BENEFITS DIGEST

The Departments posted a statement confirming that the Fifth Circuit's August 11 en banc decision in Texas Medical Association v. HHS affirmed portions of a district court judgment striking certain regulations and guidance on how the qualifying payment amount is calculated. The Departments say they are reviewing the opinion and anticipate issuing guidance shortly, and that the Federal IDR process remains operational. Until that guidance issues, the QPA methodology the rules prescribed has no replacement.

In a published opinion by Judge Berzon, the Ninth Circuit held that ERISA does not preempt an out-of-network surgery center's negligent misrepresentation claim over a benefit-verification call in which Aetna said reimbursement would run at the UCR rate, then paid roughly five percent of the bill at the Medicare rate. The provider's injury is its own, not a derivative claim for plan benefits, and letting administrators misstate coverage to providers with impunity would undercut ERISA's purposes. The court still affirmed dismissal of the companion promissory estoppel claim as preempted, and the panel's line falls almost exactly where the Sixth Circuit refused to draw one eight days later in La-Z-Boy.

The Departments released a timeline guide fixing the applicability date for each piece of the June Federal IDR Operations final rules. Two dates matter most for group health plans: the revised batching rules reach disputes whose open negotiation period begins on or after November 1, 2026, and the new remittance advice coding requirements attach to items and services furnished on or after January 1, 2027.

The full picture on the Alcoa decision the Digest flagged Monday: Roberts walks through the Seventh Circuit's holding that the CBAs' silence on benefit duration supports class treatment of 3,000-plus pre-1993 retirees, while the judicial-estoppel basis for the retirees' summary judgment win could not stand.

More than 3,000 pre-1993 Alcoa retirees sued when the company terminated their lifetime retiree healthcare benefits in 2021. On Friday the Seventh Circuit affirmed class certification, holding that the collective bargaining agreements' silence on benefit duration lets the retirees prove vesting through common evidence, but reversed the summary judgment they had won below, rejecting the district court's judicial-estoppel theory and returning the vesting question to the merits. (Blurb corrected 8/17: an earlier version mischaracterized the dispute as a pension-calculation challenge.)

The detailed accounting, published as notification letters began going out: names, Social Security numbers, member and Medicaid/Medicare identifiers, and dental and vision treatment and billing information, with independent analysis suggesting up to 23.4 million unique individuals, including 1.7 million Social Security numbers that appear to belong to children. Affected individuals are being offered 24 months of credit monitoring.

Segal examines what the early end of the Medicare Part D Demonstration program means for premiums and retiree health plans.

Physician and outpatient services and prescription coverage pose a significant threat to US fiscal resources, according to Boston College’s Center for Retirement Research.