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Health plans - design


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First-Year Results from Reinsurance and Risk Adjustment Programs
"Nationally, many of the new cooperative plans received risk adjustment programs, but others paid into the risk adjustment program. The Blue plans, traditionally the insurer of last resort in many states, generally did well in the reinsurance programs but had mixed results in the risk adjustment program. Certainly insurers that have to pay in to the program will not be pleased, and we can expect to hear from them. There may also be mistakes in the data. Insurers can appeal results they believe to be incorrect." (Health Affairs)
Part-Time Private Industry Workers Less Likely to Have Access to Benefits in 2013
"In March 2013, nearly three-fourths (74 percent) of full-time private industry workers had access to retirement benefits, compared with just 37 percent of part-time workers. Similarly, 85 percent of full-time workers had access to health insurance through their employers, compared with only 24 percent of part-time workers. Full-time workers were also much more likely than part-time workers to have access to paid holidays, sick leave, and vacations." (U.S. Bureau of Labor Statistics [BLS])
What All Employers Need to Know About the Upcoming 'Cadillac' Excise Tax
"While most employers have not focused on the Excise Tax, a few have been forward looking and creative in seeking to reduce its potential impact on them.... [P]opulation health strategies look to bend the cost curve by making employees healthier.... Some employer plans are changing the paradigm and contracting directly with the providers who are willing to go at risk for the cost and quality of services they provide or provide flat fee pricing for a suite of services needed to treat a particular condition." (InsideCounsel)
Description of Health Benefits for Members of Congress and Designated Congressional Staff (PDF)
"[B]eginning January 1, 2014, Members and designated congressional staff are no longer able to purchase FEHB plans as active employees; however, if they enroll in a health plan offered through a small business health options program (SHOP) exchange, they remain eligible for an employer contribution toward coverage ... This report summarizes the provisions of the final rule and describes how it affects current and retired Members and congressional staff. OPM has indicated that Members and congressional staff are still eligible for other health benefits related to federal employment, and these additional health benefits are outlined in this report." [Report No. R43194, dated June 17, 2015] (Congressional Research Service [CRS])
ACA and Narrow Networks
"[A]lthough only 36% of networks are narrow with respect to primary care physicians, for oncologists 59% of networks are narrow. Thus, access to high cost oncology services is more limited. It is not clear whether narrow networks are moving patients towards oncology specialist or simply reducing patient access to care." (Healthcare Economist)
Five Lingering Threats to Obamacare
"[1] Repeal ... [2] Marketplaces failing ... [3] Rising costs ... [4] Enrollment challenges ... [5] Another lawsuit." (The Hill)
The Same-Sex Marriage Ruling: Key Employee Benefits Take-Aways
"State insurance laws may require insurance carriers to offer same-sex spouses the same coverage and benefits that they offer to opposite-sex spouses.... A self-funded medical plan that is not subject to state insurance laws, but is subject to non-discrimination laws, may be required to cover same-sex spouses if the plan covers opposite-sex spouses.... Same-sex spouses would ... be able to obtain Qualified Domestic Relations Orders assigning portions of retirement plan accounts to current or former spouses or to the children of the same-sex marriage.... Same-sex couples will be able to adopt children as couples ... so benefit plans that provide coverage to adopted children of an employee will cover the children of the family.... Children of a same-sex spouse probably will be step-children of the employee and entitled to benefits offered to step-children." (Ogletree Deakins)
[Opinion] The Uncertain Effect of Obamacare on Employer Sponsorship of Health Plans
"Before Congress passed the Affordable Care Act in 2010, many experts anticipated that it would lead to a hemorrhaging of employer-based benefits, as businesses and their employees figured out that going into ObamaCare's exchanges would reduce their net tax burden. Unfortunately, the data so far are inconsistent and even contradictory." (National Center for Policy Analysis Health Policy Blog)
[Opinion] What's Next for the ACA? Life After King v. Burwell
