States Crack Down on Balance Billing

medical-moneyCurrently, only 21 states offer some protection against balance billing and most existing laws apply to emergency services required from out-of-network providers. Few, if any, address balance bills received for treatment by an out-of-network provider in an in-network hospital. In Pennsylvania, the Governor and General Assembly have introduced two bills aimed at taking consumers out of the middle of the reimbursement process. These bills have come after several other states have adopted more comprehensive laws that prohibit balance billing entirely.

Some measures addressed in Connecticut, New York, Maryland, Florida and New Jersey include:

  • Protections in emergency department and in-network hospital settings
  • Prohibiting providers from balance billing and requiring carriers to hold their members harmless
  • Adopting reimbursement rate standards and a payment dispute resolution process
  • Applying these laws to all types of managed care products, including HMOs and PPOs

The goal of the proposals is to keep covered persons out of the middle of carrier-provider payment disputes. In non-emergency procedures, healthcare facilities in New Jersey are required to disclose whether they are in-network and advise the covered person to ask if their physician is in or out-of-network. Individual healthcare professionals must inform the patient if they do not participate in the person’s plan network and provide a billing estimate and applicable CPT codes. With healthcare costs continuing to rise and a lack of federal regulations, we can expect more states to take measures to protect healthcare consumers. We will strive to keep our clients informed as changes develop.

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Deductibles Keep Rising

acaThe International Foundation of Employee Benefit Plans reports that individuals enrolled in employer-sponsored healthcare plans are now paying an average deductible of $1,491 for individual coverage and nearly $2,800 for family coverage. These numbers are up from $1,300 and $2,500, respectively, in 2016.

Individuals covered by HDHPs have average deductibles of $2,296, with families averaging $4,104 – more than twice the averages for traditional, non-high deductible plans. The online survey included nearly 700 U.S. members of IFEBP and was conducted in February.

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Healthcare Consumers About to Have Their Day

ebso-giantsFrom Amazon, Berkshire Hathaway and JP Morgan to Walmart and Humana – disruption is all around us. The future of our healthcare system is unfolding right before our eyes and regardless of how this giant chess match turns out, health plan participants just may be the biggest winners.

The Retail Effect
While many healthcare plans have done well under Obamacare, they need to review what many retailers have experienced since Amazon began building its Prime subscriber base of 100 million plus. When you consider the scope of Walmart, their potential for retail clinics is virtually unlimited. Whether by Amazon, Walmart or others, home delivery of prescriptions could make things very difficult for brick and mortar pharmacies. No matter what area you examine, these mega-partnerships have the potential to impact access to care in ways that most traditional healthcare providers have never imagined. And, if recent retail history means anything, healthcare consumers are sure to benefit.

Self-Funding Will Rule
Most working Americans are already covered by self-funded health plans, and we would expect the new Amazon, Berkshire Hathaway, JP Morgan family to offer at least one self-funded option. Studies show that self-funded plans offer employers far more flexibility than fully insured counterparts and Berkshire Hathaway’s Specialty Services unit certainly has the resources to provide the required stop loss insurance.

A Transparency Opportunity
With a little creativity, the transaction processing infrastructure of JP Morgan could make real-time claims processing a reality for fellow plan members. Real-time payments may encourage providers to discount more. Add telehealth and enable physicians to view electronic medical records and patients may know what to expect from their visit and what they will pay before they make the appointment. The bottom line is that as the level of information sharing increases, cost transparency and the potential for savings will grow.

As a TPA dedicated to controlling costs for self-funded health plans and members, we know these deals will keep more people out of the hospital and increase competition for outpatient care. Technology will move forward, actionable data will be more accessible and consumers will have their day as costs become more transparent and delivery more user-friendly.

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Economies of Scale for Small Businesses

ebso-embIn late June, the Department of Labor introduced final rules on Association Health Plans (AHP), which will allow bonafide associations to offer healthcare plans to member companies. While we had hoped for a different approach to regulating these plans, association health plans will be regulated by states as MEWAs.

According to the final rules, an association that wants to establish a healthcare plan must already exist for another purpose. In other words, an association cannot be formed for the exclusive purpose of offering healthcare plans to its members. Another stipulation is that new self-funded association health plans cannot be established until April 1, 2019.

