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Health plans - design

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2015 Obamacare Deductible and Out-of-Pocket Averages
"The average bronze plan deductible for 2015 is $5,181, up from $5,081 in 2014. The average 2015 bronze plan deductible for an individual is 326% higher than the average deductible amount documented for employer-sponsored health plans (deductibles in employer-sponsored health insurance were $1,217 on average for individual coverage according to the Kaiser Family Foundation's 2014 Employer Health Benefits Survey)." (HealthPocket)
Obamacare: A Blessing for Some Small Businesses, and a Nightmare for Others
"Now entering the second year under some of the law's key provisions, the reviews from small employers have been anything but uniform. Some say they can now afford plans for the first time, thanks to new government-run insurance exchanges ... Other small businesses haven't fared nearly as well. New coverage standards have resulted in some companies' plans being cancelled, while others say their premiums have skyrocketed as insurers conform to the new rules.... And there are more changes to come." (The Washington Post; subscription may be required)
[Guidance Overview] ACA Tasks: Preparing for the Shared Responsibility Excise Tax (PDF)
37 presentation slides. Topics: [1] Excise Tax: How it works, Which employees it applies to, Practical observations; and [2] Reporting: General rules; Individual mandate, Employer mandate, Practical observations. (Morgan Lewis)
ACA Resources for Frequently Asked Questions
Updated Nov. 14, 2014. "This report provides resources to help congressional staff respond to constituents' frequently asked questions about the [ACA]. The report lists selected resources regarding consumers, employers, and other stakeholders, with a focus on federal sources. It also lists CRS reports that summarize ACA's provisions. The resources are arranged by topic. This list is not a comprehensive directory of all resources on the ACA, but rather is intended to address a few questions that may arise frequently." (Congressional Research Service [CRS])
[Guidance Overview] Text of DOL Compliance Assistance Guide for Health Benefits Coverage: Mental Health Parity Provisions (PDF)
8 pages; updated Nov. 19, 2014. "MHPAEA generally applies to group health plans and health insurance issuers that provide coverage for either mental health or substance use disorder benefits and medical/surgical benefits. These FAQs provide basic information about the important protections MHPAEA provides with respect to parity in coverage of mental health and substance use disorder benefits and medical/surgical benefits provided by employment-based group health plans. Reviewing your group health plan for compliance with the mental health parity requirements may be complicated depending on your plan's design." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
[Guidance Overview] Text of DOL Self-Compliance Tool for Part 7 of ERISA: HIPAA, MHPAEA and Other Health Care-Related Provisions (PDF)
67 pages; updated Nov. 19, 2014. "This self-compliance tool is useful for group health plans, plan sponsors, plan administrators, health insurance issuers, and other parties to determine whether a group health plan is in compliance with some of the provisions of Part 7 of ERISA.... While this self-compliance tool does not necessarily cover all the specifics of these laws, it is intended to assist those involved in operating a group health plan to understand the laws and related responsibilities. It provides an informal explanation of the statutes and the most recent regulations and interpretations and includes citations to the underlying legal provisions.... [S]ome of the provisions discussed involve issues for which the rules have not yet been finalized. Proposed rules, interim final rules, and transition periods generally are noted." (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
Modest Health Benefit Cost Growth Continues as Consumerism Kicks Into High Gear
"[A]verage total health benefit cost per employee rose 3.9% in 2014. Enrollment in high-deductible, consumer-directed health plans (CDHPs) jumped from 18% to 23% of all covered employees following a surge of new implementations. Nearly half of large employers (48%) now offer a CDHP, up from 39%. Private exchanges used by 3% of large employers, with 28% likely to make the shift within five years." (Mercer)
[Guidance Overview] New FAQs Address Premium Reimbursement Arrangements (PDF)
"These recent FAQs clarify (and appear to modify the IRS position) that even after-tax amounts designated or otherwise limited to reimburse premiums will be considered a group health plan that will fail to meet market reforms and which could trigger penalties. Presumably, an employer could provide additional (undesignated) salary to employees, which would not be considered a group health plan, even if at some point, the employee chooses to use the money to purchase individual health insurance." (Buck Consultants at Xerox)
What to Expect During Open-Enrollment Season: Findings From the SHRM/EBRI 2014 Health Benefits Survey (PDF)
"[O]nly 1 percent of plan sponsors are planning to eliminate health benefits in 2015. However, while most workers will not see major changes to their benefits next year, they are likely to see a continuation of changes that employers have been making for a number of years. A relatively large number of employers continue to introduce wellness rewards and penalties ... Few employers are planning to make changes to eligibility for spousal coverage and part-time worker benefits, and few are moving toward tiered networks, private health insurance exchanges, value-based insurance design, and reference pricing." (Employee Benefit Research Institute [EBRI])
[Guidance Overview] Government Moves to Prevent Health Policy Reimbursements
"On November 6, 2014 ... [the DOL] killed cost savings strategies that were especially helpful to small and mid-size businesses. Employers may not reimburse employees for the cost of individual health policies, even with after-tax dollars. The DOL opinion extends to all employers, including those which are too small -- less than 50 full-time equivalents -- for the 'pay or play' penalties ... Welcome to Internal Revenue Code Section 4980D tax penalties, and the self-assessment process of Form 8928." (Chimento & Webb, P.C.)
