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Health plans - design


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Pittsburgh Health Care Giants Take Fight to Each Other's Turf
"For decades, Highmark BlueCross/Blue Shield and University of Pittsburgh Medical Center worked together. But as the line between insurance companies and health care providers across the country blurs, these longtime allies are venturing into each other's business and becoming competitors.... There's another reason an insurance company would decide to become a healthcare provider: the Affordable Care Act. It tells insurance companies what basic services to offer; who they must insure and even what percent of premiums can go to administrative expenses and profits. That takes away a lot of what insurance companies used to do, so they're looking for new reasons to exist." (National Public Radio)
HMO, PPO, EPO: How's a Consumer to Know Which Health Plan Is Best?
"Ideally, plan type provides a shorthand way to determine what sort of access members have to providers outside a plan's network, including cost-sharing for such treatment, among other things. But since there are no industry-wide definitions of plan types and state standards vary, individual insurers often have leeway to market similar plans under different names." (Kaiser Health News)
[Guidance Overview] ACA Compliance: Changes in Employment Status Under the Look-Back Measurement Method
"While these rules appear simple and straightforward, this is not always the case in practice.... [W]hat happens if a newly hired employee changes his or her status during his or her initial measurement period or the corresponding stability period? The final regulations provide the following rules: Full-time employee... New variable hour, seasonal, and part-time employees... Ongoing employees." (Mintz Levin)
Prescription Drug Benefits: An Important Part of a Compensation Plan
"[P]rescription drugs can substitute for a more expensive medical service, reduce absenteeism and improve on-the-job worker productivity. If not managed, prescription drugs represent a constant financial drain on company resources that undermines the return on investment of the entire health care benefits program." (Idaho Business Review)
[Guidance Overview] Individual Medical Policy Arrangements May Result in Significant Excise Tax Liability (PDF)
31 pages. "[ECFC agrees] that the payment of [individual market (IM)] policy premiums is a permissible cafeteria plan qualified benefit and that the provision of such coverage through the cafeteria plan continues to be exempt from income and employment tax under the Internal Revenue Code. We also agree that a cafeteria plan, in and of itself, is not a group health plan subject to the ACA. However, the Agency Guidance clearly states that any arrangement, which pays or reimburses an employee's IM policy premiums on a pre-tax basis would be an 'employer payment plan', which the Agency Guidance clearly indicates is a 'group health plan' subject to the ACA. The Agency Guidance is also clear that an employer payment plan violates the ACA and employers who sponsor such arrangements would be subject to a potential excise tax of $100 per employee per day." (Employers Council on Flexible Compensation [ECFC])
Patient Advocacy Groups Claim Insurance Discrimination in New Forms
"Ending insurance discrimination against the sick was a central goal of the nation's health care overhaul, but leading patient groups say that promise is being undermined by new barriers from insurers. The insurance industry responds that critics are confusing legitimate cost-control with bias. Some state regulators, however, say there's reason to be concerned about policies that shift costs to patients and narrow their choices of hospitals and doctors." (ABC News)
[Opinion] How We Can Transcend Obamacare
"If we were to spend all our capital 'repealing and replacing' Obamacare, we might not have enough left to tackle the real drivers of unsustainable single-payer health care in America: Medicare and Medicaid.... Exchange-based plans would give those below the poverty line access to high-quality, private insurance and phase out single-payer public-option health insurance. Over the long run, only private insurers will have the competence and the incentive to come up with innovative, cost-efficient ways to improve health outcomes for the poor.... [M]igrating future retirees and low-income Americans onto exchanges could yield substantial benefits to the quality and cost of subsidized health coverage. But there's no reason we should accept the Obamacare exchanges as they are." (Avik Roy, in National Review)
California's Enrollment Success Is Its Greatest Challenge: 30% of Population Now on Medicaid
"Altogether, there are now about 11 million Medi-Cal beneficiaries, constituting nearly 30 percent of the state's population. That has pushed the public insurance program into the spotlight, after nearly 50 years as a quiet mainstay of the state's health care system, and it has raised concerns about California's ability to meet the increased demand for health care. Even as sign-ups continue, state health officials are struggling to figure out how to serve a staggering number of Medi-Cal beneficiaries while also improving their health and keeping costs down." (Kitsap Sun)
[Official Guidance] Text of CMS Technical Assistance on State-Specific Data for the Actuarial Value Calculator (PDF)
"The purpose of this document is to provide technical guidance to states that are interested in submitting data to be considered for approval for use in a state-specific Actuarial Value (AV) Calculator.... [T]he federal AV Calculator uses a standard population to calculate plans' AVs, and since last year, states have had the option to submit data to be used as the standard population in the template of the federal AV Calculator to create a state-specific AV Calculator beginning in 2015.... All states have the option of continuing to use the federal AV Calculator, and any state that chooses to continue using the federal AV Calculator will not need to take any of the actions described in this document." [The document is dated August 15, 2014; no identifying number.] (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Are Pharmacy Discount Cards Still Relevant?