"The ACA's increased stability ... is not simply the result of judicial interpretation, politics, or serendipity. Its stability also reflects significant accomplishments and reforms.... There are numerous improvements in health coverage and care that should receive increasing attention. They include: Improving the value of the care we receive ... Closing the coverage gap that harms the poor ... Eliminating the 'family glitch' ... Ensuring that out-of-pocket costs are affordable ... Advancing equity in health and health care." (Health Affairs)
GOP Funding Bill Proposes Cuts to CMS, DOL
"[T]he U.S. House Appropriations Committee released its draft fiscal year 2016 Labor, Health and Human Services (LHHS) funding bill, which includes substantial cuts to [CMS] and the [DOL]. The bill also appears designed to block several key provisions of the ACA.... Specifically, the bill: [1] Prohibits all funding for Center for Consumer Information and Insurance Oversight (CCIO) programs; [2] Eliminates the Health & Human Services' Agency for Health Research on Quality; [3] Bans use of funds to: [a] Support patient centered outcomes research (rescinding $100 million in funding for the Patient Centered Outcomes Institute (PCORI)), [b] Implement, further, enforce or advance the Navigators program, or [c] Carry out Title X of PHS -- the National Family Planning Program." (HighRoads)
Fate of Domestic Partner Benefits in Question After Marriage Ruling
"[A] national right to marry calls into question the fate of domestic partner benefits. Though it is unclear what most employers will decide, some companies are likely to deliver what feels like an ultimatum, at least to some: Marry within a certain time frame, or lose your partner's health care coverage. Some large employers -- including Verizon, Delta Air Lines, IBM and Corning -- already have." (The New York Times; subscription may be required)
DOJ Girds for Strict Review of Any Health-Insurer Mergers
"Many of the mergers under discussion have the potential to raise antitrust concerns, a senior Justice Department official said, adding that health insurers considering such deals should do a careful antitrust risk-assessment of the transactions. Antitrust enforcers have had initial discussions about how they would approach any insurance tie-ups, and they are preparing for the possibility they could face multiple deals simultaneously, this official said." (The Wall Street Journal; subscription may be required)
High Court Decides Same-Sex Marriage Issue (PDF)
"Public sector employers, such as state and local governments, will be required to recognize same-sex spouses and treat them the same as opposite-sex spouses if spousal benefits are offered. Private employers will not be required to recognize same-sex spouses, nor provide equal treatment, but could face litigation alleging sex discrimination.... [To] the extent state insurance law requires coverage of same-sex spouses when spousal coverage is offered, a plan will not be able to purchase insured coverage that excludes same-sex spouses.... For public sector employers, the ruling will require that plans extend to same-sex spouses the same spousal protection under their retirement plans as they extend to opposite sex spouses." (Buck Consultants at Xerox)
Supreme Court Ruling May Impact Domestic Partner Coverage Under Group Health Plans
"[To] only offer domestic partner coverage to individuals of the same gender as opposed to all domestic partners (whether of the same or opposite gender) may trigger employment discrimination claims.... [E]mployers offering domestic partner group health coverage may need to open up the coverage to partners of both the same or opposite gender. On the other hand, because same-sex marriage will now be available in all 50 states and because of the adverse tax consequences associated with domestic partner health coverage (usually the value must be included in the employee's income), employers currently offering domestic partner coverage may want to consider discontinuing it." (Miller Johnson)
Marriage with a Capital 'M': What Employers Need to Know About the Supreme Court's Decision in Obergefell v. Hodges
"Employers navigating this issue should undertake a review of their policies and benefits plans and make sure they are treating all married couples equally. This is true with regard to not only leave policies and non-discrimination provisions, but also benefit plans, retirement plans, and other benefits offered to spouses of employees. Past practices of, for example, requiring differing forms of proof of marriage, depending upon whether the marriage involved same- or opposite-sex couples, likely no longer will be permissible following Obergefell." [Obergefell v. Hodges, No. 14-556 (U.S. June 26, 2015)] (Littler)
King v. Burwell: The Supreme Court as Interpreter