Incentives for Small Firms to Self-Fund Their Health Plans
"This article will first explain the ACA's regulatory incentives for small firms to self-fund their healthcare plans. Second, it will review the potential risks involved with self-funding by small firms even with stop-loss reinsurance. Third, it will discuss various proposals to reduce these risks within current political and legal constraints." (The Brookings Institution)
[Guidance Overview] CalPERS Announces Guidance Regarding Eligibility for Health Benefits of ACA Variable-Hour Employees and Retired Annuitants
"A CalPERS agency can now enroll previously ineligible variable-hour employees (who work full-time under the ACA) into [Public Employer Medical and Hospital Care Act (PEMHCA)] health benefits by written designation.... The designation is a permitting event outside of open enrollment.... CalPERS developed a designation template that employers can use to designate an employee as PEMHCA-eligible.... CalPERS recommends that employers develop policies prohibiting retired annuitants from working full-time, as defined by the ACA." (Liebert Cassidy Whitmore)
Medical and Prescription Drug Deductibles for Plans Offered in Federally Facilitated and Partnership Marketplaces for 2015
"[This] slide show provides an initial look at the deductibles for medical care and the specific deductibles applied to prescription drugs for the plans offered in the federally facilitated and partnership Marketplaces available The amounts are simple averages of the plans available[.]" (Henry J. Kaiser Family Foundation)
The Shrinking Market for Employer-Sponsored Health Insurance
"This year, 75 percent of the brokers surveyed had at least one employer client decide to end health coverage and instead urge their workers to buy insurance through public exchanges. In 2015, 17 percent of brokers expect to lose about a quarter of their group clients because of coverage cessation ... Almost 75 percent of brokers surveyed saw premium increases for small and mid-sized businesses in the double-digits and more than one-third saw rate increases of at least 60 percent." (Healthcare Payer News)
Private Exchanges: Do You Really Know All the Questions to Ask?
