The United States Department of Health and Human Services (HHS) has filed court pleadings stating that it does not intend to initiate enforcement actions against plans that maintain copay accumulator programs....more
Summary - Employers taking advantage of copay accumulator programs now face unexpected administrative complications following a recent federal court decision....more
On September 29, 2023, the U.S. District Court for the District of Columbia vacated a Trump-era rule from 2021 that allowed insurers to exclude drug manufacturer co-pay support coupons and assistance from a patient’s annual...more
How could alleged kickbacks threaten to render insolvent a publicly traded company with assets (taken from its latest SEC filing) in excess of $43 billion? The answer stems from a recent decision by the United States District...more
Key Points - A new legal challenge to OIG on Medicare Beneficiaries’ ability to receive co-pay assistance has emerged. The Supreme Court has been asked to review HHS’s prohibition of co-pay assistance programs under the...more
Governor Lamont’s recent renewal of his declaration of the public health and civil preparedness emergencies through July 20, 2021 was followed by Executive Order 12B that repeals portions of previously-issued Executive...more
Patient access to behavioral health and substance use disorder services has increasingly become the subject of legislation. Although the federal Mental Health Parity and Addiction Equity Act (MHPAEA), introduced in 2008,...more
During 2020, a number of newly enacted laws created flexibility for various employee benefit plans. The Consolidated Appropriations Act of 2021 (the “Act”), which was signed into law on December 27, 2020, provides additional...more
Massachusetts began this year by enacting comprehensive health care legislation that will have a lasting impact on the provision of telehealth within the Commonwealth. Massachusetts had previously expanded the use of...more
On March 17, the New York State Department of Financial Services (DFS) announced the issuance of a new emergency regulation requiring insurance companies in the state to waive cost-sharing, including deductibles, copayments,...more
Effective March 18, 2020, group health plans and health insurance policies are required to pay for COVID-19 testing and related health provider visits, without imposing any cost sharing requirements, such as a deductible,...more
HDHP and HSA participants - The IRS has expanded prior guidance to allow health plans to pay first-dollar costs for testing and treatment of COVID-19 without jeopardizing the participant’s HSA eligibility. ...more
Underfunded pension liabilities get needed attention The topic of Vermont’s overwhelming state employee and teachers’ pension burdens rears its head on occasion, but legislators quickly move on to challenges more easily...more
Background. These days, almost all employer-sponsored group health plans require an employee (and any dependents) covered under the plan (each are referred to as a “member”) to pay “out-of-pocket” for covered expenses in the...more
Employer plans will still be able to exclude the value of drug manufacturer coupons from annual out-of-pocket maximums, even when no generic equivalent is available, under new guidance from the Department of Labor, Department...more
Pharmacy Benefit Managers (PBMs) are increasingly utilizing gag clauses in pharmacy contracts as a means of prohibiting pharmacies from telling customers that paying for drugs out of pocket would cost them less than if they...more
I am occasionally asked by providers whether or not they can waive a co-pay for a particular patient. There are many reasons providers wish to waive co-pays: financial hardship, professional courtesy, employee discounts, etc....more
While the term “co-pay” might suggest a sharing of costs between patients and their health plans, a recent study by the University of Southern California Schaeffer Center found that almost a quarter of patients are paying...more
Ohio is preparing a Section 1115 Medicaid demonstration waiver application that, if approved, would require most of the members enrolled in Ohio’s Healthy Ohio Program to pay premiums and copayments for their health care...more
Arizona seeks Medicaid Waiver to implement new coverage restrictions for Medicaid expansion enrollees and delivery system reform; Tennessee’s uninsured rate continues to drop; and Louisiana gubernatorial candidates line up...more
Recent changes to policy and plan language and increased litigation by third-party payers suggests that out-of-network providers who waive co-pays and deductibles may be in for some rough sailing. Providers must be aware of...more
“You scratch my back, I scratch yours” arrangements are common in business transactions. These agreements are risky in the healthcare space, however, with the potential to implicate civil and criminal sanctions. Whether...more
In recent years, copayment coupon programs have become standard promotional practices for both large and small pharmaceutical manufacturers. Copayment coupons are typically offered to commercially insured patients in order...more