"Providers of prescription drug discount cards are increasing their efforts to reach out to employers, even as the [ACA] is expected to decrease the ranks of those most likely to use the cards -- those without health insurance.... But not everyone agrees that these types of prescription drug discount cards still offer value in the post-ACA world." (Employee Benefit News)
Be Careful with Plan Rules: The Trouble with Exceptions
"[If] the ultimate purpose of a benefit plan is to provide benefits to participants, plan administrators and sponsors should look at possible exceptions as a means of tweaking and improving their plan to really provide benefits. A proposed exception might suggest a logical amendment to a plan that makes the exception the new rule. It is also possible that a requested exception can actually be justified because of ambiguities or silence in the actual plan itself." (Fox Rothschild LLP)
Large Employers Trimming Healthcare Spending
"Big companies are taking a broad range of actions to cut spending on employee healthcare benefits. That means higher costs for workers, a push for more consumer engagement, and greater use of telemedicine." (HealthLeaders Media)
[Opinion] New Jersey Bill Would Harm Smaller Employers' Health Care Plans
"If the [New Jersey] Legislature is serious about preserving employer-sponsored health care for workers and their families, it should amend the state's 10-year old MEWA law and permit employers to choose the plans that best meet their needs and bear the risk that they can afford.... [A] bill improvidently passed by the Assembly and now in the Senate would require MEWAs to be regulated as insurance companies. This is a mistake, considering that MEWAs already provide coverage for most state-mandated benefits, including hearing aids, mental health services and autism benefits." (NJ.com)
Wal-Mart Wants to Be Your Doctor
"Wal-Mart's decision to have these clinics act as a primary care provider is notable because of the company's footprint in rural areas, where access to care can be a major challenge. It's also an area that retail clinics historically haven't been in.... As millions more low- and middle-income people gain insurance under the [ACA], retail clinics can appeal to especially cost-conscious consumers looking for basic health-care services." (The Washington Post; subscription may be required)
Early 2014 Stakeholder Experiences with Small-Business Marketplaces in Eight States
"Sources reported that there is a tremendous lack of awareness of the SHOP at the most basic level within the small-employer community, and that many of those who are aware of it do not understand its function or role in the market.... [D]eveloping an accurate, convincing description of the added value of SHOP has been challenging because of limitations of the reach of the small business tax credit, early renewals, extensions of non-ACA compliant plans, and other issues." (Robert Wood Johnson Foundation)
Analysis of Health Claims Data Drives Appropriate Plan Design and Targeted Wellness (PDF)
"Data drives the ability for employers and insurers to address trends in claims data via plan design, plan election steerage, incentives and disincentives for use and participation, and targeted wellness programs. Self-funding (aka self-insurance, partial self-funding, etc.) has traditionally provided the greatest ability for employers to have access to and analyze their employee, dependent, and spouse claims data.... [T]he self-funding trend is beginning to move to smaller employers ... and that creates a significant opportunity for employers of all sizes to review their claims data." (Kushner & Company)
Applied Behavior Analysis Therapy Coverage as Autism Treatment: Implications for the ACA
"[T]he United States District Court for Oregon ruled that Providence Health Plans are required to cover Applied Behavior Analysis therapy for a class of plaintiffs who are covered by Providence's insured ERISA employer group plans and diagnosed with an autism spectrum disorder.... Providence Health Plan had excluded coverage for 'services related to developmental disabilities, developmental delays, or learning disabilities.' The court held that the exclusion violated Oregon's Mental Health Parity Act and Mandatory Coverage for Minors with Pervasive Developmental Disabilities Act ... [as well as] ERISA because it violated the federal Mental Health Parity Act." [A.F. v. Providence Health Plan, No. 3:13-cv-00776-SI (D. Ore. Aug. 8, 2014)] (Timothy Jost for Health Affairs)
Impact of the Affordable Care Act: 2014 Survey
"About 83 percent of respondents believe that the ACA will continue to put upward pressure on medical plan costs.... One out of four respondents are hiring more part-time workers, with another 14.5 percent considering similar action.... Almost 25 percent of respondents indicated they are considering the elimination of employer-sponsored plans.... 25.7 percent of respondents indicated they have already reduced expenditures or are considering such action on dental, vision and life coverage's as a result of the ACA's impact on medical plan costs.... 73 percent of respondents indicated that the ACA will negatively impact profits." (Cherry Bekaert Benefits Consulting, LLC)
The Evolution of a Two-Tier Health Insurance Exchange System