"The private health insurance exchange market is very complex, and each exchange or marketplace is different. In fact, many employers remain largely unaware of the variety of solutions available today under the 'private exchange' label.... [Is] the exchange you are considering a technology company or a marketplace offered by a broker, consultant, association or health plan?" (KTP Advisors, via The Institute for HealthCare Consumerism [IHCC])
[Guidance Overview] Agencies Close Loopholes, Limiting Employers' Health Coverage Options in 2015 and Beyond
"The IRS has been publicly discouraging use of non-hospitalization/physician services plans for months leading up to the issuance of Notice 2014-69, and the timing of the release (election day) was likely no coincidence. The only unanswered question was whether the IRS would 'grandfather' plans that had already adopted this approach. It appears employers who got in the door before election day will receive a free pass for a year before being forced to expand coverage or explore other options in 2016. It also appears that the IRS still hopes to make a premium tax credit or subsidy available to employees offered such a MV plan this year." (Seyfarth Shaw LLP)
Impacts and Implications of Rising Out-of-Pocket Health Care Costs and the Hidden Costs of Health Care
"This report: [1] Examines the impacts and implications of the increasing consumer health care cost burden. [2] Shares results from Deloitte's Hidden Costs Analysis, which reveals how consumers' OOP purchases add considerably to the total cost of health care. [3] Explores anticipated OOP spending changes resulting from the 2014 expansion of coverage through health insurance marketplaces and Medicaid. [4] Suggests strategies for hospitals, life sciences companies and health plans to deal with the impacts of rising consumer OOP costs." (Deloitte Center for Health Solutions)
Your Kaiser Permanente Doctor Will See You Now -- at Target
"Target Corporation is teaming up with Kaiser Permanente to open four in-store Target Clinics in Southern California, taking a host of services directly to thousands of customers.... While Target has maintained clinics for the past 10 years at a number of stores, the partnership will allow for a much broader array of services than it typically offered at retail outlets. Expanded services include telemedicine consultations, prescription reviews, pediatric primary care visits, OB-GYN services, vaccinations and flu shots, pediatric and adolescent care and management of chronic illnesses like diabetes and high blood pressure, according to John Holcomb, vice president of healthcare for Target." (MedCity News)
Six Plan Design Changes for a Higher Return on Your Company's Health Care Investment
Infographic. "To manage costs, most [companies] plan to make moderate to significant changes between now and 2017 -- 81% for full-time active employees and 69% for part-timers. These changes are likely to include cost-effective and sustainable solutions such as.... Specialty Pharmacy Strategy ... Employee Accountability ... Technology ... Spouse and Dependent Financial Support ... Exchange-Based Benefit Delivery ... Network Optimization." (Towers Watson)
Findings from the 2014 Health and Voluntary Workplace Benefits Survey (PDF)
"Three-quarters of workers state that the benefits package an employer offers prospective workers is extremely (32 percent) or very (44 percent) important in their decision to accept or reject a job. Nevertheless, 34 percent are only somewhat satisfied with the benefits offered by their current employer, and 22 percent are not satisfied. Eighty-six percent of workers report that employment-based health insurance is extremely or very important, far more than for any other work place benefit. Workers identify lower cost (compared with purchasing benefits on their own) and choice as strong advantages of voluntary benefits." (Employee Benefit Research Institute [EBRI])
[Opinion] Tell Senate to Pass Fix to ACA's Full-Time Employee Definition
"Pending in the Senate since the House passed it on September 13, 2014, the [Jobs For America Act] ... would: [1] Raise from 30 to 40 hours per week the number of hours per week that an employee would need to work to count as a 'full-time employee' for purposes of Code Section 4980H's employer 'pay-or play' shared responsibility rule ... [2] Amend the Code to let an employer, for purposes of determining whether such employer is an applicable large employer and thus required to provide health care coverage to its employees under ACA, to exclude employees who have coverage under a health care program administered by the Department of Defense (DOD), including TRICARE, or the Department of Veterans Affairs (VA)[.]" (Solutions Law Press)
More Than Four Years After Passage: Assessing Your Plan's Compliance with the ACA