Association Health Plans will be exempt from the federal mandate on essential health benefits, but will remain consistent with popular Obamacare rules such as coverage of pre-existing conditions and bans on lifetime limits.

While reserve requirements will vary from state to state, we expect that these plans will be quite costly to establish and closely monitored by state regulators. Nonetheless, for large associations with significant cash reserves, we expect this option to make it possible for thousands of small businesses to lower their cost of employee health benefits.

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Employees’ health care burden growing 8 times faster than wages

This article was published on October 3, 2018 on BenefitsPro, written by Emily Payne.

When the Kaiser Family Foundation started tracking employer health benefits 20 years ago, employee deductibles weren’t a concern. Over the years, though, the survey has adjusted to reflect not just the growing percentage of employees with a deductible (85 percent in 2018) but the growing amount of that deductible ($1,573 for an individual in 2018) .

In fact, according to the 2018 KFF Employer Health Benefits Survey, the burden of deductibles has tripled in the past decade and increased eight times faster than wages. Among small employers, 42 percent of workers pay a deductible of $2,000 or more.

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“Rising health care costs absolutely remain a burden for employers, but they’re a bigger problem for workers, as cost-sharing has been rising much faster than wages in recent years,” KFF president and CEO Drew Altman said in a press briefing.

This year’s survey shows no dramatic shifts in the employer-sponsored health care space but continues to illuminate a number of trends, including increasing health care premiums, greater focus on employee wellness and alternatives to traditional health care providers.

Premiums have increased five percent this year, costing a family for four an average of $19,616. Of that cost, employees contribute $5,547, and employers pay the rest. For single-coverage, premiums increased 3 percent to $6,896.

“Premium growth is important, but it’s only part of the story,” noted Altman. “The bigger issue is rising cost-sharing. What happens with wages can be as important to closing that gap as what happens to cost-sharing itself.”

Almost half of employers continue to offer PPO plans, while three in 10 offer a high-deductible plan with a savings component. Some employers (13 percent) offer an incentive to encourage employees to opt for one plan over another.

HDHP adoption is stagnating, comprising 29 percent of all plans. Part of this slowdown may be due to the uptick in the economy. “Given the economy is good and health care costs are relatively tame, I think employers don’t have a strong incentive at the moment to push people into plans they may not be as comfortable with,” said Gary Claxton, KFF vice president and director of the Health Care Marketplace Project. “I think we’ve stalled a bit on the growth of HDHPs. Things will get more interesting if we move into a recession.”

Wellness is getting more of employers’ attention. Seventy percent of large firms now offer health-risk assessments, and 81 percent use data from those assessments to better understand health risks, target their wellness program promotions, design new programs and/or measure health care costs. “As employers have gotten more involved in trying to develop programs to encourage employees to be healthy, having the info is necessary to determine what kind of programs to sponsor and what employees need information about,” Claxton said.

More employers are looking at workers’ activity data–21 percent now collect information from a wearable device as part of their wellness program, an increase from last year’s 14 percent.

Interest in telemedicine and retail clinics continues to grow. Among large employers, 74 percent offer telemedicine services, an increase of 63 percent since last year. In addition, 76 percent cover retail clinic services, and some offer employees a financial incentive to choose these services.

A number of factors, including wages and the economy, will continue to impact the employer health care space in the coming years. Ten percent of employers expect that the elimination of the individual mandate will result in fewer workers purchasing employer-sponsored coverage.

Another factor asked about during the briefing was the increase in prices by health care systems and providers. Consolidation among major health care systems continues to shift the balance of power when it comes to price negotiation. “We’re in a competitive health care system,” Claxton noted. “We rely on private insurers and employers to mediate prices. They haven’t been very successful in recent years. It is hard because most workers work for fairly large employers with multiple locations. It’s hard to develop narrow, efficient networks that would cover all of your employees, and the large health plans don’t really have an incentive to create these options.”

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Transitioning small employers to self-funding strategies

This article was published on September 4, 2018 on BenefitsPro, written by Cort Olsen.

