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What Federal Mandates Apply to Our Company’s Group Health

Details: Mental Health Parity Addiction Equity Act (MHPAEA). If a group health plan that provides medical/surgical benefits also provides either mental health or substance use disorder bene-fits, the plan may be subject to the MHPAEA mental health parity requirements. These requirements include mandates regarding annual or lifetime limits, parity as to

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PPC's Guide to Health Care Consulting Business Valuation

Details: The health care industry is constantly evolving and providing consulting services to health care entities can be challenging. PPC's Guide to Health Care Consulting provides the technical guidance and practical advice you need to successfully serve your health care clients.

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IRS Information Letters Explain Post-Termination Health

Details: However, health FSAs generally are not required to provide COBRA coverage unless, as of the date of the qualifying event, the amount the participant may receive as a reimbursement for medical care from the health FSA for the rest of the plan year (including any carryovers) exceeds the amount that the health FSA may require to be paid for the

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Court Dismisses Facility’s Claim Against Grandfathered

Details: For more information, see EBIA’s Health Care Reform manual at Sections VI.B (“What Is the Significance of Grandfathered Plan Status”) and XIV.F (“Comprehensive Health Coverage Requirement (Essential Health Benefits Package)—Applicable Only in the Individual and Small Group Markets”). Contributing Editors: EBIA Staff.

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Health Care Reform Quickfinder Handbook: Health Care

Details: Health Care Reform has wide-ranging implications for individuals and employers. Employer mandates to provide insurance coverage, credits and subsidies to help individuals purchase coverage, marketplaces for acquiring coverage and reporting requirements and taxes are …

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Healthcare Expenses Table Thomson Reuters

Details: Our nationally recognized Health Care Expenses Table makes it easier for employers, employees, administrators, and others to determine what expenses will qualify for reimbursement under a health FSA or HRA or for a tax-free distribution from an HSA. It’s a "must-have" resource for health FSAs, HRAs, and HSAs. Over 350 Entries. EBIA’s Health Care Expenses Table classifies over 350 common

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PPC's Guide to Health Care Reform Corporations Pension

Details: The Affordable Care Act and recent health care reform legislation has significantly altered the landscape for obtaining and providing health care benefits. PPC's Guide to Health Care Reform provides practical, easy-to-understand guidance on the key provisions of the many legislative changes in …

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PPC's Guide to Health Care Reform Corporations Pension

Details: Product Code: The Affordable Care Act and recent health care reform legislation has significantly altered the landscape for obtaining and providing health care benefits. PPC's Guide to Health Care Reform provides practical, easy-to-understand guidance on the key provisions of the many legislative changes in the last several years that affect

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EBIA Health Care Reform for Employers and Advisors

Details: Contact Your Account Manager to learn more about our Checkpoint online solutions. Written and edited by experienced employee benefits attorneys, EBIA Health Care Reform is your essential partner for employer plan compliance, and provides up-to-date expert analysis of the key requirements that affect employers, advisors, and insurers. It features in-depth coverage of legal requirements and

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Is Stop-Loss Insurance Required for a Self-Insured Health

Details: Because stop-loss insurance is not health insurance, the stop-loss insurer is allowed to impose limits and exclusions that are not permitted for group health plans—for example, to exclude coverage of particular individuals or for particular services, or to impose an annual or …

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Citator 2nd Law Firms Tax Thomson Reuters

Details: alternative health care advocates, et al--alumae chapter beta of clovia ALUMAX INC & CONSOLIDATED SUBSIDIARIES--ALVORD, MARY H., EXECX. ALWARD, VESTA K., EST OF--AMAZON.COM, INC.

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HHS Guidance Addresses COVID-19 Coverage Under Existing

Details: HHS has issued FAQ guidance on whether various COVID-19 items and services are covered as essential health benefits (EHB) under existing rules. As background, non-grandfathered insured health plans in the individual and small group markets (whether purchased in or outside of the Exchanges) are required to cover EHB in ten specified categories

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Is Health Club Membership an ERISA Benefit

Details: While health and fitness clubs and on-site fitness centers promote general good health, they normally are made available without regard to sickness or disability and do not diagnose or treat specific medical conditions, so they typically do not provide medical care, benefits in the event of sickness, or any other ERISA benefit.