"Arguably, small and mid-sized employers could benefit even more than large employers from exchanges, because large employers already enjoy a competitive insurance market, have the resources to manage health care costs, and experience economies of scale ... [P]rivate exchanges could provide greater choice of health insurance plans; increase competition among insurers; offer lower cost, cheaper products for employees; and enable employees to pick a health plan that fits their needs. Thus, insurance agents, brokers, and some small business associations -- who see public exchanges as a potential threat to their business -- are leaping into the breach to fill the need that SHOP exchanges are failing to fill." (Health Affairs Blog)
Simplifying Retiree Health Benefits: Where Less Is More
"Rather than requiring retirees to select from a vast and often confusing array of individual Medicare products, the single-carrier national Medicare Advantage strategy streamlines and simplifies the transition process. Unlike local Medicare Advantage plans that have been around for many years, this new breed of national Medicare Advantage plan provides retirees with national coverage and larger networks of doctors and hospitals, as well as the ability to tailor benefits to each employer's needs." (Employee Benefit News)
Employers Modify Health Plans to Control Rising Costs, Comply with ACA
"[E]mployers project their health care benefits costs will increase by an average of 6.5% in 2015. That is slightly lower than the 7.0% increase employers would have experienced this year had they made no changes to their plan design. However, employers expect to keep increases to 5% next year after making changes to their plans, such as increasing cost-sharing provisions, implementing and expanding CDHPs, and broadening their use of wellness programs and Centers of Excellence." (National Business Group on Health [NBGH])
EBRI Survey: Employee Satisfaction with Health Coverage and Care (PDF)
"The overall satisfaction rate among consumer-driven health plan (CDHP) enrollees increased in most years ... while it decreased in most years among traditional enrollees.... In 2013, 44 percent of traditional-plan participants were extremely or very satisfied with out-of-pocket costs (for health care services other than for prescription drugs), while 20 percent of high-deductible health plan (HDHP) enrollees and 31 percent of CDHP participants were extremely or very satisfied.... CDHP and HDHP enrollees were less likely than those in a traditional plan both to recommend their health plan to friends or co-workers and to stay with their current health plan if they had the opportunity to switch plans." (Employee Benefit Research Institute [EBRI])
[Opinion] Downward Spiral Begins? 'If You Hate Your Health Insurance, You Can Drop It'
"The returns are admittedly early but Obamacare needs to grow in headcount to remain actuarially sound. And that is not happening. Initial reports from the State of Washington as well as insurer, Cigna, also indicate that the tide of discouraged outweighs any new sign ups. Unfortunately, we have no official statement from the federal government, since it stopped reporting the numbers after issuing the high-water mark of 8 million in the spring." (Benefit Revolution)
Entrepreneurs Set Sights on Self-Insured Market
"As more companies migrate to self-funding, insurers are trying to meet demand with better outsourced management and new stop loss products. But a few startups with radical ideas are trying to beat them, offering new services to capitalize on frustration with the status quo.... Collective Health officially launched this month with venture capital backing, hoping to use software-guided self-funding services to bring employers and their workers a better, less expensive health plan experience." (Healthcare Payer News)
More Employers Limit Health Plan Networks But Seek to Preserve Quality
"Those employers who are going to stay in the game -- which is the majority of them -- in many cases have to [improve] what they're covering. They have to offer the essential health benefits, they must meet affordability for the premiums and they have a looming Cadillac tax [on very generous health plans] in 2018. They now have to use the managed care tools that they all abandoned 15 years ago. So the answer is narrow networks[.]" (Kaiser Health News)
Top Insurers Say Exchange Enrollment Is Shrinking
"The nation's third-largest health insurer had 720,000 people sign up for exchange coverage as of May 20 ... At the end of June, it had fewer than 600,000 paying customers. Aetna expects that to fall to 'just over 500,000' by the end of the year.... Cigna said that it expects its individual market customers, including more than 100,000 in the exchanges, to 'move from 300,000 down to 280,000 in that range,' ... Other major insurers danced around questions about attrition ... but none denied that it was occurring." (Investor's Business Daily)
Employers Act to Control Health Care Costs [Infographic]
"Insights from the 2014 Towers Watson/National Business Group on Health (NBGH) employer survey on purchasing value in health care [include the following:] ... Nearly all employers are changing their health care strategy.... Employers use [account-based health plans] to avoid excise tax.... Employers rethink support for spouses.... Best performers spend significantly less and deliver high-performance benefits." (Towers Watson)
[Guidance Overview] Insurance Premium Rebates: Can the Employer Keep the Money?
