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Health plans - design

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Telemedicine and the Long-Tail Problem in Healthcare
"Utilization of telemedicine is significantly higher for the Medicare population compared with commercial ... Telemedicine utilization rates appear to be higher in Alaska and in the Midwest and Southwest regions of the country ... Average charge levels for telemedicine services are approximately 9.4% lower than the equivalent services delivered on-site for Medicare, and 0.9% higher for commercial plans." (Milliman)
Healthcare and Wellness Benefits Trends for Washington, DC Employers
"Washington, DC employers aren't embracing private exchanges, are still utilizing early adopter wellness strategies and continue to struggle with the administrative and financial burdens of health reform.... Local employers still rely heavily on cost-shifting tactics to manage their annual healthcare plan rate increases.... Local employers are still not leveraging social media as part of their employee benefit communication strategies." (Lockton)
[Opinion] How Obamacare Can Fix Employer-Sponsored Health Plans
"The whole value of pooling Americans based upon where they work only functions when the worker base itself is homogeneous and stable. But today, with the average millennial worker's tenure of three years, and declining, that necessary stability is disappearing.... The 'new' individual market, with 22 million Americans, is an unexpected, but refreshing alternative for employers that provides access to the largest and most stable commercial pool in the country." (CNBC)
Humana Might Leave Some ACA Exchanges Next Year
"[Humana], which is being acquired by rival Aetna, said ... that it expects to make a number of changes to its business for 2017, and that may include leaving some markets both on and off the exchanges or changing prices. Humana Inc. sold coverage in 15 states this year." (
Rx Drugs and Telemedicine Maximize Self-Funded Plan Value
"Virtually all brand name pharmaceutical manufacturers provide rebates to PBMs.... Negotiating with the PBM to pass on these rebates (in whole or in part) to the employer can have a significant impact on lowering prescription spend.... Many insurance carriers who offer self-funded services have recently introduced telemedicine as an option.... The value proposition of telemedicine is that it improves productivity by giving employees immediate 24/7 access to board-certified physicians who can diagnose and write prescriptions for common conditions." (Corporate Synergies)
Eligibility and Coverage Trends in Employer-Sponsored Health Insurance
"Between 2000 and 2015, the share of workers covered by health benefits offered by their employers dropped from 63 percent to 56 percent, with some firms not offering coverage and some employees not enrolling when coverage is offered. The biggest decrease occurred among employees working for small firms (3-199 workers)." (Henry J. Kaiser Family Foundation)
Matching Payment Methods with Healthcare Benefit Designs to Support Delivery Reforms
"This report analyzes patient-centered medical homes, 'focused factories,' and accountable care organizations to determine which payment methods and benefit designs best align the incentives of providers and consumers to support delivery reform through these models." (Urban Institute)
A Typology of Healthcare Benefit Designs
"In this report, [the authors] develop a new typology of benefit designs under two categories -- cost sharing and contingent coverage -- and focus only on designs that have the potential to change consumer behavior and its alignment with payment reform." (Urban Institute)
Healthcare Benefit Designs: How They Work
"All payment methods have strengths and weaknesses, and how they affect the behavior of health care providers depends on their operational design features and how they interact with benefit design.... This report analyzes the nuances of how seven different benefit designs work. These designs include narrow networks, tiered networks, reference pricing, high-deductible health plans, centers of excellence, value-based insurance design, and alternative sites of care." (Urban Institute)
[Guidance Overview] ACA Implementation Round-Up: Insurer Quality Ratings and More
"For 2017, star ratings will only be available in the FFM in five states: Michigan, Ohio, Pennsylvania, Virginia, and Wisconsin.... CMS hopes that the further pilot testing will give it additional time to better ascertain how consumers will use quality reporting, to develop technical assistance and educational tools to facilitate the use of quality ratings, and to allow insurers to measure and improve the quality of their QHP offerings." (Health Affairs) to Feature Simplified Plans and Pilot Star Ratings
"Simple Choice Plans are standardized health plans with uniform deductibles, out-of-pocket limits and standard copayments that are options for insurers to offer.... Health insurers opposed them, arguing that they may inhibit their ability to promote more economical plans, such as those that have narrow provider networks.... And congressional Republicans wrote Andy Slavitt, acting administrator of [CMS], saying they are concerned the policy 'will continue a pattern of allowing Washington bureaucrats to pick winners and losers by propping up plans that meet arbitrary requirements, instead of preserving choice and encouraging consumers to select plans that best meet their unique needs.' " (Bloomberg BNA)
Businesses Are Opting for Freelancers to Dodge Health Care Fees
"According to a [recent] study ... [the ACA] is leading companies to hire more freelance workers rather than bring on more in-house staff.... Since 2016, health care fees including the tax penalty for having uninsured employees increased because of the act, causing 74 percent of companies to opt for freelance hires instead, the study says. In fact, 60 percent said they planned to hire more freelancers in place of full timers.... And though most companies agreed benefits were the key to attracting desirable employees, nearly one third of them are eliminating their benefit plans because of fees associated with the new health care policies." (Entrepreneur)
34% of Employees at Midsize Firms Elect High Deductible Health Plans When Given the Choice
