Tag Archives: HHS

Rebate considerations for prescription drug stakeholders

The prescription drug distribution chain is complex and involves several stakeholders. There are generally six in the supply and demand of prescription drugs: pharmaceutical manufacturers, health insurers (including self-insured employers), pharmacy benefit managers (PBMs), pharmacies, wholesalers, and patients.

These stakeholders’ contracts determine how much a patient’s health insurance pays for prescription drugs and the patient’s out-of-pocket costs. Pharmaceutical manufacturer rebates are one of the key drivers that influence how health insurers cover prescription drugs. Rebates affect the finances of all stakeholders involved in the prescription drug distribution chain.

Prescription drug rebates are generally paid by a pharmaceutical manufacturer to a PBM, who then shares a portion with the health insurer. Rebates are mostly used for high-cost brand-name prescription drugs in competitive therapeutic classes where there are interchangeable products (rarely for generics), and aim to incentivize PBMs and health insurers to include the pharmaceutical manufacturer’s products on their formularies and to obtain preferred “tier” placement.

The May 2018 “American Patients First: The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs” from the U.S. Department of Health and Human Services targets rebates as part of its goal to lower prescription drug prices. In this article, Milliman’s Gabriela Dieguez, Maggie Alston, and Samantha Tomicki explain the finances associated with rebates and their impact on health insurer coverage decisions.

Implications of proposed changes to short-term medical plans

In February 2018, the Departments of Health and Human Services (HHS), Labor, and the Treasury released a proposed rule that would change the maximum duration of short-term, limited-duration insurance (STLDI) policies. Under the proposed rule, STLDI plans, or “short-term medical” plans, may emerge as an alternative form of individual health insurance. In this article, Milliman actuaries Jason Karcher and Nick Ortner discuss the proposed changes and the potential effect they might have on the individual health insurance market.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

IRS releases final and temporary rule on health providers’ fee
The Internal Revenue Service (IRS) released final regulations that provide rules for the definition of a covered entity for purposes of the fee imposed by section 9010 of the Patient Protection and Affordable Care Act (ACA), as amended. The final regulations supersede and adopt the text of temporary regulations that provide rules for the definition of a covered entity. These regulations affect persons engaged in the business of providing health insurance for U.S. health risks.

To read the entire rule, click here.

Federal agencies propose rule on short-term, limited-duration insurance
The U.S. Departments of Treasury, Labor (DOL), and Health and Human Services (HHS) have released a proposed rule that would amend the definition of short-term, limited duration insurance for purposes of its exclusion from the definition of individual health insurance coverage.

The proposed rule would make it easier to obtain coverage through short-term health insurance plans by allowing insurers to sell policies that last under a year. The new rules stem from an executive order the president signed in October aimed at boosting competition, giving consumers more choices, and lowering premiums.

To learn more, click here.

How CBO and JCT analyze major proposals that would affect health insurance coverage
The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) released a report that estimates the budgetary effects of most types of major legislative proposals that would affect both spending and revenues using a process that involves many steps and many analysts. The report focuses on the process that the agencies use to analyze proposals affecting health insurance coverage for people under age 65, such as legislation that would make major changes to the ACA.

For more information, click here.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

Health plan choice and premiums in the 2018 federal health insurance exchange
The U.S. Department of Health and Human Services (HHS) has issued a brief that presents information on qualified health plans (QHPs) available on the federal health insurance exchange for states that use the HealthCare.gov platform. National estimates and summary tables are presented in each section of the text. State-specific estimates are in the appendix.

For more information, click here.

ACA AIR submission composition and reference guide published
The Internal Revenue Service (IRS) has published “Affordable Care Act (ACA) Information Returns (AIR) Submission Composition and Reference Guide.” The document provides details on composing and submitting Forms 1094/1095-B and Forms 1094/1095-C by transmitters to the IRS. The scope of the document addresses the application-to-application (A2A) messages exchanged on a Simple Object Access Protocol (SOAP) basis between client and exposed web service endpoints and the user interface (UI)-browser-based web, requiring human initiation.