"[If] employees contributed to the cost of the group medical insurance plan, they are entitled a percentage of the rebate equal to the cost paid by the employees.... [In] deciding on an allocation method, companies can weigh the costs to the plan and the ultimate plan benefit as well as the competing interests of participants or classes of participants provided such method is reasonable, fair and objective.... Generally, ERISA plan assets must be held in a trust. However, if the premium rebate is allocated within 3 months of receipt, companies are permitted to rely on an exemption to the trust requirement." (Masuda Funai via Lexology)
Employee Benefits 'Crisis' Management: Uncertainty and the Workplace (PDF)
16 pages. "Whether it's the looming retirement crisis some see (or see for some) on the horizon, the crippling impact of college debt on the finances (and future financial security) of younger Americans, or the health care crisis that the [ACA] was designed to forestall (or that some say is destined to create), those at nearly every point of the political spectrum are challenged with the urgency of the need to address the 'crisis.' But do current circumstances actually constitute a 'crisis'?" (Employee Benefit Research Institute [EBRI])
Providence's Autism-Related Coverage Denials Violated Mental Health Parity
"[The Oregon District Court] ruled Aug. 8 that the insurer's failure to cover applied behavior analysis (ABA) therapy violated the federal mental health parity act, because it imposed a treatment limitation on mental health benefits that didn't apply to other types of benefits. The coverage denials also violated Oregon law mandating mental health parity and coverage for minors with developmental disorders, the court determined." [A.F. v. Providence Health Plan, No. 3:13-cv-00776-SI (D. Ore. Aug. 8, 2014)] (Bloomberg BNA)
D.C. Court of Appeals Grants Contraceptive Coverage Exemption for Freshway Foods
"Fresh Unlimited Inc. won't have to provide contraceptive coverage for its employees under the Obama administration's health-care reform law, in what may be the first exemption granted since a June U.S. Supreme Court ruling. The parent of Freshway Foods [on August 8] won an appeals court ruling that qualifies it for the same treatment the high court approved in its June 30 Hobby Lobby decision allowing family-run businesses to claim a religious exemption from the requirement to include contraceptives in their health insurance plans." (Bloomberg)
Voluntary Benefits Provide Safety Net for Employees with High-Deductible Health Plans
"Some employers have even gone as far as providing employees with a base level of critical illness, hospital indemnity or accident coverage at no cost, and then offering them the option to purchase additional levels of voluntary coverage for a higher premium. Since these types of scenarios tend to increase employee participation rates, insurance carriers are more likely to offer lower coverage rates as well." (William Gallagher Associates)
Use Open Enrollment to Make Improvements and Ensure ACA Compliance
"Open enrollment is a good time ... to update materials to prepare for 2015 changes, including eligibility terms in those materials that might reflect an employer's pay or play strategy with regard to the ACA's employer mandate, and for reviewing processes for offering coverage to employees identified as full-time. Employers can also use the open enrollment process to capture 2015 data needed for minimum essential coverage and employer shared responsibility reporting." (Wolters Kluwer Law & Business)
GAO Report: Cost-Effective Services in Recent Peer-Reviewed Health Care Literature
"Given the lack of readily available detailed information on the value of preventive services, GAO was asked for additional information on the services that may be potentially cost-effective or cost saving. In this report GAO examined recent peer-reviewed literature to identify preventive services that were shown to be cost-effective and the extent of potential cost savings of these services." (U.S. Government Accountability Office [GAO])