"An assessment will identify any actions that should be taken to reduce the risk of penalties and fines associated with noncompliance. An assessment will also help safeguard the plan from [ACA] violations in the event of an audit by the [DOL], as part of the DOL's ongoing health and welfare plan audit program. While the DOL provides self-compliance tools for part of the areas it audits, these online tools have not been updated for the most recent portions of the [ACA] that have come into effect." (Segal Consulting)
[Guidance Overview] Labor and Treasury Departments Play Whack-A-Mole with Employer Payment Plans
"A recent set of FAQs makes short shrift of two arrangements -- after-tax subsidies and a pre-tax reimbursement arrangement -- that are on solid regulatory ground. These arrangements are not now and never were ... viable, and their promotion was both reckless and irresponsible. The Departments' treatment of a third arrangement -- giving employees with high claims risk a choice between group health plan enrollment or cash -- is well-intentioned and may even be the 'right' result. But it rests ... on less solid legally and regulatory ground." (Mintz Levin)
Trouble Brewing in the Workplace: Benefits to the Rescue
"Employees are concerned with their financial wellness, as evidenced by the research. And, when asked, they pinpointed some specific things employers can do to help them address these concerns. Nearly a third (29%) of respondents said that the ability to 'borrow' money from employer at 0% interest for necessary purchases would influence them to stay with their employer longer 30% said that reduced cafeteria food costs or lunch vouchers would have the same effect 21% said that they would be influenced to stay with their employer longer if the employer offered financial wellness counseling. Massages and in-house services got a positive reception from 25%, who said it may also influence their likelihood to stay with an employer." (
Text of DC Court of Appeals Opinion Rejecting Challenge to Contraceptive Mandate Accommodation (PDF)
86 pages. "All Plaintiffs must do to opt out is express what they believe and seek what they want via a letter or two-page form. That bit of paperwork is more straightforward and minimal than many that are staples of nonprofit organizations' compliance with law in the modern administrative state.... The accommodation requires as little as it can from the objectors while still serving the government's compelling interests. Because the regulatory opt-out mechanism is the least restrictive means to serve compelling governmental interests, it is fully consistent with Plaintiffs' rights under RFRA." [Priests for Life, et al. v. Burwell, Nos. 13-5368, 13-5371, 14-5021 (D.C. Cir. Nov. 14, 2014)] (U.S. Court of Appeals for the District of Columbia Circuit)
Second Circuit: Group Health Plan Has No Claim for Reimbursement of Benefits from Individual Policy Where Both Claim to Provide Secondary Coverage
"After it paid the claims, Central States sought reimbursement from Gerber, whom it considered the primary insurance provider. Gerber refused to pay, taking the position that ... its policies provided only excess, secondary coverage.... [We] are not free to fill in unwritten gaps in ERISA's civil remedies by reading into the statute additional causes of action derived from federal common law.... [A]lthough Central States might well be left without an appropriate remedy as a result of this decision, and that in the future its beneficiaries may be put in the unfortunate position of having to sue their insurance companies to receive benefits to which they are indisputably entitled, the claims raised by Central States are legal, not equitable, and therefore may not be brought under Section 502(a)(3)." [Cent. States, Se. & Sw. Areas Health & Welfare Fund v. Gerber Life Ins. Co., No. 13-4834 (2d Cir. Nov. 14, 2014)] (U.S. Court of Appeals for the Second Circuit)
The Supreme Court's 2013-2014 Labor and Employment Law Decisions: Consensus at the Court
"This Article is a review of the Supreme Court's 2013-2014 labor and employment law decisions. Among the cases discussed are ... Fifth Third Bancorp v. Dudenhoeffer, Heimeshoff v. Hartford Life & Accident Ins. Co. ... and Burwell v. Hobby Lobby Stores. The Article notes the relative lack of sharp divisions among the Justices -- a result that appears to largely be the result of a less controversial labor and employment docket. However, as some of even this year's decisions show, sharp divisions on the Court still exist, and we're likely to see a return to the usual ideological decisions in later terms." (Jeffrey M. Hirsch, University of North Carolina School of Law, via SSRN)
[Guidance Overview] ACA Implementation FAQs Emphasize Compliance Pitfalls for Premium Reimbursement Arrangements
"This third shot across the bow includes a reminder that the arrangements described in these FAQs can trigger penalties such as excise taxes of $100 per day for each affected individual under Code Section 4980D. Employers currently using, or considering, these arrangements should seek legal advice." (Thomson Reuters / EBIA)
DOL Opines on State Regulation of Stop-Loss Insurance and Reports to Congress on Self-Insured Health Plans
