Safe Step Act: does it undermine step therapy?

Drug expenditure in the United States has continued to increase unsustainably; the specialty of dermatology has been particularly affected. Resources are limited - someone has to make decisions about what treatments will be covered and how they will be reimbursed. Step therapy is a cost-control method used by insurers to encourage the use of the most cost-effective treatments before more expensive options are attempted. However, a rigid step therapy policy can be problematic when protocols are out of date, or delay necessary treatment leading to unnecessary suffering, increased morbidity, and overall cost. To address some of these concerns, the proposed Safe Step Act (S. 2546 and H.R. 2279) attempts to create a requirement that insurers provide a transparent, expeditious exceptions process for step therapy protocols. Increased flexibility in this process will allow for the unique circumstances of individual patients and improve access to expensive drugs for special cases. However, this bill may be exploited, further weakening insurers' ability to negotiate on cost. We should be cautious about measures that reduce the effectiveness of this tool, particularly if we, as a society, aim to expand access to basic care to all Americans.

States as Policy Laboratories: The Politics of State-Based Single-Payer Proposals.

Although the focus for most single-payer advocates is in Washington, DC, and on proposals for Medicare for all, there are also efforts in a handful of states to enact a state-based single-payer program. Moreover, the odds of legislative passage are better in a state like New York than at the federal level.Even if enacted, however, state-based single-payer proposals face a distinct set of obstacles, including (1) the need to obtain federal permission (via waivers) to repurpose federal dollars, (2) the federal Employee Retirement Income and Security Act, and (3) the burden of state-only action in an interconnected 50-state economy.The most likely result of the energized single-payer movement will be incremental public insurance expansions at the federal and state levels, including state programs to permit the uninsured to buy into the Medicaid program. Such an outcome is consistent with the most plausible path (incrementalism) to a US version of universal coverage.

The Importance of Preserving Tax-Preferred Status for Employer-Sponsored Health and Retirement Plans.

The future of employer-sponsored health and retirement plans may be at risk. For years, employers have struggled to maintain and pay for these plans despite the increasing compliance and financial burdens imposed by legislative and regulatory action. Now, as Congress begins to lay the foundation for comprehensive tax reform, the need to raise federal revenue may trump the continuation of the tax preferences for employer-provided health and retirement benefits. Recent actions illustrate that the drive for federal revenue may not be sufficiently tempered by the potential negative impact on employers and employees who must bear the brunt of these revenue-induced changes. This article considers the erosion of protections offered by the Employee Retirement Income Security Act (ERISA) and the importance of maintaining the tax treatment of employer-provided benefits.

ERISA in 2015.

The federal Employee Retirement Income Security Act (ERISA) helps medical practices make carriers pay on claims that are now being denied, delayed, and recouped. Only a small percentage of practices understand how ERISA works. Yet with appropriate guidance, ERISA could possibly become a practice's best friend! Practices are in the dark when it comes to understanding how to protect their rights in collecting the monies owed them. ERISA regulates the practice's health benefits, health benefit payments, explanations of benefits, and, most importantly, appeal rights. This article covers ERISA in 2015 and how practices can capture the thousands of dollars that carriers currently are unfairly denying. This overview will empower the reader to stop the unfair recoupments and the timely filing and improper appeal periods that carriers mistakenly quote to physicians and hospital offices.

What is ERISA and why should it matter to your medical practice?

The Federal law ERISA (Employee Retirement Income Security Act) helps the majority of medical practices make carriers pay on claims that are now being denied, delayed, and recouped. Only a small percentage of practices understand how ERISA works. Yet with appropriate guidance, ERISA could possibly become a practice's best friend! Practices are in the dark when it comes to understanding how to protect their rights in collecting the monies owed them. ERISA regulates the practice's health benefits, health benefit payments, explanations of benefits, and most importantly, appeal rights. This article covers how to capture the funds on thousands of dollars that carriers are now unfairly denying, and will empower the reader to stop the unfair recoupments and illegal timely filing and improper appeal periods that carriers mistakenly quote to physicians and hospital offices.

The Affordable Care Act, remedy, and litigation reform.

The Patient Protection and Affordable Care Act of 2010 (ACA) rewrote the law of private health insurance. How the ACA rewrote the law of civil remedies, however, is a question largely unexamined by scholars. Courts everywhere, including the U.S. Supreme Court, will soon confront this important issue. This Article offers a foundational treatment of the ACA on remedy. It predicts a series of flashpoints over which litigation reform battles will be fought. It identifies several themes that will animate those conflicts and trigger others. It explains how judicial construction of the statute's functional predecessor, the Employee Retirement Income Security Act of 1974 (ERISA), converted a protective statute into a uniquely effective piece of federal litigation reform. Ultimately, it considers whether the ACA--which incorporates, modifies, and rejects ERISA in several notable ways--will experience a similar fate.

Amendment to the interim final rules for group health plans and health insurance coverage relating to status as a grandfathered health plan under the Patient Protection and Affordable Care Act. Amendment to interim final rules with request for comments.

This document contains an amendment to interim final regulations implementing the rules for group health plans and health insurance coverage in the group and individual markets under provisions of the Patient Protection and Affordable Care Act regarding status as a grandfathered health plan; the amendment permits certain changes in policies, certificates, or contracts of insurance without loss of grandfathered status.

Interim final rules for group health plans and health insurance coverage relating to status as a grandfathered health plan under the Patient Protection and Affordable Care Act. Interim final rules with request for comments.

This document contains interim final regulations implementing the rules for group health plans and health insurance coverage in the group and individual markets under provisions of the Patient Protection and Affordable Care Act regarding status as a grandfathered health plan.

Interim final rules for group health plans and health insurance issuers relating to internal claims and appeals and external review processes under the Patient Protection and affordable Care Act. Interim final rules with request for comments.

This document contains interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under the Patient Protection and Affordable Care Act. The regulations will generally affect health insurance issuers; group health plans; and participants, beneficiaries, and enrollees in health insurance coverage and in group health plans. The regulations provide plans and issuers with guidance necessary to comply with the law.