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Health plans - design


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[Guidance Overview] Toeing the Line: The Coverage Eligibility Limits for a New Full-Time Employee in 2015
"One frustrating aspect of the [ACA] for employers is they can be in compliance with one area of the ACA and not in compliance with another area of the ACA. This frustration can be seen when an employer tries to determine the latest date it can make a new full-time employee eligible for coverage while still being in compliance with all of the ACA's provisions. The purpose of this article is to discuss the issues of eligibility surrounding new full-time employees hired in 2015 and to provide a chart ... [that] accurately summarizes the article for those readers who are not interested in the details and reasoning." (Health Care Attorneys P.C.)
Should Your Company Consider a Private Health Exchange? (PDF)
7 pages. "The exchange may offer valuable support in communication and enrollment services. However, a move in this direction requires a thoughtful vendor evaluation for cost and services offered. In addition, the defined contribution approach must be evaluated. Finally, a well-managed implementation process is critical.... [1] Important considerations in determining whether a private exchange is right for you ... [2] The basics of private exchanges ... [3] The potential services private exchanges offer ... [4] Different types of private exchanges and considerations with each type." (McGraw Wentworth)
An Overview of Cafeteria Plans (Code Section 125) (PDF)
"Section 125 of the Internal Revenue Code allows most employees to pay for certain benefits with pre-tax dollars, but complex and specific rules apply. This [article] reviews the Section 125 rules including: [1] Basic Legal Requirements; [2] Mid-year Changes; [3] Flexible Spending Accounts (FSAs); [and] [4] Non-Discrimination Requirements. Health care reform has now changed several aspects of the Section 125 rules." (McGraw Wentworth)
Latest Employer Wellness Plan to Draw EEOC Fire includes Biometric Screening Requirement
"In March 2010, with the President's support for an incentive-based approach to wellness and a statement of Congress' approval of such an approach to wellness, the [ACA] amended the HIPAA nondiscrimination and wellness provisions to allow employers to provide larger incentives to employees who satisfy requirements of the employer's health promotion and disease prevention (i.e., wellness program). Regulations implementing the HIPAA provision have been issued as well. They include 'bright-line' rules for determining the nature and extent of the incentives an employer may include in its wellness program.... The [EEOC] would effectively make meaningless the ACA and HIPAA provisions and regulations." (Jackson Lewis P.C.)
[Opinion] Testing the SHOP in Ohio: Not as 'Easy as Buying a Plane Ticket'
"Ohio is one of five states with early access to the Small Business Health Options Program (SHOP).... [The web site] asked us to begin entering information for each employee. We could either do that or download an excel document and populate it into the system.... The spreadsheet has 20 columns to complete for each employee. Each dependent has an additional 8 columns to complete. You must provide date of birth, social security number, date of hire, address, employee code, and a preferred method of contact for each employee and their dependents.... Without knowing the rates and benefits it doesn't make sense to waste productivity gathering all of the data. Instead we will wait until the insurance companies are allowed to quote the plans directly. When will that be? I'm not sure but I'll bet it won't be until after next Tuesday." (InsureBlog)
How Halbig and Three Related Cases Could Affect Health Insurance Under the ACA
"[I]f proponents of these lawsuits prevail, the government will strip premium tax credits from residents in all of the 36 states with federally facilitated marketplaces. Those tax credits help low- and moderate-income residents afford to pay their monthly health insurance premiums. Without this benefit, millions of residents would not be able to pay for their health insurance. The scale of the problem is large." (Families USA)
Biometric Screening Requirement Under Wellness Program Violates ADA and GINA, According to EEOC Suit
