At the close of 2024, the US Congress passed a short-term extension of Medicare telehealth flexibilities as part of the American Relief Act, 2025. The Medicare telehealth waivers, originally enacted as part of the COVID-19 public health emergency and subsequently extended through legislation, were set to end on December 31, 2024. These flexibilities, along with the Acute Hospital Care at Home waiver program, are now set to expire March 31, 2025.
Managing healthcare costs often feels like an endless struggle for benefits professionals, employers, and employees. Nevertheless, benefits professionals persist in their efforts to control escalating healthcare expenses.
In this article, Alden Bianchi and industry members share their predictions about the healthcare landscape, zeroing in on primary care, weight loss drug coverage, the Affordable Care Act, and artificial intelligence.
The US Supreme Court is currently reviewing a case (US v. Skrmetti) concerning Tennessee’s ban on gender-affirming care for youth. If the Court upholds the ban, some employers might consider offering travel benefits to help employees access healthcare services that are prohibited by state law. This could also apply to other plan-covered services that are not available within a certain geographic distance.
Beginning in the first quarter of 2025, California healthcare service plans, health insurers, and certain other organizations must ensure that staff who have direct enrollee contact receive evidence-based cultural competency training focused on transgender-inclusive healthcare. This requirement arises from Senate Bill No. 923, a law passed by the California legislature in 2022. Provider directories must also be updated by March 1, 2025, to identify which in-network providers have previously offered gender-affirming services.
Two recently passed laws have modified the provisions of the Affordable Care Act (ACA) that require employers and insurers to prepare tax forms showing offers of health coverage, streamlining the compliance and reporting process.
Under the ACA’s employer shared responsibility provisions, applicable large employers must either offer qualifying health coverage to full-time employees (and their dependents), or they may face significant excise taxes. Employers may also face penalties if they fail to report, or make mistakes in reporting, the offered coverage. These new rules will ease the reporting burdens on employers seeking to prove that they follow these complex and demanding requirements.
Gender-affirming care has become a central topic in US political discussions, significantly affecting employer-sponsored group health plans. Depending on whether they purchase insurance or self-fund their health benefits, group health plan sponsors face different challenges in covering gender-affirming care. In this PlanSponsor article, Alden Bianchi, Sarah Raaii, and Scott Kenkel explore these challenges and share best practices for group health plans to navigate this complex issue.
Many countries finalized new regulations and released new guidance in 2024 that will impact global equity plans. This client alert highlights key updates from Canada, the European Union, the United Kingdom, Brazil, and other jurisdictions, and recommends steps companies should take to address them.
The No Surprises Act, a law that ended the practice of “balance billing” by certain out-of-network providers, was enacted as part of the Consolidated Appropriations Act of 2021 on December 27, 2020. While the law was passed during President Trump’s first term in office, the Biden administration has been fully responsible for its implementation to date.
In this insight, McDermott+’s Jeffrey Davis and Kristen O’Brien highlight four major areas of No Surprises Act implementation that the Trump administration could decide to focus on in the months following the inauguration.
Payor contracting can seem daunting, particularly for new companies and innovative organizations that are unfamiliar with the nuances of providing a product to health insurers and health maintenance organizations. Navigating regulatory considerations and payor contract complexities requires a solid understanding of the basics. During this webinar, McDermott Partners Gregory Mitchell, Mimi Alexandre, and Erin Kelly discussed some key principles of payor contracting.
The Mental Health Parity and Addiction Equity Act (MHPAEA) generally requires group health plans and health insurance issuers to ensure that financial requirements (such as copays and deductibles), quantitative treatment limitations (such as visit limits), and nonquantitative treatment limitations (such as prior authorization and concurrent review) applicable to mental health or substance use disorder (MH/SUD) benefits are generally no more restrictive than the requirements or limitations applied to medical/surgical (M/S) benefits. The Consolidated Appropriations Act, 2021 imposed further obligations in the case of nonquantitative treatment limitations (NQTLs), which are the subject of final regulations issued in September 2024. (We explained the final regulations here.)
Among many other things, the final regulations establish a two-part test that applies to NQTLs consisting of:
The relevant data evaluation requirement has proven especially challenging for self-funded group health plans of every size, as third-party administrators fail, refuse, or are otherwise unable to provide the information necessary to comply. There may be another option, however.
The final regulations do not specify the data set on which compliance with the relevant data requirement is tested. Rather, the regulations, which apply to both plans and issuers, seem to assume that the plans test on the basis of plan data, and issuers test on the basis of the issuer’s corresponding block of business. In their informal remarks at trade and industry conferences, representatives of the US Department of Labor (DOL), expressing their own views and not those of the DOL, have acknowledged that they are aware of and are considering their options related to the proper testing data set.
Some large carriers have shared the NQTL analysis that they previously prepared for their fully insured groups with the self-funded group to whom they provide administrative services. Presumably, this will give their self-funded groups a starting point. Many self-funded groups, particularly smaller groups, are not inclined to modify the standard set of NQTLs offered by their carriers/administrative-service-only (ASO) providers. If these groups were allowed to test based on the carrier’s corresponding book of business, a good deal of the work would be done. This would also have the salutary effect of exerting market pressure [...]
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