"The DOL's stop-loss guidance seems likely to prompt further state regulation of stop-loss attachment points.... Although not mentioned, the release seems to be a product of the 2012 tri-agency request for information regarding stop-loss insurance ... which noted similar concerns about low attachment points, and which some feared could lead to federal regulation. The report on self-insured plans, which is based on 2011 data, may not fully reflect trends (e.g., toward or away from self-insurance) resulting from health care reform implementation over the last three years." (Thomson Reuters / EBIA)
Obamacare Architect Describes 'Mislabeling' in Sixth Video
"[MIT economist Jonathan] Gruber explains that by drafting the bill this way, they were able to pass something that would initially only impact some employer plans though it would eventually hit almost every employer plan. And by that time, those who object to the tax will be obligated to figure out how to come up with the money that repealing the tax will take from the treasury, or risk significantly adding to the national debt. 'What that means is the tax that starts out hitting only 8% of the insurance plans essentially amounts over the next 20 years essentially getting rid of the exclusion for employer sponsored plans,' Gruber said. 'This was the only political way we were ever going to take on one of the worst public policies in America.' " (CNN)
[Opinion] A 'Shameful Day': Text of Business Roundtable Letter to HHS, IRS and DOL in Response to EEOC Actions Targeting Employer Wellness Programs
"Allowing the EEOC to act in contravention to the positive provision of the ACA without reproach from the Departments charged with governing and overseeing these programs will send a message to employers that certain ACA provisions are interpretative only and remain subject to litigation. It is a shameful day when well-intentioned and well-informed reliance on regulations, driven by the good will of employers to offer positive, innovative programs to their employees, can result in litigation." (Business Roundtable [BRT])
Projected Savings Needed for Health Care in Retirement Continue to Fall
"[S]avings targets declined between 2 percent and 10 percent between 2013 and 2014. For a married couple both with drug expenses at the 90th percentile throughout retirement who wanted a 90 percent chance of having enough money saved for health care expenses in retirement by age 65, targeted savings fell from $360,000 in 2013 to $326,000 in 2014." (Wolters Kluwer Law & Business)
U.S. Wants Another ACA Case Put on Hold
"The federal government's opening brief in the Tenth Circuit case is now due on November 18, but the Justice Department asked for a seven-day extension. 'The extension is requested,' the motion said, 'because the federal government intends to move to hold this appeal in abeyance pending the Supreme Court's decision in King v. Burwell, which presents the same issue as this case.' " [Oklahoma ex rel. Pruitt v. Burwell, No. CIV-11-30-RAW (E.D. Okla. Sept. 30, 2014)] (SCOTUSblog)
Consumers Want to Choose Their Own HSA Financial Institutions
"More than half of consumers indicated that they would highly value the ability to choose their own HSA financial institution, rather than have their employer choose it for them. Forty-one percent of consumers want their HSAs to be managed by the same financial institution that manages their other deposit and investment accounts." (Alegeus Technologies)
Employers Scaling Back Health Coverage for Spouses and Dependents
"[By] 2017, 63% of employers will add surcharges or exclude spouses from coverage when employer-sponsored health coverage is available elsewhere.... in 2014: 49% of employers increased employee contributions for spouse and dependent coverage at a faster rate than for individual employee coverage. 24% implemented spouse coverage surcharges in 2014 of about $100 per month or more when other coverage was available to the spouse.... 2% offered no subsidy at all for spouse coverage." (Towers Watson)
Small Business Health Insurance Exchanges: Low Initial Enrollment Likely Due to Multiple, Evolving Factors
"In this report GAO describes [1] SHOP functionality, enrollment, plan availability, and premiums and [2] stakeholders' views on key factors that have affected current SHOP enrollment or may affect future enrollment growth. GAO reviewed relevant information from CMS and states, including data on employer and employee enrollment, plan availability, and premiums generally through June 1, 2014. GAO also interviewed representatives of key stakeholders that operate SHOPs (CMS and states), offer coverage in SHOPs (health insurance issuers), obtain coverage through SHOPs (small employers), or assist in obtaining coverage through SHOPs (agents and brokers) on a national basis and, for certain stakeholders, in five states -- California, Illinois, Kentucky, Rhode Island, and Texas.... The experiences of these stakeholders cannot be generalized to other states or stakeholders." (U.S. Government Accountability Office [GAO])