From Initial Rate Filings to Final Premiums: Peering Into the Black Box (PDF)
"Final premiums paid by consumers are the end results of a months-long process that begins with the development of rates for proposed 2015 insurance policies.... Filing requirements and rate review apply to policies offered in a given state, whether or not they are offered through exchanges ('marketplaces') established under ACA. Each state specifies the timeline by which these processes occur; therefore, any rates made publicly available at this time should be viewed with caution. Often early analysis of '2015 premiums' is based on information from form and rate filings." (Congressional Research Service [CRS])
How the ACA and Exchanges Are Driving a New 'Whole Workforce' Strategy
"One of the more prevalent and potentially game-changing perspectives is what [the authors] refer to as 'benefits for the whole workforce.' ... It's an incredible -- and incredibly complex -- challenge to address the needs of each type of employee. But new technology and connectivity options through private and public marketplaces are making it possible to not only meet the needs of a company's whole workforce, it's making it easy to thrive as a broker and as a consumer in this new world order." (The Institute for HealthCare Consumerism [IHCC])
Washington's $10 Billion Search for Health Care's Next Big Ideas
"The [ACA] created the Center for Medicare and Medicaid Innovation to launch experiments in every state, changing the way doctors and hospitals are paid, building networks between caregivers and training them to intervene before chronic illness gets worse.... In several states the office is working to overhaul medicine for nearly all residents -- not just those with government Medicare and Medicaid coverage.... More than $2 billion has been doled out or committed since 2011. One of the biggest experiments is the center itself." (Kaiser Health News)
Bundled Payment Contracts Under ACA Continue to Gain Influence
"Proponents of the bundled payment initiative are hopeful that this new approach to health care can lead not only to increased accountability for health care spending (and therefore greater cost-consciousness from providers), but also more transparency for health care consumers, whether employers, health insurers, or the patients themselves. Early market studies are showing a hearty enthusiasm from consumers, who are eager to better understand the costs of their care." (Sheppard Mullin)
Text of Eighth Circuit Opinion Recognizing Surcharge Relief, Contract Reformation and Equitable Estoppel Claims (PDF)
"To obtain relief under the surcharge theory, a plan participant is required to show harm resulting from the plan administrator's breach of a fiduciary duty.... It was arguably fraudulent for MetLife to collect premiums from [the plaintiff,] a Savvis employee who, MetLife now argues, never had an approved policy. Further, MetLife did not just erroneously collect premiums from [the plaintiff] -- an internal MetLife investigation showed that roughly 200 Savvis employees had been paying premiums for policies that were never approved by MetLife. We conclude that [the plaintiff] is allowed to make his waiver argument on remand, and if successful, receive monetary damages" [Silva v. Metropolitan Life Ins. Co., No. 13-2233 (8th Cir. Aug. 7, 2014)] (U.S. Court of Appeals for the Eighth Circuit)
[Guidance Overview] Agencies Issue Guidance on Notice Requirements When Dropping Preventive Services
"Of special interest is that the FAQ [issued on July 17, 2014] did not address the advance notice requirement under Section 2715 of the [ACA]. That section, in relevant part, provides that a health plan must issue notice of any material modification in coverage that is not reflected in the summary of benefits coverage provided to participants at enrollment at least 60 days before the effective date of the modification. Presumably, in light of the FAQ, the DOL will not require plans to comply with the 60-day advance notice requirement under the [ACA] when reducing or eliminating contraception coverage." (Bloomberg BNA)
Health & Welfare Plans and Same-Sex Spouses: Where Are We Now?