"Failure to participate in the screenings would subject the employee to financial penalties. For example, an employee that does not participate would not be able to receive a company contribution to the employee's health savings account of up to $1,500 for the year. Additionally, the employee would be subject to a $500 surcharge on medical plan costs, as well as tobacco surcharges of $1,000 that apply to the employee and the employee's spouse if they fail to take the screenings.... Because of the incentives ... the EEOC claims that the examinations are involuntary, effectively forcing employees to submit to the biometric screenings. The Eleventh Circuit rejected a similar challenge in Seff v. Broward County, FL, applying a separate 'safe harbor' provision of the ADA." [EEOC v. Honeywell Int'l Inc., No. 14-cv-04517-ADM-TNL (D. Minn., petition filed Oct. 27, 2014)] (Jackson Lewis)
Text of EEOC Memorandum on Law in Support of Application for Temporary Restraining Order Against Honeywell International (PDF)
"Based upon the EEOC's preliminary review, Honeywell's medical examinations are unlawful. The ADA prohibits employers from conducting medical examinations that are not job-related and consistent with business necessity. While an employer can ask the employees to undergo voluntary health exams, an examination is not voluntary when the employer imposes a penalty on the employee if he or she declines to participate. The EEOC's preliminary investigation also indicates that the ongoing medical testing violates GINA. Honeywell requires that the employees' spouses be tested or the employees will be penalized. GINA prohibits employers from offering inducements (or alternatively imposing penalties) to employees to obtain medical information about an employee's family members. Honeywell's program, if not enjoined, will irreparably harm the EEOC and Honeywell's employees. The EEOC's mission will be thwarted. It will be forced to sit by and watch Honeywell violate the ADA and GINA, thereby irreparably damaging the EEOC's role as the agency charged with enforcing those statutes and preventing discrimination under them." [EEOC v. Honeywell Int'l Inc., No. 14-cv-04517-ADM-TNL (D. Minn., petition filed Oct. 27, 2014)] (Equal Employment Opportunity Commission [EEOC], via Jackson Lewis)
Honeywell: Driving Health Engagement
A description of the health & wellness program sponsored by Honeywell International. Excerpt: "Today, Honeywell has shifted from just offering health care as a benefit to engaging and equipping employees to lead healthier and productive lives, and has found that incentives coupled with targeted communications can be effective in engaging employees." (Business Roundtable [BRT])
[Opinion] National Business Group on Health Sees Profound Implications for Corporate Wellness Programs from EEOC Lawsuit Against Honeywell International
"The EEOC is suing Honeywell International over a wellness program that provides financial incentives to employees and their spouses who undergo biometric screenings and participate in smoking cessation programs.... Wellness programs with incentives for biometric screenings are prevalent: According to a survey by the National Business Group on Health and Fidelity Investments, 95% of employers offer a health risk assessment, biometric screening or other wellness program in 2014. About three in four (74%) employers use incentives to engage employees in these programs." [EEOC v. Honeywell Int'l Inc., No. 14-cv-04517-ADM-TNL (D. Minn., petition filed Oct. 27, 2014)] (National Business Group on Health [NBGH])
As Employers Try to Avoid ACA Excise Tax, Lower-Cost Health Plans Face Biggest Test
"The excise tax should be given a more middle-class status name, such as the 'Camry tax,' because it is to affect more than just high-cost plans, [said Helen Morrison, a principal with Ernst & Young LLP]. Even plans with a 70 percent actuarial value -- a silver-tier plan under the ACA -- will reach the thresholds soon after 2018 ... Because the tax threshold is tied to the urban consumer price index and not to health cost trends, which has been rising much faster, the tax will affect more than just high-cost plans, Morrison said." (Bloomberg BNA)
EEOC Sues Honeywell Over Employee Wellness Testing
"Honeywell employees could be penalized up to $4,000 each, through surcharges and lost contributions to health plans, if they or their spouses do not comply with the biometric testing, according to the lawsuit, filed on [October 27] in U.S. District Court in Minnesota.... Of Honeywell employees and spouses enrolled in a health plan, 77 percent of participated in the company's wellness program last year, up from 36 percent in 2011, the company said." [EEOC v. Honeywell Int'l Inc., No. 14-cv-04517-ADM-TNL (D. Minn., petition filed Oct. 27, 2014)] (Reuters)
[Opinion] ERIC Outraged Over Latest Wellness Suit Brought by EEOC