Too High a Price: Out-Of-Pocket Health Care Costs in the United States
"Americans are paying more out-of-pocket for health care now than they did in the past decade.... More than one of five 19-to-64-year-old adults who were insured all year spent 5 percent or more of their income on out-of-pocket costs, not including premiums, and 13 percent spent 10 percent or more." (The Commonwealth Fund)
[Guidance Overview] FAQ Offers Additional Guidance on Reference-Based Pricing and Out-of-Pocket Maximums (PDF)
"Although the guidance does not limit the use of referenced-based pricing, the fairly prescriptive standards will likely require many plans that use reference-based pricing to credit any employee cost-sharing for non-accepting providers to the in-network [out-of-pocket] maximum. This could limit the effectiveness of these programs in controlling benefit costs." (Buck Consultants at Xerox)
[Guidance Overview] Agencies Take the Wind Out of the Sails of Minimum Value Plans
"Employers considering the offer of a non-hospital/non-physician services plan that have not already entered into a binding, written commitment regarding the plan, or who have not already started enrolling employees in such a plan, should NOT offer such a plan in for 2015 for the purpose of satisfying the minimum value requirement under Code 4980H(b). If such a plan is offered, it will leave the employer exposed to penalties." (Hill, Chesson & Woody)
HSA-Eligible Plans Are Widely Available in Obamacare Exchanges
"To improve competition between HSA and non-HSA plans on the exchanges, [the authors] suggest a number of reforms for HSA-eligible plans, including: Improve transparency.... Standardize and simplify.... Improve affordability for low-income consumers." (National Center for Policy Analysis Health Policy Blog)
[Guidance Overview] Minimum Value Plans Without Hospital or Physician Services (PDF)
"As it stands today, if an employer offers affordable, minimum value coverage to full-time employees, any employees eligible for that coverage are blocked from receiving subsidies in the Marketplace. However, employees are not required to treat plans without inpatient hospital or physician services as minimum value plans when determining their eligibility for tax credits in the Marketplace. For 2015 only, employees may be able to purchase subsidized coverage, and there will be no penalties assessed for the employer." (McGraw Wentworth)
[Guidance Overview] DOL Supports Barring Low Stop-loss Attachment Points
"DOL gave credence to the view that self-funding by smaller companies poses a threat to health care reform.... The National Association of Insurance Commissioners adopted a model law that prohibits attachment points with specific attachment points below $20,000. States may typically use NAIC models as templates for their own legislation. It is DOL's position that such laws should not be invalidated as a result of ERISA preemption." (Thompson SmartHR Manager)
EEOC Challenges Some Employer Wellness Programs
"The EEOC's primary concern seems to be how wellness program incentives will impact people with disabilities and whether the wellness program affects people within particular protected classes under the ADA. If a wellness program neither asks for an employee's medical information nor requires medical exams, it seems relatively clear that the ADA is unlikely to be implicated and the EEOC would have no reason to challenge the wellness program under that law. However, the EEOC's complaints leave employers with a number of unanswered questions[.]" (Towers Watson)
Obamacare Delay Provides Relief -- and an Opportunity
"The most recent health-reform implementation roadblock involves a tool the feds created to help employers with administration issues. But problems with that very tool directly led to a delay that benefits employers.... If your company offers a skinny or low-cost health plan that fails to meet the health reform law's 'minimum value' test, you have an extra year before you'll face any penalties." (HR Benefits Alert)
Supreme Court Justices Dust Off Contracts Treatises for Dispute Over Retiree Health Benefit Vesting
"The Justices on [November 10] spent the argument convincing themselves that this case is nothing but a dispute about contract interpretation, with the only issue left for decision what would seem to be an unimportant detail of applying ordinary precepts of interpretation to this particular set of contracts. A closer look, however, suggests that the Justices' discussion involves a little more than that." (SCOTUSblog)
Visualizing Health Policy: Recent Trends in Employer-Sponsored Insurance
"[This] infographic takes a look at recent trends in employer-sponsored insurance, including average premium increases for workers with family coverage, the average yearly cost of premiums for single and family coverage and how those costs have increased in the past decade, along with the prevalence of health promotion programs (such as wellness programs) offered by large firms. It also looks at differences in premium and worker contributions at firms with many lower-wage workers and firms with many higher-wage workers; the average general annual deductible for workers who face a deductible for single coverage; and the percentage of workers covered by employers' health benefits at offering and non-offering firms, from 2000 to 2014." (Henry J. Kaiser Family Foundation)
