Hamilton Headlines
April 18, 2016

HHS Finalizes 2017 OOP Maximums and Marketplace Guidance

The Department of Health & Human Services has finalized the 2017 out-of-pocket maximums of $7,150 for self-only coverage and $14,300 for other than self-only coverage, and provided guidance on other marketplace issues, including notices for employers and the open enrollment period for 2017 and later years.


Each year, the Department of Health & Human Services (HHS) releases the HHS Notice of Benefit and Payment Parameters that provides important guidance related to the Affordable Care Act (ACA) marketplaces and various ACA provisions. Late last year, HHS released the proposed rule for 2017 and a fact sheet that summarized the guidance. (See our December 23, 2015 For Your Information.) On February 29, HHS issued the final rule for 2017 and an updated fact sheet. Although the final guidance is primarily focused on the ACA marketplaces and insurers offering programs, it includes items that affect large employer and self-insured group health plans, such as: 
  • ACA out-of-pocket maximums
  • Marketplace notices to employers
  • 2017 marketplace open enrollment period

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Medicare Is Often Overbilled by Hospices, and Pays Twice for Some Drugs

WASHINGTON - Hospices often bill Medicare for a higher level of care than patients need, and Medicare often pays twice for the prescription drugs provided to people who are terminally ill, federal investigators say in a new report. The extra cost to Medicare was put at more than $260 million a year.

"Many hospices have been billing far more than they should have," said Nancy T. Harrison, a deputy regional inspector general at the Department of Health and Human Services who led the investigation.

The investigators found that Medicare was paying hospices almost four times as much as it should have for some patients. The patients were receiving "inpatient care" when all they needed was less-expensive routine care in their homes, the report said.

Medicare now pays hospices an all-inclusive rate of $720 a day for inpatient care and no more than $187 a day for routine home care.

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Departments Finalize New Version of the Summary of Benefits and Coverage  

Today, the Department of Health and Human Services (HHS), the Department of Labor (DOL) and the Department of the Treasury announced key enhancements to the Summary of Benefits and Coverage (SBC) template and Uniform Glossary. The improvements include an additional coverage example and language and terms to improve consumers' understanding of their health coverage.
Under the Affordable Care Act, issuers and health plans are required to provide a brief summary of what the plan covers and the cost sharing responsibility of the consumer, in order to help individuals make more informed choices among health plan options and better understand their coverage. Plans and issuers are also required to provide a comprehensive uniform glossary of commonly used health coverage and medical terms.

"Only when a consumer has a clear understanding of what their plan can do for them as well as what they are responsible for can they feel completely confident in their health plan choice," says Marketplace CEO Kevin Counihan. "That is why we continue to improve upon the SBC requirements in order to provide that peace of mind to our consumers."
OSHA Sets 400% Fine Increase for Reporting Rule Violations

Raising the maximum fine 400 percent for failing to timely report a work-related severe injury and increasing the likelihood for on-site inspections of employers who report a serious injury are among changes reflected in new guidance released by the Occupational Safety and Health Administration.

Under 29 CFR ยง1910.39, employers must report an in-patient hospitalization, amputation, or eye loss to OSHA within 24 hours of the incident. Under previous guidance, the recommended maximum fine for failing to comply was $1,000, not including reductions for small businesses and other allowances. The new recommended unadjusted penalty is $5,000. However, as before, the new guidelines permit area directors to boost the fine to $7,000 to achieve the "necessary deterrent effect" for such reporting violations, which will still be classified as "other than serious." The penalty for failure to report a fatality or three or more in-patient hospitalizations within eight hours and other work-related events remains unchanged, according to the agency. OSHA issued 627 citations for reporting violations in fiscal year 2015, with fines averaging $1,445, Bloomberg BNA reported.
New York Passes Family Leave Mandate

Starting January 1, 2018, new parents in New York will have something to celebrate: paid parental leave.

New York joins California, New Jersey, and Rhode Island as the latest state to mandate paid leave. That said, at 12 weeks paid time off, New York's leave is the most generous in the country, doubling the time California and New Jersey offers, and tripling that of Rhode Island's paid leave. Washington also passed a family leave measure in 2007, but has yet to implement it. (Should Washington D.C. put in place its proposed family leave plan, it will take the top spot from New York with 16 weeks of paid leave.)


Forms 1094-C and 1095-C to be filed with the IRS by May 31, 2016 (instead of February 29, 2016) or June 30, 2016 (instead of March 31, 2016), if filing electronically.

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Please note that Hamilton Insurance does not provide legal advice, and this does not constitute advice of any kind for any 
particular situation. Instead, this is intended as non-comprehensive general information serving as a starting point for further 
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H amilton Insurance , a top ranked independent broker in the Washington DC/Metropolitan Area and the nation, has over 35 years of experience in providing insurance brokerage, risk management and employee benefit solutions. It represents a full suite of commercial, health & welfare, and personal insurance solutions, supported by risk compliance and group benefit administrative services. 

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