"Workplace wellness programs have a central role to play in the nation's efforts to improve the health of American workers, and they have proved effective in containing health costs, reducing disability claims, and improving workers' productivity. 'These suits by the EEOC will undercut efforts by employers to create a healthier workplace, will put a damper on the future development of wellness programs, will deny employees and their spouses the opportunity to live healthier lives, and ultimately, if left unchecked, will lead to a sicker population,' [said Gretchen Young, ERIC Senior Vice President for Health Policy]." [EEOC v. Honeywell Int'l Inc., No. 14-cv-04517-ADM-TNL (D. Minn., petition filed Oct. 27, 2014)] (The ERISA Industry Committee [ERIC])
Common Wellness Program Designs Under Attack by EEOC (PDF)
"[C]ourts are loathe to assume that Congress intended to make laws that conflict with each other. Where laws appear to conflict, as the ADA and ACA/HIPAA appear to do with respect to wellness programs, courts will search for a way to reconcile them. It seems plausible to us that the courts will allow the ACA/HIPAA rules to trump the EEOC's more restrictive interpretation under the ADA. But all that remains to be seen." (Lockton)
Impact on Employee Benefit Plans of the Supreme Court's Recent Actions on Marriage
"[F]or employee benefit plan issues that are not dictated by the Code or ERISA -- such as designing the eligibility of a health or welfare plan -- the recent Supreme Court decision does not directly impact an employer's ability to decide whether to extend coverage to a same-sex spouse. As the law stands today, sponsors of self-insured health plans may continue to choose whether or not to offer coverage to same-sex spouses (and a state law that provides otherwise should be preempted by ERISA).... [This article includes] a list of the protections and rules that currently apply under ERISA and the Code to 'spouses,' using the IRS's and DOL's definition that looks to the state of ceremony for determining the legality of the marriage." (Ogletree Deakins)
Insurers Limit Access to Pricey Drugs for Hepatitis C Patients Unless Illness Is Advanced
"Faced with a cost per patient of roughly $95,000 or more for a 12-week course of treatment, many public and private insurers are restricting access to those who already have serious liver damage. Other strategies that limit access include restricting who can prescribe the drugs or requiring early proof the drug is working before continuing with treatment. In addition, many state Medicaid programs require that patients be drug and alcohol free for a period of months before they can get the hepatitis C drugs." (Kaiser Health News)
CMS Presentation: FF-SHOP Updates and Live Q&A, October 23, 2014 (PDF)
37 presentation slides. Topics include; Vendor Registration; Increment 2 Testing. "[T]he intended audience for this call is medical and dental issuers operating within the Federally-facilitated Small Business Health Options Program (FF-SHOP)." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
SHOP Early Access Available to Small Businesses in Five States
"The Federally-Facilitated Small Business Health Options Program (SHOP) Marketplace Early Access [was launched on Monday, Oct. 27] in Delaware, Illinois, Missouri, New Jersey and Ohio. The SHOP Marketplace helps small businesses provide health coverage to their employees and is open to employers with 50 or fewer full-time equivalent employees. 'SHOP Early Access' will allow small businesses, agents, and brokers to try out new online pre-enrollment SHOP features, and help set the stage for the full online debut on November 15." (U.S. Small Business Administration [SBA])
Planning for Health Care Costs in Retirement: A 2014 Survey of Age 50+ Workers
"Almost four in ten 50+ workers (38%) are not saving for health care costs, and many (44%) do not have any plans to do so in the future.... While a majority of 50+ workers (62%) say they are saving for health care costs, more than half (55%) are worried they may not be able to afford health care costs.... A majority of 50+ workers (57%) plan to work past the age of 65, including roughly two in ten (18%) who say they will never retire." (AARP)
Choosing a Health Plan Is Hard, Even for a Health Economist
"Already, the lack of price transparency is enough to make a health economist despair. But it gets worse. Some aspects of plan quality are available to most consumers, like consumers' ratings of customer service and how well doctors in each plan communicate with their patients. But a crucial feature of health plans is not as easily or widely accessible: the extent to which each covers services provided by one's favorite doctors and hospitals." (The New York Times; subscription may be required)
Is the Affordable Care Act Working?
