements shall only apply after the enrollee has satisfied the minimum statutory deductible, except with respect to items or services that are preventive care as defined by the IRS (in which case the cost-sharing requirements shall apply regardless of whether the minimum statutory deductible has been met).
SB 341 allows enrollees to receive prior authorization for prescribed medications to treat chronic conditions requiring ongoing medication therapy under certain circumstances.
Under this law, if a healthcare provider receives a prior authorization for a medication prescribed to a covered person with a chronic condition that requires ongoing medication therapy and continues to prescribe the medication, the prior authorization shall be valid for the lesser of one year or the last day of the plan coverage. Additionally, the authorization shall cover any change in dosage prescribed by the healthcare provider during the authorization period.
These provisions shall become effective on January 1, 2023, and shall apply to policies or contracts issued, delivered, issued for delivery or renewed in the state on or after such date.
Employers should be aware of these upcoming changes and review the legislation and/or contact their carrier for further information.
Washington
Washington State Paid Family and Medical Leave (PFML): Waiting Period Clarified
May 24, 2022
Recently, Washington State revised the waiting period rule under PFML that will take effect on June 9, 2022. Under the new definition, a "waiting period" is the first seven consecutive calendar days beginning with the Sunday of the first week an eligible employee starts taking paid family or medical leave. A waiting period does not reduce the maximum duration of an employee's available paid family or medical leave.
Employers should be aware of this recent update.
Washington PFML: Rulemaking »
Washington PFML: Amendments to Waiting Period, Proration and Weekly Claim Hours, and Petitions for Review »
Wyoming
Extended Relief for Non-ACA-Compliant Small Group and Individual Policies and Plans
May 24, 2022
On May 5, 2022, Commissioner Rude extended the ability of health insurance carriers in the individual and small group market to continue transitional health insurance plans indefinitely until such time as CMS issues an announcement ending the nonenforcement of certain market reforms.
On March 23, 2022, CMS provided guidance for a transition policy extension that allows insurers the option to renew non-grandfathered non-ACA-compliant plans, if the state allows for such an extension. Such transition policies are not required to comply with certain ACA mandates, including community rating, coverage of essential health benefits, prohibition on pre-existing condition exclusions and the annual out-of-pocket maximum limit. This bulletin applies this most recent federal extension to Wyoming and allows the issuer to renew these non-ACA-compliant plans.
Small employers that are interested in renewing their non-ACA-compliant plan should work with their advisors and insurers.
This material was created by PPI Benefit Solutions to provide accurate and reliable information on the subjects covered but should not be regarded as a complete analysis of these subjects. It is not intended to provide specific legal, tax or other professional advice. The service of an appropriate professional should be sought regarding your individual situation. PPI does not offer tax or legal advice. "PPI®" is a service mark of Professional Pensions, Inc., a subsidiary of NFP Corp. (NFP). All rights reserved.