"While the IRS has yet to issue much guidance for health and welfare plans, employers need to look at state laws to determine whether the plan must provide the same benefits to same-sex spouses as it provides to opposite-sex spouses.... Some plans have not specifically defined 'spouse' to exclude a same-sex spouse from coverage, but have instead relied on state laws to exclude same-sex spouses from coverage. Since state laws that do not recognize same-sex marriage are under legal challenge, an employer that has relied on this approach should revise its plan's eligibility rules." (Warner Norcross & Judd LLP)
Guess Who's Moving to Consumer-Driven Health Plans: Doctors' Offices
"'The [American Medical Group] survey revealed that HDHPs along with CDHPs made up more than 1/3 of health plans analyzed and were as prevalent as PPOs. These plan types dwarfed HMOs, which made up only about 10% of analyzed plans.' ... The use of the verb 'dwarfed' to describe the tiny share of HMO coverage is interesting. Physicians and their staff -- by their behavior -- are telling us that they trust themselves as consumers to keep health costs down and quality up better than they trust themselves as bureaucrats in a top-down system." (National Center for Policy Analysis Health Policy Blog)
[Guidance Overview] HHS Clarifies Applicability of Certain ACA Provisions to Insurers in Puerto Rico
"Regardless of the HHS' recent clarification, however, since the Puerto Rico Health Insurance Code had previously incorporated the ACA, until new guidance is issued under Puerto Rico law, such provisions will continue to apply to Puerto Rico through local law (and not through federal law).... Puerto Rico has now the authority to amend such counterpart ACA provisions included in the Puerto Rico Health Insurance Code to better fit the needs of the health insurance market in Puerto Rico." (Littler)
CalPERS 2012-17 Strategic Plan: Annual Report July 2014 (PDF)
"As of June 30, 2014, [CalPERS] earned a preliminary 18.4 percent net rate of return ... exceeding [its] actuarial assumed rate of 7.5 percent. The funded status ... is estimated to be 76 percent as of June 30, 2014.... [CalPERS] negotiated health care premium rates for the new calendar year that reduce premiums for a majority of our members by approximately 3 percent." (CalPERS)
Challengers Pressing for Speed by Supreme Court on ACA Subsidies
"Seeking to get early action by the Supreme Court on the major test case on access to federal subsidies to help people buy health insurance, attorneys for the challengers ... asked the full Court to weigh any request by the federal government for more time to answer the appeal ... The letter strongly implied that the Court should take steps to insure that the government responds quickly. That response is now due on September 3, but a Court rule allows requests to extend such deadlines." [King v. Burwell, No. 14-1158 (4th Cir. July 22, 2014; cert. pet. filed July 31, 2014)] (SCOTUSblog)
Faith-Based Pennsylvania College Files Challenge to ACA Abortion Pill Mandate
"According to the complaint [filed in the Eastern District of Pennsylvania by Valley Forge Christian College], the Mandate grants exemption for a narrowly defined group of religious employers, but not the College.... 'It is unlawful for our government to determine when a ministry is religious enough to qualify for an exemption,' said Jeff Mateer, Liberty Institute general counsel." (Liberty Institute)
[Guidance Overview] IRS Increases 9.5% Affordability Threshold -- Or Did It?
"Some vendors, consultants and others have announced that employers can now use the increased 9.56% to determine whether coverage is affordable for purposes of the safe harbor. Based on the literal regulatory rules, this is not correct.... [T]he IRS regulations on affordability have 'hard-wired' the 9.5% standard into those regulations; the regulations do not cross-reference to the statutory reference for affordability." (Proskauer's ERISA Practice Center)
Global Employers Step Up Commitment to Wellness
"Seventy-eight percent of the world's employers are strongly committed to creating a workplace culture of health, to boost individual engagement and organizational performance.... 43 percent say they created a brand identity for their employee wellness programs, 52 percent offer health insurance premium reductions, and 65 percent believe wellness programs are extremely or very important to attract and retain workers." (Buck Consultants at Xerox)
U.S. Health Care Reform for Employer-Sponsored Plans: Are We There Yet?