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EBIA Form 5500 Workbook for Health & Welfare Plans 2016

Details: EBIA. Description. Penalties for Form 5500 failures—already some of the toughest in benefits law—have increased significantly in the past year, making careful compliance a must for plan sponsors, service providers, and advisors. Let EBIA help you with our popular Form 5500 Workbook for Health & Welfare Plans (2016 Plan Years).

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EBIA Group Health Plans: Federal Mandates Other Than COBRA

Details: Mental Health Parity, Newborns' & Mothers' Health Protection,Women's Health and Cancer Rights. These laws require specific coverages, notices and disclosures. Analysis and compliance tools will help you comply. Sample Documents. Sample documents for many of the above topics are included.

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Health care and employee benefits solutions for corporations

Details: Health care and employee benefits solutions for corporations Authoritative guidance and employee benefit solutions for employers and advisors like you Get in-depth guidance on complex topics such as HIPAA, health care reform, COBRA, fringe benefits, and more with EBIA compliance publications that are written and edited by experienced benefits

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EBIA Self-Insured Health Plans Public Accounting Firms

Details: Quantity. Written and edited by experienced employee benefits attorneys, EBIA Self-Insured Health Plans is the go-to resource for employers that sponsor self-insured health plans and their advisors. For employers considering self-insurance, it answers all of your questions about what self-insurance means, why employers choose to self-insure

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Is There an Official List of Expenses That Can Be

Details: Health Insurance Premiums. Taxpayers may deduct health insurance premiums on their tax returns if certain requirements are met. However, reimbursement of such premiums by health FSAs, HRAs, and HSAs is subject to restrictions that vary according to the type of tax-favored account.

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Amounts Paid for COVID-19-Related PPE Qualify as Medical

Details: EBIA Comment: Health FSA and HRA administrators will want to take note of this announcement, which will be welcomed by participants and other stakeholders. While some plans may already have been reimbursing COVID-19 PPE, others may …

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EBIA Consumer-Driven Health Care Law Firms Pension and

Details: With EBIA Consumer-Driven Health Care you will get guidance on: The Premier HSA and HRA Resource. All the basics and many complexities of HSA and HRA design and implementation are covered. This is your HSA and HRA guidebook. Recent Legislation. Updates on the many HSA changes first effective in 2007.

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Must a Self-Insured Health Plan Offer HIPAA Special

Details: Instead, the group health plan’s eligibility definitions determine whether a spouse or dependent is eligible for special enrollment. Thus, a marriage will trigger HIPAA special enrollment rights for a spouse (same-sex or different-sex) only if the spouse is otherwise eligible under the plan’s terms.

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In What Order Should Reimbursements Be Paid When Employees

Details: The HRA and health FSA plan documents could provide that the HRA pays last, after the health FSA has been exhausted. This design is often chosen by employers offering HRAs and health FSAs that cover the same employees for the same medical care expenses, because it reduces health

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Report on ERISA Enforcement Identifies Common Violations

Details: EBSA’s health plan investigations often focus on compliance with federal health plan coverage and availability requirements and returning money to plans and participants affected by improper administrative practices or mishandling of plan funds (especially in the context of MEWAs). Since 2013, EBSA has prioritized cases that may result in

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Must a Health Plan Certify Compliance With HIPAA’s

Details: ANSWER: Although the Affordable Care Act (ACA) added a requirement for health plans to file statements with HHS certifying that their data and information systems comply with any applicable HIPAA standards and operating rules, that requirement is not currently being enforced. The ACA gave HHS substantial discretion to determine how the

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EBIA ERISA Compliance for Health & Welfare Plans Law

Details: Contact Your Account Manager to learn more about our Checkpoint online solutions. EBIA ERISA Compliance for Health and Welfare Plans on Checkpoint discusses what benefits are subject to ERISA, then explains ERISA's requirements in detail with examples, checklists, court case summaries, tables, Q&As, and compliance tips. It includes in-depth coverage of reporting & disclosure requirements …

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Ninth Circuit Affirms ERISA’s Preemption of State-Law Claims

Details: A health plan participant brought state-law claims against the plan’s insurer, alleging the insurer engaged in deceptive practices, breached its contract, and committed fraud in handling his claim. After a federal trial court dismissed the case based on ERISA’s preemption of state-law claims, the participant appealed.