"The Court concluded that the issue in [King v. Burwell] was too fundamental to the ACA for the Court to rely on an implicit delegation of authority and that if Congress had wanted the IRS to decide this issue, it would have explicitly said so. Rather, the Court stated that it is 'our task' to determine the correct reading of the statute.... The Court's approach could have potential ramifications on Executive power/authority and on administrative law and challenges to administrative actions for years to come." (Alston & Bird LLP)
Effect of the New York State Marriage Equality Act on Health Insurance Coverage
"On July 24, 2011, New York State began licensing same-sex marriages under the state's Marriage Equality Act ... This study investigated the association between legalizing same-sex marriage in New York and changes in health insurance coverage in men and women.... Compared with men in opposite-sex relationships, same-sex marriage was associated with a 6.3 percentage point increase in [employer-sponsored insurance (ESI)] ... for men in same-sex relationships ... Same-sex marriage was also associated with an 8.9 percentage point increase in ESI ... for women in same-sex relationships vs. women in opposite-sex relationships." (JAMA)
Legal Challenges Remain for Health Law
"One of the more significant tests is a lawsuit filed by Speaker John A. Boehner and other House Republicans who contend that the Obama administration is spending billions of dollars without the necessary appropriations from Congress. The government is also trying to fend off dozens of lawsuits challenging rules that require health plans to offer women coverage for contraceptives without co-payments or deductibles. The suit filed by Mr. Boehner, in the name of the House of Representatives, is not just a bookkeeping dispute. It involves fundamental questions of executive power and Congress's power of the purse." (The New York Times; subscription may be required)
Employee Benefits Effects of Supreme Court Same-Sex Marriage Decision
"On June 26, 2015, the Supreme Court struck down all state bans on same-sex marriage ... For employers, this decision raises the issue of what changes must be made in employee benefits ... [This article] will look at three categories of employers: those that have already been offering benefits to same-sex spouses, those that have not previously offered benefits to same-sex spouses, and those that have been offering benefits to domestic partners." [Obergefell v. Hodges, No. 14-556 (U.S. June 26, 2015)] (Calhoun Law Group, P.C.)
Class Action Suit Alleges Employee Work Hours Cut to Skirt ACA Obligation to Offer Health Coverage
"In the first lawsuit of its kind, a purported class of approximately 10,000 workers at Dave & Buster's, the restaurant chain, filed a lawsuit in the Southern District of New York (Marin v. Dave & Buster's, Inc., S.D.N.Y., No. 1:15-cv-03608) alleging that their employer reduced the workers' hours to keep them from attaining full-time status for the purpose of avoiding the requirement to offer them health coverage under the Affordable Care Act's (ACA's) employer mandate." (Franczek Radelet P.C.)
Context Is King: Analysis of the U.S. Supreme Court Decision in King v. Burwell (PDF)
8 pages. "The bigger question now, with King v. Burwell in the rearview mirror and most of the ACA intact, is whether President Obama will be willing to consider legislative proposals to improve the law.... The large employer community, unions and other patient groups are already speaking out against the looming ['Cadillac'] tax, which does not take effect until 2018. Legislation to modify the definition of full-time employee from 30 to 40 hours is high on the Republican list of priorities, but has earned limited Democratic support to date. Action to address unintended consequences that have emerged through implementation of the law could also see a renewed sense of urgency." (Squire Patton Boggs)
Supreme Court Rules That ACA Tax Subsidies Are Available Through Federal Exchanges (PDF)
6 pages. "The Court held that there was no dispute that a federal Exchange qualified as an 'Exchange' within the meaning of the ACA ... [and] found that although the statutory language was ambiguous, the role of federal Exchanges when read in the context of the ACA as a whole indicated that Congress viewed federal Exchanges as equivalent to state Exchanges. Significant to this conclusion is the ACA's mandate that HHS 'establish such Exchange' when a state declines to do so. According to the Court, 'By using the phrase 'such Exchange,' [the ACA] instructs [HHS] to establish and operate the same Exchange that the State was directed to establish[.]' " [King v. Burwell, No. 14-114 (U.S. June 25, 2015)] (Groom Law Group)
[Guidance Overview] Wellness Programs: New Proposed Regulations Add More Compliance Requirements (PDF)