How States Could Avert a Supreme Court Obamacare Disaster
"States looking to take ownership of their marketplace would have to establish a legal authority for operating the marketplace; detail a plan to the feds how they'd make sure it works; and set up a governing body to oversee the marketplace.... [T]he state-run exchanges have to handle certain functions like overseeing health plans and consumer outreach, but they could still rely on for enrollment -- which means states wouldn't have to bear the major cost of setting up that technical infrastructure." (The Washington Post; subscription may be required)
King v. Burwell and the 'Plain Meaning' Rule of Statutory Interpretation
"What each state will do if faced with the prospect that its citizens will no longer get subsidies to buy insurance if it does not establish and operate an insurance exchange is entirely unknown. Moreover, even a victory by the government will hardly guarantee the ACA's success in regulating the private insurance market.... Two important issues are raised by the decision. First, how broad is the 'absurdity' exception to the plain meaning rule? Second, to what degree and extent should the unusual factual circumstances that led to the ACA's passage affect the operation of the plain meaning rule?" (SCOTUSblog)
[Guidance Overview] Final Rule Addresses ACA 'Excepted' Benefits (PDF)
"Employee assistance programs (EAPs) and dental, vision, and long-term care benefits that satisfy newly relaxed requirements under a recent final rule are exempt from the [ACA's] health insurance market reforms, starting with plan years that begin on or after Jan. 1, 2015.... [T]hese programs and 'limited scope' benefits will not have to satisfy the ACA's requirements on preexisting condition exclusions, prohibition on discrimination based on health status, and guaranteed renewability, among other standards." (Milliman)
Health Care Executives Embracing Telemedicine
"Eighty-four percent of respondents felt that the development of telemedicine services is either very important (52 percent) or important (32 percent) to their organizations.... This attitude is partly due to the shift in financial and payment incentives under the ACA. As health care providers move from a fee-for-service model to one that reimburses based on positive patient outcomes, providers bear a greater share of the risk -- and potential reward -- for keeping their patients healthy.... the customary fee-for-service environment makes it challenging to be paid for medicine practiced outside the traditional spheres of interaction." (Foley & Lardner LLP)
[Guidance Overview] Guidance Addresses Premium Reimbursement Arrangements and ERISA Preemption of State Stop-Loss Insurance Laws
"[T]he Departments rejected a new market product under which employers are being encouraged to drop their group policies and establish an IRC Section 105 reimbursement plan ... In the Departments' view, these arrangements are group health plans in their own right and therefore participating employees are ineligible for premium tax credits or cost-sharing reductions for exchange coverage.... In Technical Release 2014-01, the DOL takes the view that ... state regulation of stop-loss policies can have an effect similar to that of insurance regulation of group health insurance ... without running afoul of ERISA's preemption general rule. As a result, a state law prohibiting insurers from issuing stop-loss contracts with attachment points below the applicable limit would not, in the DOL's view, be preempted by ERISA." (Practical Law Company)
[Guidance Overview] Agencies Plug Several Holes in the ACA Dike
"[The] agencies have now issued a number of pieces of guidance designed to plug several holes in the ACA dike resulting from what they perceive as abusive practices by employers and their advisers. This guidance will [1] require that any plan claiming to satisfy the ACA's 'minimum-value' standard offer substantial coverage for inpatient treatment, [2] prevent employers from providing even after-tax incentives for their employees to waive coverage under an employer plan, and [3] encourage state insurance regulators to impose minimum attachment points on stop-loss policies issued to self-funded health plans." (Spencer Fane)
[Guidance Overview] Cafeteria Plans and Cash Alone Fail ACA Employer Mandate
"The nondiscrimination rules do allow some 'benign discrimination,' such as offering enhanced coverage to an at-risk employee with a history of high-cost claims, but the departments do not consider it benign to offer cash to employees with high claims risks as an incentive to disenroll from standard group health plan coverage. Instead, any arrangement that ushers such an employee out of a plan because of his or her high-cost history or reputation, will be seen to violate HIPAA and expose the plan to ACA penalties." (Thompson SmartHR Manager)