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Certain Genetic Testing Services Qualify as Code § 213(d

Details: The letter responds to a health FSA participant seeking to purchase genetic testing services and reports regarding ancestry and health. The participant asked whether the amounts spent on the health-related services and reports and the DNA collection kit were Code § 213(d) medical care expenses that could be reimbursed by the health FSA.

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Health Insurer Ordered to Reprocess 67,000 Claims, Follow

Details: Health Insurer Ordered to Reprocess 67,000 Claims, Follow Independent Claim Guidelines. Wit v. United Behavioral Health, 2020 WL 6479273 (N.D. Cal. 2020) Following last year’s ruling that an insurer breached its fiduciary duty to health plan participants by using overly restrictive claim guidelines in its administration of mental health and

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Agency FAQs (Part 50) Address COVID-19 Vaccine Coverage

Details: Group health plans may offer participants a premium discount for receiving a COVID-19 vaccination, so long as the discount complies with the agencies’ final (2013) wellness program regulations. This means that the premium discount must comply with the five HIPAA criteria for activity-only health-contingent wellness programs (i.e., discount of

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PPC's Guide to Physicians and Other Health Care

Details: Physicians and other health care professionals often need a wide variety of professional services from their trusted CPA. PPC's Guide to Physicians and Other Health Care Professionals covers a wide range of profitable services, including write-up, financial planning, federal income tax planning, retirement plans, and payroll taxes - and the

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What Are the Transparency Requirements for Handling

Details: For instance, a group health plan is required to establish a database on its public website that contains directory information for each provider and facility with which it has a direct or indirect contractual relationship for furnishing items and services. A plan must also establish a process to verify and update the information included in

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IRS Announces 2022 HSA and EBHRA Contribution Limits, HDHP

Details: EBIA Comment: Because the HDHP out-of-pocket maximums and the HSA contribution limits for 2022 are increasing by the same amount, individuals will generally pay the same proportion of their out-of-pocket expenses with the benefit of the HSA tax break as they did in 2021. The catch-up contribution limit (for HSA-eligible individuals age 55 or older) is set forth in Code § 223(b)(3) and …

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Tax Court Issues Health and Safety Protocols for In-Person

Details: Protocols for in-person proceedings. The Tax Court’s Administrative Order 2021-02 provides a summary of the health and safety protocols that must be observed by any visitor to its Washington, D.C. courthouse. The Court has also posted a new publication, “Court Standards and Protocols to Protect Public Health,” to its COVID-19 resources page.

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How Do the HIPAA Privacy Rules Apply to a Participant's

Details: QUESTION: If a participant asks our self-insured health plan to send their claim file to a third party, such as their attorney, how do the HIPAA privacy rules apply to these requests? ANSWER: HIPAA limits disclosures of protected health information (PHI) to third parties. Generally, disclosures for treatment, payment, or specified health care operations do not require an individual authorization.

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IRS Information Letters Address Substantiation Rules for

Details: Letter 2021-0003. Letter 2021-0013. The IRS has released two information letters that address the substantiation rules for health FSA debit card programs. One letter responds to an inquiry on behalf of an individual whose card was deactivated for failure to provide requested documentation to substantiate expenses paid with a health FSA debit card.