28 presentation slides. Topics include: [1] Two types of programs, nine main compliance requirements: HIPAA and ADA; [2] GINA; [3] ACA market reforms; [4] ERISA; [5] COBRA; [6] HIPAA Privacy/Security; [7] ADEA and FLSA. (ABD Insurance & Financial Services, and Trucker Huss, APC)
[Official Guidance] CMS Fact Sheet: The Accountable Care Organization Investment Model
"The ACO Investment Model is a new model of pre-paid shared savings that builds on experience with the Advance Payment Model to encourage new ACOs to form in rural and underserved areas and current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk.... The ACO Investment Model will be available to: New Shared Savings Program ACOs that joined in 2015 or are joining in 2016.... [and] ACOs that joined the Shared Savings Program starting in 2012, 2013 or 2014." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Legal Hurdle Cleared -- The ACA Will Survive
"[A]ny employer with 50 or more full-time employees (including equivalent employees) will need to comply with the law in 2016. The transition relief that largely limited the Play or Pay Mandate to employers with 100 or more full-time employees (including equivalent employees) concludes at the end of 2015.... [At] the beginning of 2016 employers will have Form 1094 and 1095 reporting obligations.... [In] 2016 no employer will be able to rely solely on the MV Calculator to demonstrate that a non-hospital/non-physician services plan provides minimum value. Consequently, some employers will have to reassess the plan(s) they are offering their workforce." (Health Care Attorneys P.C.)
[Official Guidance] Text of OPM Carrier Letter for FEHB Program, Requiring Coverage of Transgender and Gender Transition Care (PDF)
"Effective January 1, 2016, no carrier participating in the Federal Employees Health Benefits Program may have a general exclusion of services, drugs or supplies related to gender transition or 'sex transformations.' This letter clarifies OPM's earlier guidance recognizing the evolving professional consensus that treatment may be medically necessary to address a diagnosis of gender dysphoria." (U.S. Office of Personnel Management [OPM])
Supreme Court Upholds Tax Credits on the Federal Exchange
"As the Chief Justice had observed at the oral argument, had the Court simply deferred to the agency, a future administration could have changed the rule. The Court's decision means that if Congress wants to limit tax credits to state-operated exchanges, Congress itself will have to amend the law. The Court proceeded to determine itself what the statute meant. In doing so, the Chief Justice relied throughout on the text, context, and purpose of the ACA, not on legislative history or some abstract notion of congressional intent." [King v. Burwell, No. 14-114 (U.S. June 25, 2015)] (Timothy Jost, in Health Affairs)
Humana Said to Pursue Sale as Court's Ruling Gives Insurers a Lift
"A new round of consolidation in the health insurance industry appeared closer as companies seek to grow larger, driven in part by cost-cutting and opportunities that are part of the Affordable Care Act. In the latest jockeying, Humana, the smallest of the big five insurers, is pursuing a deal to sell itself and could reach an agreement by next week ... Among those in the running to buy it are two bigger competitors, Aetna and Cigna." (The New York Times; subscription may be required)
ACA Survives Supreme Court Challenge
"By a 6-3 vote, a divided court affirmed an Internal Revenue Service ruling that subsidies should be available not only in states that have set up their own health insurance exchanges, but also in those where consumers rely on the federal government exchange.... While there are more challenges to come, an adverse ruling in this case would have been close to a mortal blow to the act that continues to divide the nation and its political conversation." (The Washington Post; subscription may be required)
Supreme Court Upholds ACA Subsidies
"The different path the Court took ... will not impact the implementation of the ACA or affected health plans. While this decision maintains the status quo, it is significant because it supports the ACA's current infrastructure and avoids a number of problems that could have been created had the Supreme Court ruled another way.... Now that this question has been resolved, the IRS and other regulatory agencies are free to focus their efforts on the remaining outstanding ACA issues, including implementing the new reporting requirements, developing nondiscrimination rules for insured health plans, issuing guidance on automatic enrollment requirements for large employers, and promulgating regulations on the Cadillac Tax." (Thompson Hine)
Text of Supreme Court Opinion: ACA Subsidies Upheld for Insurance Purchased on Federally-Facilitated Exchanges (PDF)