"On average, 69.3% of respondents' employees enrolled in health plans in 2014, up only slightly from 69.1% in 2013, and employers predict that this number will rise only to 69.8% in 2015 ... Ten percent of respondents said they will have fewer employees working 30+ hours per week by 2015.... Number one on the list of significant or very significant employer concerns about the ACA is the increase in administrative burden.... Employers are making changes in anticipation of the 2018 excise tax to avoid it if they possibly can ... [M]ost US employers are very committed to offering benefits." (Mercer)
Why We Should Know the Price of Medical Tests
"After two years of the price transparency program, price variation between hospital and nonhospital facilities was reduced by 30 percent in areas where it was implemented ... The study also suggests that patients are more vigilant custodians of cost than their doctors. Several years ago, WellPoint gave physicians similar price information on scanning providers in their practice area but did not see a change in referral patterns[.]" (The New York Times; free registration required)
California Weighs Marketplace for Vision Care Coverage
"Building on the success of Covered California, the state's public health exchange mandated by the [ACA], the California Vision Care Council will create a 'vision care access marketplace,' which will be the place where people can access eye care options." (Employee Benefit News)
Early Outlook: State Health Exchanges in 2015
"With rate filings in for 27 states plus the District of Columbia, the early word on 2015 appears to be expansion. At least 15 of the 28 jurisdictions in 2015 will offer new individual plans this year. Thirty-seven of the 176 health plan filings are new ... At the same time at least three non-profit health Co-Ops will move into additional markets.... [The] analysis found the average monthly premium across all plans in 2015 was $384, before any subsidies are applied." (The Health Care Blog)
The Payment Reform Landscape: Accountable Care Organizations
"A growing number of large employers are piloting accountable care organizations (ACOs), working through their health plan; in some cases they are doing so directly with provider systems ... These leading purchasers intend to set the bar high. They cannot make the investment to pursue these ACO relationships if they are not assured that their populations will see meaningful, measurable gains in their health care and its affordability, as well as their health. That often means contractual commitments to lowering total costs of care and showing improved patient outcomes for targeted populations -- like high risk, medically complex patients." (Health Affairs)
ACA Calls for Some Workers to Be Automatically Enrolled in Coverage
"Does automatic enrollment help employees help themselves, or does it force them into coverage they don't want and may not need? A group of employers, many of them retail and hospitality businesses, want the provisions repealed, but some experts say the practice has advantages and is consistent with the aims of the health law." (Kaiser Health News)
[Opinion] Employer Health Insurance: A Bargain Compared to Government-Sponsored Coverage
"Employer plans' costs aren't just lower -- they've also been rising more slowly. Between 2003 and 2012, employer costs climbed 13.6 percent, after adjusting for inflation, compared with 14 percent for government programs. That difference might seem insignificant. But given that employers spend $579 billion and that government spends more than $1.1 trillion, it translates to billions of dollars." (Sally Pipes, in Forbes)
[Opinion] Employer-Based Health Insurance 'Cheaper' Than Government-Sponsored Insurance? Say What?
"[D]oes anyone possessed of a modicum of common sense really believe that the Medicaid population is even vaguely comparable to the population and the services covered by employer-sponsored health insurance? Does anyone sincerely believe that private insurers could cover Medicaid's high risk population for 60% less money than it costs Medicaid?" (Uwe Reinhardt, in Forbes)
One Insurer Says Small Employers Are Dumping Health Plans Faster Than Expected
"Already in 2014, WellPoint has watched 218,000 members of its health plans disappear because their employers have ended their group health plans. That's a 12-percent drop in WellPoint's overall small group membership.... WellPoint expects the trend of its small business customers ending their group health plans to play out in just two years, with roughly $400 million in annual profit disappearing." (Indianapolis Business Journal)
Tradeoffs in the Design of Health Plan Payment Systems: Fit, Power and Balance
"This paper proposes three metrics for grading these complex payment systems: fit, power and balance, each of which addresses a distinct market failure in health insurance.... [The authors] find that a simple reinsurance system scores better on fit, power and balance than the risk adjustment formula in use in the Exchanges." (National Bureau of Economic Research [NBER])
Text of Second Circuit Opinion: Terms of Collective Bargaining Agreement Do Not Constitute ERISA Plan Document (PDF)
"The UMM Fund argued that by failing to comply with a term of the CBA, the [Teamsters Local 210 Affiliated Health and Insurance Fund] violated the terms of an ERISA plan.... ERISA itself does not make plain where one looks to find the 'terms' of an ERISA plan ... Although the CBAs recite some of the provisions found in the ... UMM Fund trust documents, those references do not transmute the CBA itself into a plan document; and it certainly does not make the employer contribution requirement, which does not appear in the UMM Fund Trust Indenture, an UMM Fund plan term." [Silverman, Trustee of the Union Mutual Medical Fund, v. Crowley, et. al., No. 13-392-CV (2nd Cir. Aug. 1, 2014)] (U.S. Court of Appeals for the Second Circuit)
[Guidance Overview] HHS Limits Scope of Insurance Market Reforms in U.S. Territories
"The new interpretation uses the ACA's definition of a state... to exempt insurers in the territories from the [insurance market] reforms.... To the extent that ERISA and the Code make health care reform mandates applicable to group health plans, group policies sold in the territories still will need to comply with those mandates (to ensure compliance by the employer plans that purchase the policies)." (Thomson Reuters / EBIA)

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