Eric Allen Kauk, Esq., LL.M., Author at Catholic Benefit Plans

My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms?

No. If the employer uses an arrangement that provides cash reimbursement for the purchase of an individual market policy, the employer’s payment arrangement is part of a plan, fund, or other arrangement established or maintained for the purpose of providing medical care to employees, without regard to whether the employer treats the money as pre-tax […]

What is expected of non-exempt plans and issuers regarding compliance with the requirement to cover contraceptive services under PHS Act section 2713?

The Departments have received a number of complaints and reports that participants, beneficiaries, and enrollees are being denied contraceptive coverage in violation of the requirements under PHS Act section 2713. Examples include plans and issuers, as well as their pharmacy benefits managers: • Denying coverage for all or particular brand name contraceptives, even after the […]

When providing coverage of OTC COVID-19 tests, are plans and issuers permitted to address suspected fraud and abuse?

Yes. As stated in FAQs Part 44, Q2, although the FFCRA prohibits medical management of coverage of COVID-19 diagnostic testing, plans and issuers may act to prevent, detect, and address fraud and abuse. Examples of permissible activities include the following: • A plan or issuer may take reasonable steps to ensure that an OTC COVID-19 […]

If a plan or issuer provides direct coverage of OTC COVID-19 tests, may it limit coverage to only tests that are provided through preferred pharmacies or other retailers?

No. However, a plan or issuer may limit reimbursement for OTC COVID-19 tests in a manner that meets the conditions of the safe harbor described in this Q2. A reimbursement structure that removes barriers associated with upfront costs will facilitate access to COVID-19 tests and therefore, also improve health equity. At the same time, the […]

Under section 6001 of the FFCRA, are plans and issuers required to cover OTC COVID-19 tests available without an order or individualized clinical assessment by a health care provider?

Yes. Plans and issuers must cover OTC COVID-19 tests that meet the statutory criteria under section 6001(a)(1) of the FFCRA, including tests obtained without the involvement of a health care provider. Consistent with section 6001 of the FFCRA, this coverage must be provided without imposing any cost-sharing requirements, prior authorization, or other medical management requirements. […]

May a group health plan or health insurance issuer condition eligibility for benefits/coverage for otherwise covered items or services to treat COVID-19 on participants, beneficiaries, or enrollees b

No. PHS Act section 2705, ERISA section 702, Code section 9802, and the Departments’ implementing regulations generally prohibit plans and issuers from discriminating against participants, beneficiaries, and enrollees in eligibility, premiums, or contributions based on a health factor. The Departments’ implementing regulations state that rules for eligibility include, among other things, rules related to benefits […]

May a group health plan (or health insurance issuer offering coverage in connection with a group health plan) offer participants in the plan a premium discount for receiving a COVID-19 vaccination?

Yes, if the premium discount complies with the final wellness program regulations. A premium discount that requires an individual to perform or complete an activity related to a health factor, in this case obtaining a COVID-19 vaccination, to obtain a reward would be considered a wellness program that must comply with the five criteria for […]

How does the December 12, 2020 ACIP recommendation impact when plans and issuers must provide coverage without cost sharing for COVID-19 vaccines under section 3203 of the CARES Act and its impleme

Plans and issuers must now cover COVID-19 vaccines and their administration, without cost sharing, immediately once the particular vaccine becomes authorized under an EUA or approved under a BLA, and according to the scope of the applicable EUA or BLA. In a December 12, 2020 meeting, ACIP recommended: “For purposes of ACIP’s role under the […]

April 25, 2022
Eric Allen Kauk, Esq., LL.M.
Church Plans, controlled group, Religious Orders

This might be the question I hear asked most often by Catholic employers. This is also the question that I hear most often answered WRONGLY by advisers. So let’s settle the issue. Solely for benefit plan purposes, an organization is controlled by a church if a majority of its officers or directors are appointed by the […]

FAQ: After the amendments made by the Affordable Care Act, are small employers still exempt from the MHPAEA requirements? How is “small employer” defined?

FAQ: After the amendments made by the Affordable Care Act, are small employers stillexempt from the MHPAEA requirements? How is “small employer” defined? Yes. Small employers are still exempt. Although there were changes to the definition of “smallemployer” for other purposes under the Affordable Care Act, ERISA and the Code continue to define employer as […]