Source: BenefitsPro

With premiums constantly on the rise for employers offering fully insured health plans, brokers are searching for ways to convince their small and mid-size clients that switching to self funding can cut costs on their top line items.

Switching to one of these plans means that the employer assumes more risk, with stop-loss insurance providing financial protection against catastrophic claims. They can also pay medical claims as incurred as they would other corporate expenses, or can deposit expected or maximum costs into an account each month.

There are many ways brokers are going about convincing their clients to make the leap, from educating them on the cost of the medical loss ratio, highlighting the financial pressure health care is placing on their business, or just making them feel as uncomfortable as possible by explaining their fully insured payment methods.

Bob Gearhart Jr., partner at benefits brokerage DCW Group in Boardman, Ohio, says explaining the MLR and how it guarantees fully insured premiums will rise is a great starting point when initiating the conversation.

“Benefits is one of the few areas the CFO has not optimized and they are feeling pressure from the CEO to drive earnings to the bottom line,” Gearhart says. “This organizational pressure coupled with health care in the headlines is slowly changing the buyer within the organization.”

Gearhart adds that leading HR professionals recognize this and proactively engage the C-suite in the buying decision.

Robson Baker, employee benefits and HR adviser for Clarus Benefits Group in Houston, Texas, says getting the C-suite and HR through the awareness phase of the conversation is the hardest part.

“The broker needs to educate and bring the pain points to the forefront of their minds,” Baker says. “Then it moves to consideration — which can be led by a strategic CFO and compassionate HR department.”

Framing health care cost as a financial decision allows the broker to approach the CFO first and then bring the self funding plan down to HR and out to the other employees. Continue reading

How clients can help curb healthcare costs during open enrollment

This article was published on August 29, 2018 on Employee Benefit Adviser, written by Rebecca Madsen.

Technology continues to reshape how employers select and offer healthcare benefits to employees, putting access to information at our fingertips and creating a more seamless and interactive healthcare experience. At the same time, these advances may help employees become savvier users of healthcare, helping simplify and personalize their journey toward health and, in the process, help curb costs for employers.

The revolution can be important to remember during open enrollment, which occurs during the fall, when millions of Americans select or switch their health benefits for 2019. With that in mind, here are five tips employers should be aware of during open enrollment and year-round.

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Make sense of big data. Big data is a buzz word, but the applications are only meaningful if employers can make sense of that information. To help with that, employers are gaining access to online resources to help enable them to more easily analyze and make sense of health data, taking into account aggregate medical and prescription claims, demographics, and clinical and well-being information. This can provide an analytics-driven roadmap to help employers implement tailored clinical management and employee engagement programs, which may help improve health outcomes, mitigate expenses and help employees take charge of their health.

Help people understand their options. More than three-quarters (77%) of employees say they are prepared for open enrollment, yet most people struggle to understand basic health insurance terms, according to a recent UnitedHealthcare survey. In fact, only 6% of survey respondents could successfully define all four basic health insurance concepts: plan premium, deductible, co-insurance and out-of-pocket maximum. To support employees during open enrollment, employers can adopt online platforms designed to personalize and simplify the experience to help people select a health plan based on their personal health and financial preferences, while encouraging them to select a primary care physician and enroll in programs such as smoking cessation or weight loss.

Encourage your people to move more. An estimated 35% of employers now integrate wearable devices into their well-being programs, helping employees more accurately understand their daily activity levels. As these programs become more common, there may be opportunities for cost savings for companies and their workforce. For instance, some wearable device wellness programs may enable people to earn more than $1,000 per year by meeting certain daily walking goals, while employers can achieve premium renewal discounts based on the aggregate walking results of their employees.

Offer incentives to employees who comparison shop for care. More than one-third (36%) of Americans say they have used the internet or mobile apps during the last year to comparison shop for healthcare, up from 14% in 2012, according to the UnitedHealthcare survey. To encourage employees to participate in this trend, some employers are offering financial incentives — such as $25 or $50 gift cards — to employees for using healthcare transparency resources. Healthcare quality and cost varies widely within a city or neighborhood, so encouraging the use of online and mobile transparency resources may yield savings for employers and employees.

