Industry Updates

On June 26, the Centers for Medicare & Medicaid Services (CMS) released the Notice of Funding Opportunity (NOFO) for the Transforming Maternal Health (TMaH) Model. TMaH is ten-year delivery and payment model designed to test whether effective implementation of evidence‑informed interventions, sustained by a value-based payment (VBP) model, can improve maternal outcomes and reduce Medicaid and Children's Health Insurance Program (CHIP) expenditures....By: Manatt, Phelps & Phillips, LLP

Wenzel v. Homeowners Choice Prop. & Cas. Ins. Co., Fla. 4th DCA, 4D2023-0088, Apr. 24, 2024 - Following a jury trial, the circuit court entered a directed verdict for the insurer and set aside the jury’s verdict, concluding the insured failed to provide the insurer with prompt notice of the loss. The reviewing court determined that the evidence submitted to the jury was susceptible to different reasonable inferences as to whether the insurer was prejudiced by the delay in reporting the loss....By: Marshall Dennehey

Citizens Prop. Ins. Corp. v. Barberan, Fla. 2nd DCA, 2D22-2744, Apr. 3, 2024 - In April, the Second District Court of Appeal affirmed the lower court’s ruling that a statutory change, which added a definition for the term “structural damage” to a particular statute governing insurance coverage for sinkhole losses (Florida Statute § 627.706), did not alter an insureds’ burden of proof to establish that sinkhole damage to their home occurred during the period when the property had insurance...By: Marshall Dennehey

On August 27, the government filed a motion indicating that it intends to seek Supreme Court review of the U.S. Court of Appeals for the Fifth Circuit’s decision in Braidwood Management v. Becerra. In June, the Fifth Circuit ruled that the law requiring commercial health plans to cover without cost sharing certain preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) is unconstitutional because the manner of the USPSTF’s appointment violates the Constitution’s...By: Manatt, Phelps & Phillips, LLP

A state appellate court in Pennsylvania recently affirmed a trial court’s summary judgment ruling addressing a franchisor’s claims for indemnification in a personal injury dispute. Sunoco (R&M), LLC v. Pa. Nat'l Mut. Cas. Ins. Co., --- A.3d ---, 2024 WL 3688402 (Pa. Super. Ct. Aug. 7, 2024)....By: Lathrop GPM

Insurance buyers enjoyed favorable market conditions across most segments of the commercial lines market in the first half of 2024. D&O and Cyber led the way in premium decreases, even benefiting companies with claims activity. The Property market is also improving; while rates are still rising, the increases are significantly smaller. Companies with good loss experience and high-quality risk management might even see a flat renewal. However, on the Casualty side, auto, general liability and...By: Woodruff Sawyer

California’s Fourth Appellate District published its opinion in Audish v. Macias, clarifying the collateral source rule in personal injury cases. The Court built on the foundation provided by Howell v. Hamilton Meats & Provisions, Inc. finding that evidence concerning a plaintiff’s eligibility for future benefits, like Medicare, is not barred under the collateral source rule. This major development may lead to reduced damages, as the defense will be able to put on evidence that a plaintiff is...By: Kennedys

Professional liability claims impact a multitude of professions, including those in the legal, medical, financial and insurance industries. Claims for malpractice, breach of contract, breach of fiduciary duty and related issues can result in widespread premium increases and professional discipline. Originally published by Insurance Journal - September 11, 2024....By: Rumberger | Kirk

As employers look toward open enrollment for their group health plans, now is a good time to review action items needed for those plans by year-end, as well as upcoming deadlines in the near future. While fully-insured health plans generally have their compliance obligations satisfied by the insurer, self-insured health plans usually rely on the employer or the plan's third-party administrator (TPA) to meet the compliance requirements. Below is a brief summary of items that employers should be...By: Baker Donelson

Universal Property and Casualty Insurance Company a/s/o Perez v. Laguna Riviera Condominium Assn, Fla. 2nd DCA, 2D23-34, Mar. 1, 2024 - In this interesting dispute, the Second District Court of Appeal took the unusual step of granting a motion for rehearing but maintained its prior decision that affirmed the trial court’s decision in favor of Laguna Riviera in a subrogation dispute....By: Marshall Dennehey

On August 29, 2024, the Centers for Medicare & Medicaid Services (CMS) released a Center for Medicaid & Children’s Health Insurance Program (CHIP) Services (CMCS) Informational Bulletin (CIB) and an accompanying slide deck to support states that continue to face renewal backlogs....By: Manatt, Phelps & Phillips, LLP

Summary: Under a final rule released by the Biden administration on Sept. 9, 2024, health insurers will be required to cover mental health care and addiction services on par with other medical conditions. This rule is part of a broader effort to improve access to mental health and substance use disorder treatment for more than 150 million people with private health insurance....By: Nelson Mullins Riley & Scarborough LLP

Biden Administration Issues Final Reg on Mental Health Parity Requirements McDermott+ is pleased to bring you Regs & Eggs, a weekly Regulatory Affairs blog by Jeffrey Davis. Click here to subscribe to future blog posts. September 12, 2024 – Earlier this week, comments were due on the major Medicare calendar year payment regs, marking the unofficial end to the summer reg season that all in health policy “enjoy” each year......By: McDermott+

On May 31, the U.S. Court of Appeals for the Ninth Circuit published an opinion in Bristol SL Holdings Inc. v. Cigna Health and Life Insurance Co., which has significant implications for the healthcare industry. Originally published in Law360 - June 12, 2024....By: Troutman Pepper