"After a year fully in place, the [ACA] has largely succeeded in delivering on President Obama's main promises, an analysis by a team of reporters and data researchers shows. But it has also fallen short in some ways and given rise to a powerful conservative backlash.... Has the percentage of uninsured people been reduced? ... Has insurance under the law been affordable? ... Did the Affordable Care Act improve health outcomes? ... Will the online exchanges work better this year than last? ... Has the health care industry been helped or hurt by the law? ... How has the expansion of Medicaid fared? ... Has the law contributed to a slowdown in health care spending?" (The New York Times; subscription may be required)
Study Shows Employer Perceptions of Defined Contribution Health Plans and Private Insurance Exchanges (PDF)
1-page infographic providing results of a July 2103 survey of 502 employers of 60 or more employees. "90% [of the employers are] interested in exploring defined contribution. 85% [are] interested in exploring private exchanges." (AlegeusTechnologies)
Income Variability and Eligibility for ACA Subsidies
"Incomes are highly variable within any one year, particularly at the lower end of the income-distribution spectrum. The extent of income changes was sufficient to trigger changes in subsidy eligibility for up to a third of all adults eligible for Medicaid or subsidized coverage. Shifts in employment, such as losing or getting a job, changing employers, or switching to part time, were key to income volatility. Even without periods of unemployment, they were associated with income changes both up and down." (Robert Wood Johnson Foundation)
Monitoring the Impact of the ACA on Employers
"In this report, [the authors] analyze recent trends in the employer health insurance market and the anticipated effects of the [ACA] on employers, with a particular focus on small firms with fewer than 50 workers. [They] first present a detailed picture of the employer market by identifying preexisting trends in key outcomes that could be incorrectly attributed to the [ACA]. [They] also analyze the literature to identify economic factors that are important in current employer and employee decisions regarding health coverage." (Urban Institute)
Employers Will Need to Pull Multiple Levers to Avoid ACA's Excise Tax on High-Cost Plans
"Nearly half of U.S. employers with 5,000 employees or more expect to trigger the ACA tax in 2018 and 82 percent by 2023 ... Levers that employers can pull to protect themselves from the excise tax include wellness strategies targeted in areas that are driving plan costs; delivering medical services to patients by interactive audio, video and other technology; and changing the ways that employers pay for benefits[.]" (Bloomberg BNA)
Text of EBSA Revised Notice of ERISA Advisory Council Meeting on November 3-4, 2014
"[T]he 174th open meeting of the Advisory Council on Employee Welfare and Pension Benefit Plans (also known as the ERISA Advisory Council) will be held on November 3-4, 2014. No votes will occur until November 4. Despite our efforts to get this meeting notice published early, we were unable to do so. The Advisory Council meeting notice appeared on the public inspection desk of the Federal Register on October 20, 2014. This revised notice clarifies that final votes on the Council's recommendations to the Secretary will occur on November 4, 2014 ... The Council recommendations will be on the following issues: [1] Issues and Considerations around Facilitating Lifetime Plan Participation, [2] PBM Compensation and Fee Disclosure, and [3] Outsourcing Employee Benefit Plan Services." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor)
Retirement Plan's Venue Selection Clause Held Enforceable and Applied to Dismiss Participant's Benefit Claims
"The Federal courts ... have repeatedly held that adherence to the written terms of a plan in enforcing ERISA rights and obligations is of paramount importance. These decisions often demonstrate the extent to which the courts will enforce a plan sponsor's design choices provided they fit within ERISA's statutory and regulatory boundaries. Those boundaries are not endlessly elastic, but [this case] shows that they may be broader than some participants expected." [Smith v. Aegon Companies Pension Plan, No.13-5492 (6th Cir. Oct. 14, 2014)] (Williams Mullen)