Innovative Solutions for Health Adopted by Dow Chemical Company (PDF)
"The Dow health strategy has four pillars -- prevention, quality and effectiveness, health care system management and advocacy. The company offers its employees a range of programs to promote 'good health for the whole self' including smoking cessation, stress management, cancer screening, nutrition and active lifestyles.... From a 2004 baseline, wellness programs at Dow have seen a 28 percent reduction in the population at high risk. Dow also provides its employees with tools to increase health care cost and quality transparency, including an online payment estimator, drug cost calculator and tool to compare hospitals." (Business Roundtable [BRT])
[Guidance Overview] IRS Puts the Kibosh on Health Plans That Fail to Cover Hospital or Physician Services
"In plain English, government actuaries have a lot of work ahead of them to figure out exactly how the online calculator should be reconfigured to produce the intended policy result of requiring hospital and physician coverage, and what the scope of that coverage should be.... Employers that have at least some written evidence, prior to November 4, 2014 of a binding commitment to adopt an MVP plan should qualify for relief. With respect to starting enrollment, circulation of enrollment materials clearly qualifies. Arguably, notifying employees that the enrollment will commence at some time in the near future also should qualify." (Mintz Levin)
Health Insurance Without An Annual Expiration Date? A Case For Exchange-Based Long-Term Policies
"[A] greater role for exchange plans and price competition might inadvertently counteract current efforts to shift the payment system toward one that rewards providers for providing long-term health care management for their patients.... A possible solution is to introduce multi-year insurance products on insurance exchanges. Under a five-year plan, for example, insurers would find it more attractive to invest in services with long-term benefits. These investments, in turn, would reduce health care costs and some of those savings could result in lower premiums for consumers." (Health Affairs)
[Guidance Overview] Plans Excluding Hospitalization or Physician Services Still Might Have a Role
"The IRS and HHS seem determined to close this perceived loophole in MV determinations quickly and decisively ... But, due to the two-tiered nature of Code Section 4980H penalties, there may still be a place for this type of plan design ... [Applicable Large Employers (ALEs)] should be able to avoid the steeper Code Section 4980H(a) penalty by offering a Non-Hospital/Non-Physician Services Plan to the applicable percentage of their full-time employees -- incurring the Code Section 4980H(b) penalty only if one or more of those full-time employees actually receive premium tax credits. And paying the Code Section 4980H(b) penalty could be less costly for the ALE than offering MV coverage that includes inpatient hospitalization and physician services." (Thomson Reuters / EBIA)
[Guidance Overview] ACA Implementation FAQs (Part XXII) Provide Guidance on Premium Reimbursement Arrangements
"While the FAQs reiterate the agencies' general opposition to employer funding of individual policies, the third question takes direct aim at a specific plan design that some vendors are marketing. Under this design, employees purchase individual insurance policies ... and then have their individual policy premiums reimbursed by their employer tax-free. The agencies emphasize that these employer reimbursement arrangements are not permissible under health care reform[.]" (Thomson Reuters / EBIA)
Employees Offered Financial Incentives Were 33 Times More Likely to Participate in Wellness Programs
"The health coach program began in October 2010, and any health plan member was eligible to work with a coach. Employers began offering incentives to work with a coach in 2011.... During the 2.75-year follow-up period, 4,898 members worked with a coach, including 1,693 among the 16,961 with incentives (10%) and 3,205 among the 974,782 without (0.3%). In 2011, 2012, and 2013, being offered an incentive was strongly associated with time until uptake of health coaching[.]" (The Obesity Society)
[Guidance Overview] No Pre-Tax or Post-Tax Reimbursement of Individual Health Insurance Premiums, Including Those Purchased on the Exchange/Marketplace
"While the logic of using an HRA to reimburse employees for purchasing coverage on the Marketplace may make some sense, [FAQ XXII] once again confirms that it is not an allowable practice and subjects the employer to significant penalties. The idea of 'Private Exchanges' does provide a legal means of applying similar logic, but in an allowable group health insurance realm." (Kushner & Company)

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