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What Benefits Can We Offer Under Our Company’s Cafeteria Plan

Details: ANSWER: Employer-sponsored group major medical coverage, health FSAs, and DCAPs are the most common cafeteria plan benefits. Other common benefits that can be offered under a cafeteria plan include the following: group-term life insurance on the life of an employee (although the cost of coverage in excess of $50,000, less any amount paid after

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EBIA Cafeteria Plans Public Accounting Firms Pension

Details: Health FSA design and administration are covered in detail, including issues such as medical care definition, claim substantiation, and debit card programs. A quick-reference table classifies over 350 common expenses as “qualifying,” “not qualifying,” or “potentially qualifying,” making it easy to determine what can be reimbursed.

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EBIA HIPAA Portability, Privacy & Security Law Firms

Details: Group health plans may not discriminate with respect to eligibility or premiums based on a health status-related factor. What types of provisions are prohibited and what types are permissible under the final regulations? Certificates of creditable coverage. The changes made by the final portability regulations, including the requirement that

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PPC's Practice Aids for Audits of Health Care Entities

Details: Health care entities cover a wide range of service providers to health care patients, including hospitals, nursing homes, and continuing care retirement communities. The health care industry is expected to see significant growth in the next decade driven by an aging population, longer life expectancies, as well as new treatments and technologies.

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What Is the Difference Between a Grandfathered and a

Details: The grandfathered plan rules apply separately to each benefit package (e.g., PPO or HMO) made available under a group health plan. If grandfathered status is lost, it cannot be regained. On the other hand, “grandmothered plans” is a term used to describe non-grandfathered health plans that are subject to an HHS transition policy allowing

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Court Declines to Enforce Indemnification Provision

Details: Bon Secours Health System, Inc. v. Express Scripts, Inc., 2019 WL 1427746 (D. Md. 2019) This contractual dispute arose between the plan sponsor of a self-insured prescription plan and its pharmacy benefits manager (PBM) because the PBM failed to auto-enroll the plan sponsor in its program designed to combat pharmacy fraud and abuse.

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EBIA COBRA: The Developing Law Public Accounting Firms

Details: Contact Your Account Manager to learn more about our Checkpoint online solutions. EBIA COBRA: The Developing Law explores the nuances of COBRA using real-life examples as a platform for discussing the complicated COBRA rules. Written and edited by experienced employee benefits attorneys, it answers your tough questions and provides comprehensive guidance on all aspects of COBRA administration.

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Can Employees Change Health FSA Elections Midyear If They

Details: An employee’s health FSA election is irrevocable during a plan year unless an event occurs that fits within one of the exceptions available under applicable regulations or other IRS guidance. Changes in medical condition or in a health care provider’s recommendation are not changes in status, nor do they fall within the other exceptions

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Tax Planning for Individuals Quickfinder Handbook: The

Details: DESCRIPTION. Your trusted tax quick reference to tax planning for individuals. Tax rules change from year to year, and sometimes drastically. Whether it’s simply rates and amounts or the addition or expiration of new tax provisions, keeping ahead of clients is a challenge for any tax practitioner. And, many clients expect more from their tax

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Plan’s Anti-Assignment Clause Blocks Provider’s Lawsuit

Details: An out-of-network health care provider performed surgery on a participant in an ERISA health plan. After receiving payment for less than 1% of the billed charges and unsuccessfully seeking additional reimbursement using the plan’s internal claims process, the provider sued the plan and its claims administrator.

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Does a Plan With a Three-Month Waiting Period Comply With

Details: QUESTION: We sponsor a self-insured health plan that imposes a three-month eligibility waiting period. Does this comply with the prohibition on excessive waiting periods? ANSWER: A three-month waiting period does not satisfy the Affordable Care Act’s requirement to limit eligibility waiting periods to a maximum of 90 days. A waiting period is defined as the period that must pass before

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Who Must Be Bonded for Our ERISA Welfare Plan

Details: QUESTION: Our ERISA welfare benefit plan is self-insured, and we use a third-party administrator (TPA) to administer the plan’s benefits. We understand that there is a bonding requirement for welfare plans—but who exactly must be covered by our welfare plan’s bond? ANSWER: In short, ERISA § 412 requires every plan fiduciary (including named fiduciaries, plan administrators, trustees

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