[Guidance Overview] Federal Agencies Issue Final Guidance on Excepted Benefit Standards
"The final regulations give employers more flexibility in their EAPs and stand-alone limited-scope dental and vision programs. The criteria for EAPs to qualify as excepted benefits are largely the same as in the proposed regulations. The final guidance does not address limited wraparound coverage; the departments intend to publish regulations in the future on such coverage, 'taking into account the extensive comments received on this issue.'" (Towers Watson)
[Guidance Overview] Five Hot Topics in the Health Plan World
"[1] Mental Health Parity rules require immediate attention.... [2] HPID? OMG! ... [3] Whose employees are they? Temporary workers and the employer shared responsibility.... [4] Reinsurance fee deadlines looming.... [5] Reference-based pricing and MOOP limits." (Quarles & Brady LLP)
32% of Employers Delayed Health Plan Renewal Date to December 2014 to Avoid Rate Increases
"The number of employers delaying their health plan renewal dates until December 1 increased 322 percent from 2013 to 2014, with 32 percent of all employers postponing their renewal date, according to ... [this] survey of nearly 10,000 employers. Of the 32 percent, 94 percent were small businesses in the under 100-employee market. Based on current renewal rates coming in from carriers, in the states that did not allow renewal of pre-PPACA plans, many small employers are facing rate increases of 30 percent to 160 percent[.]" (United Benefit Advisors)
[Guidance Overview] Final Regs Clarify When Dental and Vision Benefits and Employee Assistance Programs Are Not Subject to the ACA
"Benefits that meet these tests are not subject to group health plan mandates under the [ACA], including the ban on annual or lifetime dollar limits. Nor would the pediatric dental or vision benefits offered under these limited-scope arrangements have to count toward the out-of-pocket limit applicable to non-grandfathered plans ($6,600 single/$13,200 family in 2015). In addition, to the extent these benefits are not already exempt, they will also be exempt from certain fees, such as the comparative effectiveness research fees7 and the transitional reinsurance fees. Treating these benefits as excepted benefits may also assist the plan to avoid the excise tax on high-cost health plans." (Segal Consulting)
Checklist for Evaluating Private Exchanges
"Important considerations include: What are my company's benefit plan objectives and does it make sense to move to a private exchange based on these objectives? Is moving to an exchange cost effective for my organization and my employees? What does moving to a private exchange entail? What are the options for both insured and self-funded arrangements? How will offering benefits through an exchange impact my company's health management strategy? What additional fees and commissions are built into the rates under a private exchange?" (Findley Davies)
As Virus Spreads, Insurers Exclude Ebola from New Policies
"As fear of Ebola infections spreads to developed economies, U.S. and British insurance companies have begun writing Ebola exclusions into standard policies to cover hospitals, event organizers and other businesses vulnerable to local disruptions. As a result, new policies and renewals will become costlier for companies opting to insure business travel to West Africa or to cover the risk of losses from quarantine shutdowns at home[.]" (Reuters, via The Baltimore Sun)
Open Enrollment: Insights from Medicare for Health Insurance Marketplaces
"Health insurance plans often change from one year to the next, and some of these changes could have a real impact on costs and coverage, including changes in premiums, cost-sharing, benefits, formularies and choice of doctors and hospitals. Consumers are advised to review their options carefully before deciding whether to renew their current plan or enroll in a new one. But will they?" (Henry J. Kaiser Family Foundation)
[Guidance Overview] Can Dependents Trigger an ACA Employer Penalty Under Section 4980H(a) or 4980H(b)?
"The final regulations make it clear to utilize the 95 percent rule, a full-time employee's dependents must be offered coverage along with the full-time employee. Therefore, an employer not offering a full-time employee's dependents coverage would not have the protection of the 95 percent rule." (Health Care Attorneys P.C.)