Policyholders frequently are vexed by the nuances of reporting requirements in claims-made policies, which generally provide coverage only for a “Claim” made during the policy period. While this may sound like a straightforward inquiry, the definition of “Claim” and the specific language used in a policy’s notice section may lead to a knee-jerk denial from an insurer followed by costly “form over substance” debates that may conclude with lasting financial consequences. As always, the words...By: Lowenstein Sandler LLP

The post-Covid influence over the “gig economy” has led to an expansion of self-employed or by-the-job employed individuals in the delivery and transportation industry. CDL jobs have proven they are not immune to this economic trend....By: Goldberg Segalla

On September 9, 2024, the three federal departments responsible for regulating the health care benefits for more than 175 million Americans with private health insurance issued a final rule (the “Final Rule”) implementing amendments made by the Consolidated Appropriations Act, 2021 (CAA), to the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)....By: Epstein Becker & Green

The operating provisions of the corporate income tax regime for Bermuda legislation will be effective for fiscal years beginning on or after 1 January 2025. This will apply to "Bermuda Constituent Entities" of an "In Scope MNE Group", each as defined in the legislation. Many captive insurers will not be big enough to fall into scope of the new tax regime. In addition, it is expected that no additional tax liability will need to be paid by US-owned captives in Bermuda that make the 953(d)...By: Walkers

The White House has finalized the new Mental Health Parity rule, which focuses on increasing access to mental health/substance use disorder treatment through nonquantitative treatment limitations (NQTL) data and reporting, network composition, out-of-network reimbursement rates, prior authorization requirements, and comparative analyses requirements. Specifically, the rule mandates that plans provide significant outcomes data analyses, including all “relevant outcomes data that it knows or...By: Troutman Pepper

On Monday, September 9, 2024, the Departments of Health and Human Services, Labor and Treasury (the “Departments”) issued their final rule regarding the nonquantitative treatment limitation (NQTL) comparative analysis required under the Mental Health Parity and Addiction Equity Act (MHPAEA). (These acronyms roll right off the tongue, don’t they?) The Departments note that final rules reflect thousands of comments they received after publishing their proposed rules last August 2023. They remark...By: Seyfarth Shaw LLP

Cyber risk is now a normal part of our personal and professional lives. When companies suffer a cyber incident, they often look to their insurance policy for coverage to help mitigate the financial exposure. Additional external resources, such as incident response firms, also help the insured get back to normal operations....By: J.S. Held

As the Atlantic hurricane season reaches its peak in September, bringing with it rainfall and flooding, a recent New Jersey court held a sewer overflow resulting from rainfall was not caused, directly or indirectly, by a flood and therefore did not trigger a flood exclusion. This decision, and the insured’s submission of evidence to prove causation, serves as a roadmap for policyholders challenging an insurer’s overbroad application of an exclusion......By: Bradley Arant Boult Cummings LLP

Both companies and their C-suite executives should be mindful of the interactions between COBRA and Medicare and their implications when negotiating a severance or retirement arrangement. This is because Medicare enrollment can terminate COBRA coverage, depending on the timing of when an executive elects COBRA and when they enroll in Medicare, and because an executive will be penalized under Medicare if they do not timely enroll after their medical coverage as an active employee ends....By: Proskauer - Employee Benefits & Executive

Conversion of State-Law Declaratory Judgment Actions Concerning First-Party Coverage Disputes into Federal Declaratory Judgment Actions Is Not Required Upon Removal - Addressing the thorny issue of whether a state-law declaratory judgment action had to be converted into a federal cause of action under 28 U.S.C. § 2201-2202 to defeat remand to state court, a federal court in Florida recently held the lawsuit was properly removed to federal court and that it did not have to be converted into a...By: Butler Weihmuller Katz Craig LLP

Congress is back from a long August recess. However, it is only back for a few weeks. During this window, there is only one major thing Congress must do: extend government funding past the September 30 deadline through a short-term continuing resolution (CR). This will be accomplished, but it will not be without drama along the way......By: McDermott+

Until recently, Oregon courts did not allow policyholders to bring claims against their insurers under Oregon’s Unfair Claims Settlement Practices Act and only allowed tort-based “bad faith” claims in narrow circumstances. This left Oregon policyholders seeking recovery from their insurers with only contract-based claims and remedies. But the Oregon Supreme Court’s decision in Moody v. Oregon Community Credit Union, 371 Or 772, 542 P3d 24 (2023), which allowed a policyholder to recover on a...By: Miller Nash LLP

This month’s Friday Five discusses cases addressing the effect of continuing to receive benefits during the period of alleged disability, reliance on an employer’s records in making a disability determination, the admissibility of expert and lay testimony from a physician in a trial over LTD benefits, the effect of failing to comply with governing claims regulations and whether the risk of COVID-19 can qualify a claimant as disabled....By: Saul Ewing LLP

A little more than three years ago, the U.S. Department of Labor (DOL) posted cybersecurity guidance on its website for ERISA plan fiduciaries. That guidance extended only to ERISA-covered retirement plans, despite health and welfare plans facing similar risks to participant data....By: Jackson Lewis P.C.

On August 29, the Attorney General for the District of Columbia (DC AG) released four assurances of voluntary compliance against several real estate companies for allegedly using “illegal kickback schemes” in the title insurance market. The DC AG stated in each assurance that it sought injunctive relief, consumer restitution, civil penalties, costs and attorneys’ fees for violations of DC’s Consumer Protection Procedures Act (CPPA). Although only recently published, two of the settlements were...By: Orrick, Herrington & Sutcliffe LLP

Regulations under Section 1557 of the Affordable Care Act and HIPAA will require health plans and health care providers to take action in the coming months to meet new requirements. Health plan sponsors and providers that have not started to prepare for these new requirements should begin to take measures now....By: Ballard Spahr LLP