"When read in context, the phrase 'an Exchange established by the State under [42 U.S.C. Section 18031]' is properly viewed as ambiguous. The phrase may be limited in its reach to State Exchanges. But it could also refer to all Exchanges -- both State and Federal -- for purposes of the tax credits.... The argument that the phrase 'established by the State' would be superfluous if Congress meant to extend tax credits to both State and Federal Exchanges is unpersuasive.... [T]he statutory scheme compels the Court to reject petitioners' interpretation because it would destabilize the individual insurance market in any State with a Federal Exchange, and likely create the very 'death spirals' that Congress designed the Act to avoid.... Petitioners' plain-meaning arguments are strong, but the Act's context and structure compel the conclusion that Section 36B allows tax credits for insurance purchased on any Exchange created under the Act. Those credits are necessary for the Federal Exchanges to function like their State Exchange counterparts, and to avoid the type of calamitous result that Congress plainly meant to avoid." [King v. Burwell, No. 14-114 (U.S. June 25, 2015)] (Supreme Court of the United States)
[Opinion] Six Problems with the ACA That Aren't Going Away
"There is an urgent need to make major changes in the law regardless of how the Supreme Court rules. These are changes that will require bi-partisan cooperation -- something that is rare in health policy. The changes are needed because there are at least six major problems that aren't going away. [1] An impossible mandate ... [2] Unworkable subsidies ... [3] Perverse incentives for insurers ... [4] Other perverse incentives for buyers ... [5] Lack of access to care ... [6] Impossible burden for the elderly and the disabled." (John Goodman, in Health Affairs)
40% of Physician Networks Could Be Considered Narrow
"The results of the study found that 41% of networks on the marketplaces are considered small or x-small. Only 11% are considered x-large and include more than 60% of office-based practicing physicians in the area. The majority of the networks on the marketplace are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs), and there is a sharp distinction between the size of their networks. More than half (55%) of HMOs have x-small or small networks compared with only 25% of PPOs." (American Journal of Managed Care)
[Guidance Overview] IRS Transition Relief for Small Companies Offering Employer Payment Plans Ends on June 30
"[E]mployers are no longer allowed to reimburse employees for individually purchased health insurance policies, because they violate the ACA's market reforms. However, the IRS had issued transition relief for small employers that offered this type of arrangement to provide them with additional time to obtain group health coverage. Small employers should be aware that this transition relief is ending on June 30, 2015. Any small employer that still offers this type of arrangement after June 30 could be subject to an excise tax of $100 per employee per day until the violation is corrected." (Wolters Kluwer Law & Business)
The Skinny on Narrow Networks in Health Insurance Marketplace Plans
"The 'narrowness' or size of a network can be quantified, and 41 percent of silver plan physician networks in the ACA marketplace are small or extra small. While consumers are likely to select plans with low premiums, they are not fully aware of the characteristics of narrow networks. Well-functioning narrow networks will survive only if their characteristics are communicated more clearly to consumers and they are regulated to ensure adequacy." (Robert Wood Johnson Foundation)
Multiemployer Plans: Current ACA Issues (PDF)
"The study found some regional differences in the implementation of cost-management strategies: Implementation of reference-based pricing was highest in the West. Implementation of both onsite clinics and wellness with incentives was highest in the Midwest. Implementation of narrow networks was highest in the Northeast... A large majority of plans in the study have not changed coverage for spouses.... Similarly, most plans in the study have maintained coverage for retirees." (Segal Consulting)
[Opinion] ERIC Letter to Congressional Leaders Urging Repeal of 'Cadillac' Tax and Employer Mandate
"[We] urge Congress to move forward with legislation to repeal the mandates, taxes and reporting requirements imposed by the ACA. Specifically, we ask that Congress repeal the 40 percent health care excise tax, the employer mandate and all the related reporting requirements. These measures cause employers to devote costly resources to unnecessary compliance burdens and taxes, funds that are better spent on benefits for employees and other critical business needs." (The ERISA Industry Committee [ERIC])
When Does a Workplace Wellness Program Become Coercive, Rather Than Voluntary?