ACA Issues in Mergers and Acquisitions: New Guidance from IRS
"[In] a stock deal, Buyer will assume any unpaid ACA penalties owed by Target. Although this is generally true for any taxes or other liabilities assumed in a stock deal ... the ACA penalties are not due until the Service issues a notice and demand. Thus, for cash basis taxpayers, the ACA penalty will not be reflected on Target's financial statements ... Second, whether or not Target is acquired in a stock sale or asset sale, if Buyer hires Target's employees, any such acquired employees who are 'full-time' must be offered health insurance that provides minimum value and is affordable if Buyer wants to avoid potential ACA penalties." (Saul Ewing LLP)
More States Recognize Same-Sex Marriages But No Mandate Yet for Self-Funded ERISA Plans to Extend Coverage to Same-Sex Spouses
"Although states may have insurance, domestic relations, and nondiscrimination laws that require recognition of same-sex marriages, ERISA preemption appears to invalidate those requirements as they would apply to a self-funded ERISA plan. Plan sponsors choosing an insured plan might not have a choice, because of the way these laws impact insurers." (Lockton)
Employers Looking at 'Skinny' Health Plans to Avoid ACA Penalties
"[S]ome benefits administrators are pitching somewhat-less-skinny plans that they claim protect employers against the $3,000 penalty as well -- by meeting the law's standard of covering at least 60% of the cost of health care. Yet one such 'minimum value plan' that is being sold to employers still lacked coverage for inpatient hospital treatments, procedures at ambulatory surgery centers or most maternity care[.]" (The Wall Street Journal; subscription may be required)
Proposed Bankruptcy Fairness and Employee Benefits Protection Act of 2014 Would Place Significant Restrictions on Employers in Bankruptcy
"Various changes to the Bankruptcy Code would place greater restrictions on corporations going through a bankruptcy by limiting reductions in the compensation and benefits of employees and retirees, requiring funding of retiree health benefits in excess of that approved by the bankruptcy court, increasing the amount of unpaid wages that receive priority treatment, limiting payments and bonuses to insiders, and forcing employers to continue funding pension plans after filing for bankruptcy protection." (Thompson Coburn)
71% of Obamacare Signups Traced to Expansion of Medicaid
"In the states that adopted and implemented Medicaid expansion under Obamacare, enrollment skyrocketed as an additional 5.7 million Americans signed up for coverage. In 21 states opting out of Medicaid expansion, however, enrollment was strikingly lower.... 355,674 Americans signed up for Medicaid in those states. In all, Medicaid enrollment increased by 6 million individuals for the first half of 2014." (Melissa Quinn, in The Daily Signal)
How the Supreme Court Could Still Wreak Havoc on Obamacare
"If you have Obamacare without the subsidies, it would essentially wreak major havoc on the individual insurance market ... Premiums would be 43.3 percent higher on average in the individual market in 2015, while enrollment -- on and off the exchanges -- would drop by 68 percent ... In all, 11.3 million fewer Americans would have health insurance[.]" (The Washington Post; subscription may be required)
[Official Guidance] Text of CMS Proposed Federal Funding Methodology for Basic Health Program, for Program Year 2016
"This document provides the methodology and data sources necessary to determine federal payment amounts made in program year 2016 to states that elect to establish a Basic Health Program [BHP] under the [ACA] to offer health benefits coverage to low-income individuals otherwise eligible to purchase coverage through Affordable Insurance Exchanges.... We propose that the total federal BHP payment amount would be based on multiple 'rate cells' in each state. Each 'rate cell' would represent a unique combination of age range, geographic area, coverage category ... household size, and income range as a percentage of [federal poverty level].... [We] would develop BHP payment rates that would be consistent with those states' rules on age rating. Thus, in the case of a state that does not use age as a rating factor on the Exchange, the BHP payment rates would not vary by age." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services)
[Guidance Overview] New York State Department of Health Releases Long-Awaited Proposed Regs Authorizing Formation of ACOs (PDF)
"The Commissioner of the New York State Department of Health will issue Certificates of Authority (COA) to entities that satisfy the regulatory criteria for ACOs. Among the ACO criteria are the existence of stated mechanisms for governance, accountability, and the distribution of funds. An ACO must have a plan for coordination of care to assure that all medically necessary health care services are available to and used by the patient, including evidence-based treatment initiatives and strategies for patient engagement. The regulations specify standards for the ACO's quality management improvement program, including a process for peer review." (Epstein Becker Green)
House Approves Health Care Bills Before November Elections
"During a brief September legislative session, the House of Representatives approved a bill defining a full-time employee under the Patient Protection and Affordable Care Act (PPACA) using a 40-hour-per-week standard. Another House bill would allow insurers to sell certain health plans that fail to meet PPACA requirements. Although Senate action is not expected, these provisions could reappear on the legislative agenda in 2015." (Towers Watson)
[Guidance Overview] Overview of 2015 QRS Requirements for QHP Issuers (PDF)
"QHP issuers offering family and/or adult-only health insurance coverage of any category through the Marketplaces ... must comply with QRS requirements, if they offered coverage during the previous benefit year and meet minimum enrollment criteria.... QHP issuers are required to collect and submit third-party validated QRS measure data that will be used by CMS to calculate QHP scores and ratings." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Are Your Benefit Plans Ready for Ebola?