Integrate medical and ancillary benefits. Open enrollment is also the time for people to select important ancillary benefits, such as vision and dental coverage. While some people may overlook these plans, offering this coverage as part of an employee’s menu of benefits options may maximize the effectiveness of a company’s healthcare dollars, provide families with added peace of mind and help build a culture of health. Combining medical and ancillary benefits under a single health plan may enable for the integrated analysis of a wide range of data that can facilitate proactive outreach and clinical support for employees, including for people with chronic conditions such as diabetes, or to help prevent the development of such conditions.

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For 2019, Employers Adjust Health Benefits as Costs Near $15,000 per Employee

This article was published on August 13, 2018 on SHRM.org, written by Stephen Miller.

Plans are steering employees toward expanded telehealth options and high-value centers of excellence

With the cost of employer-sponsored health care benefits expected to approach $15,000 per employee next year, large U.S. employers continue to make changes, new research reveals.

Many want to hold down cost increases and are steering employees toward cost-effective service providers, such as telehealth options and high-value in-plan provider networks, according to the nonprofit National Business Group on Health (NBGH) survey 2019 Large Employers’ Health Care Strategy and Plan Design. The survey was conducted from May to June with 170 large employers as they finalized their 2019 health plan choices; more than 60 percent of respondents belong to the Fortune 500.

Cost Increases Hold Steady

Big employers project that their total cost of providing medical and pharmacy benefits will rise 5 percent for the sixth consecutive year in 2019. If they weren’t making benefit changes, their costs would rise 6 percent, the survey showed.

The total cost of health care, including premiums and out-of-pocket costs for employees and dependents, is estimated to average $14,800 per employee in 2019, up from $14,099 this year. Large employers will cover roughly 70 percent of those costs, leaving $4,400 on average for employees to pick up in premium contributions and out-of-pocket expenses.

Health benefit costs are still rising at two times the rate of wage increases and three times general inflation, “making this [cost] trend unaffordable and unsustainable over the long term,” Brian Marcotte, NBGH president and CEO, said at an Aug. 7 press conference in Washington, D.C.

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Consumer-Directed Health Plans

“The most unexpected data point in the survey this year is that employers are dialing back their move to consumer-directed health plans”―or CDHPs―especially as a full replacement for other health plan options, Marcotte said. CDHPs typically combine a high-deductible health insurance plan with a tax-advantaged account that employees can use to pay for medical expenses, most commonly a health savings account (HSA) or health reimbursement arrangement.

“We may be at a tipping point in terms of cost-sharing with employees,” Marcotte said.

In 2019, the number of employers offering CDHPs as a sole option will drop by 9 percent, from 39 percent to 30 percent, “reflecting a move by employers to add more choice back into the mix” by also offering traditional health plans such as preferred-provider organizations, he noted.

To lessen the pain of high deductibles while maintaining incentives for cost-conscious spending, large employers are contributing to their employees’ HSAs, on average, $500 for an individual and $2,000 for a family, NBGH found.

The shift to CDHPs as a sole option over the last decade was driven, in part, by the Affordable Care Act and its 40 percent “Cadillac tax” on high-value health plans, originally to take effect in 2018, Marcotte said. “A lot of companies moved to high-deductible health plans to minimize the impact of the Cadillac tax or to delay its impact, but the Cadillac tax has been kicked down the road, first  to 2020 and now to 2022,” Marcotte said. Many believe it may be further delayed or repealed altogether, “so employers are relaxing” about the need to reduce the scope of their plans. Continue reading

Helping with Prescription Adherence

doctorWhile prescribed medications are critical to the management of chronic illnesses such as diabetes, asthma or heart disease, they can only help when taken correctly and research shows that at least half are not taken as prescribed. This not only has a huge impact on the health of individuals but on health plan costs since failure to take medications as prescribed can result in costly emergency room visits and hospital readmissions.

Since failing to follow a doctor’s prescription plan will likely result in higher dollar claims for treatment, examining claims data is the first step to take in order to monitor this problem. Once the employees involved are identified, a health coach or support team can be assigned to help these individuals begin managing and taking their medications correctly. If cost is an issue, which is fairly common in the case of chronic problems, financial incentives or help with prescription copays might be wise.

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