"But many employers say the [EEOC] proposal doesn't clear up conflicts between the health law and the ADA. In addition, it restricts their ability to offer rewards ... Some employers say the rule could force them to cut the size of wellness programs' financial incentives or penalties, particularly for families and smokers.... Consumer groups are also unhappy, saying the proposal strips workers of important protections against health or disability-related discrimination by loosening earlier government definitions of what constitutes voluntary." (Kaiser Health News)
[Guidance Overview] ACA Rules for Embedded Individual Out-of-Pocket-Maximums to Apply in 2016
"Group health plan sponsors will need to appropriately credit incurred eligible health expenses toward the plan's [out-of-pocket maximum (OOPM)]. They must also consider whether to separate EHBs from non-EHBs or use one in-network OOPM for all health benefits. To apply the embedded OOPM only to in-network EHBs, the plan sponsor must clearly define which expenses will be considered EHBs for purposes of the plan.... [M]any employer-sponsored group health plans are expected to apply the OOPM to both in-network EHBs and non-EHBs to avoid the administrative burden of separating them out." (Towers Watson)
ACA Litigation Beyond King v. Burwell
"The courts at all levels have repeatedly dismissed ACA challenges. Some of these dismissals have addressed the merits of the challenges, but in most instances courts ... have held that the plaintiffs bringing these cases have not in fact suffered an injury from the laws or administration actions that they challenge, and thus the federal courts have no jurisdiction to hear their complaints." (Health Affairs)
Text of Fifth Circuit Opinion: Religious Accommodation for Contraceptive Coverage Does Not Violate RFRA (PDF)
"Although the plaintiffs have identified several acts that offend their religious beliefs, the acts they are required to perform do not include providing or facilitating access to contraceptives. Instead, the acts that violate their faith. are those of third parties. Because RFRA confers no right to challenge the independent conduct of third parties, we join our sister circuits in concluding that the plaintiffs have not shown a substantial burden on their religious exercise." (U.S. Court of Appeals for the Fifth Circuit)
[Opinion] Shrink Obamacare's Costs by Removing Rule Driving up Young People's Premiums
"If the age rating restrictions were lifted, the premium for the second-lowest cost silver plan could easily be expected to drop to $270, a reduction of $66. The tax credit would drop by the same amount, $66, which amounts to a drop of over one-third from $191. Aggregated over the entire Obamacare population, this would dramatically reduce Obamacare's claim on taxpayers." (National Center for Policy Analysis [NCPA])
Fact Sheet on the Essential Health Benefits Prescription Drug Standard: How It Affects Mail-Order Pharmacies (PDF)
5 pages. "Beginning in 2017, health plan enrollees will have the option of obtaining prescription drugs at in-network retail pharmacies, with some exceptions. This change is a significant step forward, but advocates will have to monitor health plan compliance with the new requirements to ensure enrollees can obtain the prescription drugs they need in a manner that is appropriate for them." (National Health Law Program [NHeLP])
[Guidance Overview] Are You My Common Law Employer?
"With the summer upon us the agriculture industry is quickly approaching one of the busier times of year. For the first time employers have to comply with the Play or Pay Mandate or risk paying a financial penalty. This risk can be completely avoided by offering full-time employees coverage that provides minimum value at an affordable price. This sounds simple enough, but in the agriculture industry determining who should offer the coverage to the employee is not so simple." (Health Care Attorneys P.C.)