"Will Ebola treatment costs be covered by commercial carriers? Maybe.... [M]ost plans include an exclusion of coverage for employees who are traveling abroad on short-term assignment.... Critical illness policies need to have an infectious disease rider included (not standard), and currently, no policies specifically cover Ebola." (William Gallagher Associates)
Australia Will Raise $5 Billion by Privatizing Its Biggest Health Insurer
"[T]he sale would remove the current conflict where the government is both the regulator of the private health insurance market and owner of the largest market participant. Medibank provides cover to 3.8 million people.... Australia has been shrinking the role of government in health care. Although a national single-payer scheme was established in 1975, the federal government re-introduced private choice within a few years." (National Center for Policy Analysis Health Policy Blog)
Essential Health Benefits: 50-State Variations on a Theme
"The interim policy that defined EHBs by benchmark plans resulted in benefit packages that varied considerably across states. On one hand, chiropractic care was most frequently included (45 states). On the other hand, acupuncture was rarely included (5 states).... 19 states included infertility treatments, 26 states covered autism spectrum disorder, and 31 states covered treatments for TMJ.... For obesity, 23 states included bariatric surgery, but only 12 of them cover nutrition counseling and just three of them cover weight loss programs." (Robert Wood Johnson Foundation)
Advisory Council on Employee Welfare and Pension Benefit Plans to Meet November 3-4
"The purpose of the open meeting on November 3 and the morning of November 4 is for the Advisory Council members to finalize the recommendations they will present to the Secretary. At the November 4 afternoon session, the Council members will receive an update from the Assistant Secretary of Labor for [EBSA] and present their recommendations. The Council recommendations will be on the following issues: [1] PBM Compensation and Fee Disclosure, [2] Outsourcing Employee Benefit Plan Services, and [3] Issues and Considerations around Facilitating Lifetime Plan Participation. Descriptions of these topics are available on the Advisory Council page of the EBSA Web site[.]" (Employee Benefits Security Administration [EBSA], U.S. Department of Labor)
[Guidance Overview] Latest ACA FAQ Provides Additional Guidance on Applying Cost-Sharing Limit to Reference-Based Pricing
"The new standards preserve the flexibility to exclude certain amounts from the out-of-pocket maximum. But plan sponsors and insurers anticipating improved cost-effectiveness from a reference-based pricing design should not overlook the additional complexity these standards are likely to create for themselves or their service providers (e.g., implementing a formal exceptions process and tracking the availability of providers willing to accept the reference price for each procedure)." [FAQs About Affordable Care Act Implementation (Part XXI)] (Thomson Reuters / EBIA)
Wellness Programs Violate ADA, Claims EEOC in Lawsuits
"In the complaints, the EEOC emphasized that the wellness program requirements were not 'job related and consistent with business necessity.' This is the standard for many complaints under the ADA. However, if this becomes the standard for wellness programs, what wellness programs could possibly pass this test?" (Winston & Strawn LLP)
To Cut Healthcare Costs, Companies Emphasize Employee Wellness
"When companies can demonstrate that their wellness plan has encouraged a significant percent of employees to receive annual physicals, address potential health concerns and embrace healthier lifestyles, they often will experience lower increases in their health insurance costs, he says. Companies will have more leverage negotiating their health insurance costs when they have about 70 percent participation[.]" (Columbus CEO)
HSAs and the Coming 'Cadillac' Tax (PDF)
"Employers are waiting for clarification of whether certain items are included when determining the cost of benefits, such as the employee contributions to HSAs.... While your organization has likely already felt the pressure to slow the rate of your health care costs, this upcoming tax forces a necessary review of your strategy for the next five years. Now is the time to evaluate tactics that will provide better results over the long haul, and to consider a multi-year approach aimed at positioning your program best in the new environment." (Fidelity Investments)
Will Employers Favor Private Exchanges Over Healthcare Coverage Sponsorship?