For more information, click here.

Guidance on the requirements for providing a qualified small employer health reimbursement arrangement released
The IRS published Notice 2017-67 offering guidance on the requirements for providing a qualified small employer health reimbursement arrangement (QSEHRA) under section 9831(d)—which was added to the Internal Revenue Code by the 21st Century Cures Act (Cures Act)—the tax consequences of the arrangement, and the requirements for providing written notice of the arrangement to eligible employees.

For more information, click here.

IRS updates FAQs on employer-shared responsibility payments
The IRS updated its website listing frequently asked questions (FAQs) on employer-shared responsibility provisions under the Patient Protection and Affordable Care Act (ACA), including questions and answers regarding employer-shared responsibility payments.

For more information, click here.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

Technical guidance for self-insured health plans on federal external review process
The U.S. Department of Health and Human Services issued “Technical Guidance – Standards for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Coverage.” This release replaces the technical guidance issued June 22, 2011, with standards adopted in the final regulation at 76 FR 37208 that further define requirements under Public Health Service Act (PHS Act) section 2719(b)(1).

For more information, click here.

Agencies issue ACA FAQs, Part 37
The U.S. Departments of Treasury, Labor (DoL), and Health and Human Services released frequently asked questions (FAQs) Part 37 regarding Patient Protection and Affordable Care Act (ACA) implementation. The FAQs highlight: health reimbursement arrangements (HRAs); integration of HRAs with group health plans sponsored by the employer of a spouse of an employee; Code Section 162(m)(6); and more.

To read the FAQs, click here.

DoL issues FY 2016 MHPAEA enforcement fact sheet
The Employee Benefits Security Administration (EBSA) enforces the law governing 2.2 million private employment-based group health plans, which cover 130.8 million participants and beneficiaries. EBSA relies on its 460 investigators to review plans for compliance with ERISA, including the Mental Health Parity and Addiction Equity Act (MHPAEA). EBSA released its first annual MHPAEA enforcement fact sheet, summarizing its enforcement activity in fiscal year (FY) 2015.

To read the fact sheet, click here.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

Final rule on health insurance premium tax credit
The Internal Revenue Service (IRS) released a final rule relating to the health insurance premium tax credit (premium tax credit). These final regulations affect individuals who enroll in qualified health plans through health insurance exchanges and claim the premium tax credit, and exchanges that make qualified health plans available to individuals and employers.

These final regulations also affect individuals who are eligible for employer-sponsored health coverage.

To read the entire rule, click here.

New HHS report details impact of the Affordable Care Act
The U.S. Department of Health and Human Services (HHS) released an extensive compilation of national and state-level data illustrating the substantial improvements in healthcare for all Americans in the last six years. According to the HHS data, the uninsured rate has fallen to the lowest level on record, and 20 million Americans have gained coverage thanks to the Patient Protection and Affordable Care Act (ACA). But beyond those people who would otherwise be uninsured, millions of Americans with employer, Medicaid, Medicare, or individual market coverage have benefited from new protections as a result of the law.

To access the report, click here.

Guide for electronically filing ACA Information Returns (AIR) for software developers and transmitters
A new IRS publication outlines the communication procedures, transmission formats, business rules, and validation procedures for information returns transmitted electronically through the AIR system.

For more information, click here.

DoL issues final rule on claims procedures for disability benefits
The U.S. Department of Labor (DoL) released a final regulation revising the claims procedure regulations under ERISA for employee benefit plans providing disability benefits. The final rule revises and strengthens the current rules primarily by adopting certain procedural protections and safeguards for disability benefit claims that are currently applicable to claims for group health benefits pursuant to the ACA. This rule affects plan administrators, participants, and beneficiaries of plans providing disability benefits, and others who assist in the provision of these benefits, such as third-party benefits administrators and other service providers.

To read the final rule, click here.