Catastrophic Claims Warrant Use of Stop-Loss Insurance
"[A recent report] shows that individuals with claims in excess of $1 million remain a major driver of stop-loss payments, accounting for $348 million of the total paid stop-loss claims. Cancer, congenital anomalies ... and premature births account for 28% of all claims breaching the $1 million mark. The findings confirm the need for self-funded employers to protect against common health events that could turn into catastrophic claims." (PLANSPONSOR)
Anthem/Cigna Mega-Merger Includes Another Major Player: The Independent Blues
"Anthem's June 20 proposal to purchase Cigna Corp. has stumbled in part because of one big unknown: how the deal would hold up against the licensing rules of the Blue Cross and Blue Shield Association, which controls utilization of the Blue brand by all BCBS carriers, including Anthem's 14 Blue subsidiaries." (HealthLeaders-InterStudy)
[Opinion] A Question of Balance (PDF)
"With healthcare, once we're in the system, we've pretty much lost control of the costs. Due to asymmetry of information, the ethos we grant providers, and our own insecurities about the fate of our unwell bodies, the providers make the vast majority of the testing and treatment decisions and, hence, make the cost decisions too. In response to the ever-rising costs, employers are increasing their use of high deductible health plans and the defined contribution approach to finance employee healthcare. These cost-shifting techniques raise the question: will employers continue to provide enough healthcare currency for their employees to maintain equilibrium with the additional services and higher provider prices?" (Chelko Consulting Group)
Eight Steps That Could Save Employers $500 Billion and Delight Their Workforce
"Despite the fact that health benefits are typically the second biggest expense (after wages) for most employers, far too many CEOs and CFOs have failed in their fiduciary responsibility [to the shareholders] to manage such a large cost item effectively. This passivity and reliance on so-called 'experts' to advise their benefits strategy has cost them and their employees dearly. Simply shifting the burden to employees in the form of high deductible health plans just adds financial stress to employees that indirectly costs the company down the road. Fortunately, there are some employers who have taken the bull by the horns." (Forbes)
Thanks But No Thanks: Cigna Declines Anthem Bid
"Anthem, the for-profit Blue Cross Blue Shield company, made a $53.8 billion bid for Cigna -- roughly $3,680 for each of its 13.7 million health plan members and $184 per share.... But Cigna's leaders have balked at the bid, describing the $53.8 billion as insufficient, rife with corporate governance problems and also lacking in the face of Anthem's own uncertainties going forward." (Healthcare Payer News)
Evaluating Private Exchanges: A Two-Step Process
"First, an employer needs to decide what they hope to accomplish by moving to an exchange. Reflecting on their own structure and strategy around employee benefits and determining what they want to accomplish by moving to an exchange will streamline the decision-making process.... The second step is vetting and evaluating the different exchanges based on the employer's specific strategy, structure and budget." (The Institute for HealthCare Consumerism [IHCC])
[Official Guidance] Text of HHS Inspector General Advisory Opinion 15-08: Medigap Premium Reduction for Use of Specific Network Hospitals Does Not Violate Anti-Kickback Statute (PDF)
"We are writing in response to your request for an advisory opinion regarding the use of a 'preferred hospital' network as part of Medicare Supplemental Health Insurance (Medigap) policies, whereby [name redacted] would indirectly contract with hospitals for discounts on the otherwise-applicable Medicare inpatient deductibles for its policyholders and, in turn, would provide a premium credit of $100 off the next renewal premium to policyholders who use a network hospital for an inpatient stay (the Proposed Arrangement) ... [A]lthough the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute ... the [OIG] would not impose administrative sanctions on [name redacted] under sections 1128(b)(7) or 1128A(a)(7) of the Act ... in connection with the Proposed Arrangement. In addition, the OIG would not impose administrative sanctions on [name redacted] under section 1128A(a)(5) of the Act in connection with the Proposed Arrangement." (Office of Inspector General [OIG], U.S. Department of Health and Human Services [HHS])
[Opinion] Business Roundtable Comment Letter to EEOC on Wellness Programs
"We strongly urge the EEOC not to undermine the value of these programs.... Under the current regime, private employers must offer programs that are well-designed to achieve the goals established; must offer reasonable alternatives for employees who cannot participate for medical reasons; and must ensure that strong privacy protections are in place. Business Roundtable believes that EEOC should not unnecessarily regulate those employers who are in compliance with the ACA. Rather, EEOC should focus their resources on identifying employers who are not compliant." (Business Roundtable [BRT])