"It remains to be seen whether private exchanges can outperform conventional self-funding arrangements over time. New data from private exchanges ... claim 5-plus percent health plan cost savings, but we don't know whether those numbers will be seen across the sector, or whether they'll be sustainable." (Health Affairs)
[Guidance Overview] New DOL Guidance Places Conditions on Employers Using Reference Pricing and Narrow Networks
"[E]mployer plans should: [1] Have procedures to ensure there are an adequate number of providers that accept the reference price ... [2] Have procedures to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards; [3] Have an easily accessible exceptions process, allowing services rendered by providers that do not accept the reference price to be treated as in-network; and [4] Disclose through the plan's Summary Plan Description, or similar document, information on the pricing structure, the list of services the pricing structure applies to, and the exceptions process." (HR Policy Association)
Trends in Employment-Based Health Insurance Coverage
"Employee access to employer-provided health insurance declined from 1991 to 2000, chiefly because of relatively low rates of access among part-time workers.... From 1991 until 2012, the access rate for all workers declined from 77.3 percent to 70.2 percent. There was little change among full-time workers, whose access rates fell from 87.8 percent to 86.4 percent (although they were higher at some points during the period examined). The drop among part-time workers, however, was much steeper -- from 28.8 percent to 23.7 percent." (U.S. Bureau of Labor Statistics [BLS])
To 'SHOP' or Not: Finding the Right Exchange Path for Your Small Business
"Most smaller companies (approximately 64.8 percent) do not offer health insurance to employees, and although SHOP offers tax credits, they're only available to businesses with a high percentage of low-income workers who would likely be eligible for Medicaid or significant subsidies on the individual exchanges. In these cases, a business may be doing its employees a disservice by offering health insurance, because providing employer-sponsored insurance prevents employees from receiving subsidies on the individual exchange." (Society for Human Resource Management [SHRM])
Now That Almost Every Large Employer Has One, EEOC Targets Wellness Programs (PDF)
"According to the EEOC, wellness programs are becoming more popular, and 94 percent of employers with more than 200 workers offer one, as well as a majority of all employers.... [A]fter the initiation of the Orion suit, the EEOC reiterated that voluntary wellness programs are completely legal and encouraged, 'but they have to be actually voluntary.... Having to choose between responding to medical exams and inquiries -- which are not job-related -- in a wellness program, on the one hand, or being fired, on the other hand, is no choice at all.'" (Winston & Strawn)
Public and Union Employers Attack Upcoming 'Cadillac Plan' Excise Tax
"The truth for most employers is that the Affordable Care Act's feared excise tax is coming in 2018. In the public sector, major employers such as the City of Boston are utilizing vendor and plan management strategies, with the help of union negotiations, to control their health plan costs.... 'If you're trying to change the employer/employee contribution mix, that is not going to affect your excise tax liability,' [Kathryn L. Bakich, Segal's national health compliance practice leader] said ... That's 'because you're looking at the value of the plan -- not who pays the premiums.'" (Employee Benefit News)
Health Savings Accounts Under the ACA: Challenges and Opportunities for Consumer-Directed Health Plans
"Recent evidence suggests that high-deductible health plans in the employer market have played a significant role in moderating premium-cost increases over the last several years -- 'bending the curve' for employer health care spending. If HSA-eligible plans are structured correctly in ACA exchanges, such plans could play a similar role in the non-group market (as the number of enrollees with individual coverage grows quickly over the next few years)." (Manhattan Institute for Policy Research)

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