[Opinion] U.S. Chamber of Commerce Comment Letter to EEOC on Proposed Wellness Regulations: 'Fundamentally Flawed' (PDF)
30 pages. "[T]he Chamber believes that the EEOC's approach to restricting workplace wellness program incentives is fundamentally flawed. The Proposed Rule, if promulgated, will discourage employers from instituting or sponsoring workplace wellness programs -- a tool authorized by Congress in amending [HIPAA] through the [ACA] -- to improve employees' health and lower employees' health care costs. With this Proposed Rule, the EEOC not only exceeds its jurisdiction and authority under the ADA, but the Commission also contradicts both the text of the ACA and the Tri-Agency Regulations." (U.S. Chamber of Commerce)
[Opinion] HR Policy Association Comments to EEOC on Proposed Wellness Program Rule: 'EEOC Does Not Have the Statutory Authority'
"Although the proposed rule would restrict the ability of employers to administer gated health care plans, the EEOC does not have the statutory authority under the ADA's insurance safe harbor provision to impose such restrictions ... The EEOC's blanket rejection of a key 11th Circuit decision involving the ADA's 'safe harbor' (Seff v. Broward County) is inappropriate, and the agency should recognize that some wellness plans may fall within that provision." (HR Policy Association)
CBO Finds 19 Million Would Become Uninsured If Health Law Repealed
"The report is the first time CBO has analyzed the costs of the health law using a format favored by congressional Republicans that factors in the effects on the overall economy.... CBO projected that a repeal would increase the federal deficit by $353 billion over 10 years because of higher direct federal spending on health programs such as Medicare and lower revenues. But when including the broader effects of a repeal on the economy, including slightly higher employment, it estimated that the federal deficit would increase by $137 billion instead. Both estimates are higher than in 2012, the last time that the CBO scored the cost of a repeal." (Kaiser Health News)
Achieving High Performance with Onsite Health Centers
"Nearly four out of 10 respondents (38%) plan to add more centers, and two-thirds (66%) expect to expand health services by 2018. 75% of employers offering health centers have measured ROI, up significantly from 2012." (Towers Watson)
Pioneer ACOs: Anatomy of a 'Victory'
"[T]he top eight performers saved Medicare $295 million, 78 percent of the consultant report's claimed savings! ... [T]wo of the ten participants ... generated almost 70 percent of the savings.... But look at what CMS paid out in performance bonuses to their biggest Pioneer savers: $295 million in savings generated only $31.4 million in bonus payments." (Health Affairs)
[Opinion] ERIC Comments to EEOC on Proposed Wellness Regs
"ERIC suggests that the Commission incorporate the following ... modifications into the final rules: [1] Eliminate incentive limitations on wellness programs that qualify for an exemption from such limitations as 'participatory' programs' ... [2] Eliminate new notice requirements for wellness programs that are provided as part of group health plans ... [3] Eliminate the language in the proposed regulation that would prohibit the use of 'gateway' plan designs ... [4] Adopt an effective date no sooner than January 1, 2017 ... In addition, ERIC has identified ... four further compliance obstacles that were not included in the proposed regulations[.]" (The ERISA Industry Committee [ERIC])
If Uber Drivers Are Employees, Company Faces Hard Choice on Healthcare
"Uber CEO Travis Kalanick said the ACA has been 'huge' for his business, by creating a stable individual insurance market and helping entrepreneurial-minded individuals quit their jobs to become part-time drivers. But now Uber may face the other side of the Affordable Care Act: Its requirement that companies pay for full-time workers' health insurance, or pay a penalty." (Forbes)
[Opinion] Uber and the 1950s Logic of the ACA's Employer Mandate
"[A] recent ruling by the California Labor Commission reminds us of what must be one of the worst features [of the ACA] -- the requirement that large employers provide health insurance to all employees working more than 30 hours per week. This mandate is a remnant of a 1950s economy where workers remained employed at the same firm for decades and the Internet was just a series of tubes that existed in our dreams. Ironically, the ACA insurance exchanges not only make the employer mandate obsolete, but the mandate actually weakens the viability of the exchanges by locking a large portion of the healthy population into the employer provided insurance market." (David Dranove and Craig Garthwaite, at Code Red)

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