"[T]raditional health plans -- primarily PPOs -- dominate the mix for midsize employers (87 percent), but when given the choice, over one-third (34 percent) of employees selected an HDHP, with millennials over age 26 the most likely to opt in (40 percent). Forward thinking employers -- 13 percent -- now offer at least one high-deductible health plan (HDHP).... [R]egardless of health plan, employees are facing higher out-of-pocket costs, and with copays and coinsurance across both PPOs and HDHPs, the average family could spend nearly 40 percent more on health care in 2016 than food[.]" (Benefitfocus)
[Guidance Overview] IRS Announces 2017 HSA/HDHP Limits (PDF)
"The IRS has released the health savings account and high-deductible health plan limits for 2017. The HSA annual contribution limit for self-only coverage increased over the 2016 limit, but the limits are otherwise unchanged." (Xerox HR Services)
Differing Impacts of Market Concentration on ACA Marketplace Premiums
"In New York, premium rates grew faster in areas with greater insurer concentration (i.e., less competition). In California, areas with less insurer competition had slower premium growth, which may be related to the state marketplace's use of selective contracting with a limited number of plans and direct negotiations with plans on premium rates.... In both California and New York, there was higher premium growth in markets with greater hospital concentration." (The Commonwealth Fund)
[Opinion] Another Exciting Day in Washington: Legislators Take Aim at Healthcare
"Republicans are preparing to issue five position papers to spell out their legislative agenda and priorities. One of these concerns healthcare. Speaker Ryan is pushing to finally create a Republican plan to deal with the ACA. We were told the plan would promote health savings accounts, encourage innovation, and protect the doctor-patient relationship. It will also embrace technology and electronic health records. Now the bad news: in place of the Cadillac Tax, this plan will likely contain a cap on the employer exclusion." (Frenkel Benefits)
[Guidance Overview] DOL Issues Guidance on Interaction Between ACA and Fringe Benefit Requirements Under Service Contract, Davis Bacon and Related Acts
"DOL emphasizes that the [ACA] and the SCA and DBRA are independent laws, and government contractors are expected to comply with each of them. In other words, no provision of either set of laws exempts contractors from the obligations of the other. The DOL then goes on to answer a variety of common questions that have been raised." (Proskauer Rose LLP)
Understanding Domestic Partner Health Benefits After Obergefell
"[M]ost domestic partner health benefits plans today rely on some sort of certification by the employee, rather than state action, to determine who is a domestic partner.... In most instances, employers see a domestic partner benefit as being equivalent to a spousal benefit. However, domestic partner health benefits policies raise a variety of concerns not present in spousal benefits.... [1] Compliance with federal and state nondiscrimination statutes. [2] Defining who is a domestic partner. [3] Federal and state tax concerns. [4] COBRA issues." (Calhoun Law Group, P.C.)
Managing Prescription Drug Plan Costs: Pricing Tricks Employers Should Watch For
"Make sure the PBM contract has minimum pricing guarantees. A PBM that passes the pricing it pays the pharmacies on to you (rather than charging you a higher price than the PBM pays the pharmacies for drugs) is a great way to help ensure the best pricing. Carefully review and negotiate virtually every word in the contract to ensure the PBM will actually deliver the pricing promised. Negotiate generous rights to audit the PBM. Even with a carefully negotiated contract, it's not at all uncommon for PBMs to breach the negotiated contract with complete disregard for its provisions." (Marsh Consulting Group)
[Guidance Overview] Simplifying Choices in the Marketplace: Simple Choice Plans and Quality Star Ratings
"To improve decision making, Simple Choice plans will display prominently in Plan Compare, with clear visual cues that show consumers the plans that are easy to compare vs. the ones that should be researched for differences. Consumers also will be able to choose to only see these types of plans, if they want to quickly compare them." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Guidance Overview] Medicaid Managed Care Final Rule: Examining the Alignment with Qualified Health Plan Requirements
"CMS has rechristened standardized plans as 'simple choice plans.' These are plans with standardized benefit and cost-sharing parameters. Although CMS has not yet decided how exactly these plan options will be displayed or described, the blog post does say that they will be displayed prominently in Plan Compare and that consumers will be able to choose to see only standardized plans if they want to compare only these plans." (Health Affairs)
CMS Looks to Simplify Insurance Shopping with 'Simple Choice' Plans, Quality Star Ratings on Exchanges
"The federal insurance exchanges will offer standardized health plans and display a five-star ratings system as pilot program during the fourth open enrollment period, scheduled to open later this year.... The standardized plans, called 'Simple Choice plans' will have a uniform set of features which will allow customers to compare plans on just a few important factors, such as monthly premiums and which providers are part of a plan's network." (Morning Consult)
[Opinion] Paul Ryan Does Not Seem to Understand High-Risk Pools
"[W]hat about the 10 percent of people who account for two-thirds of our health care costs. Their premiums would have to be about 7 times what the premium would be if everyone were covered under a common risk pool, or about 20 times what everyone else is paying. As Paul Ryan says, they are 'really kind of uninsurable.' So he proposes high-risk pools at the state level, with subsidized premiums. Expecting the states to subsidize two-thirds of our health care costs is a non-starter. Without massive increases in taxes, which are opposed by the Republicans anyway, the states would not be able to fund those pools." (Physicians for a National Health Program [PNHP])
[Official Guidance] Text of IRS Rev. Proc. 2016-28: 2017 Inflation Adjusted Amounts for Health Savings Accounts (HSAs) (PDF)
"For calendar year 2017, the annual limitation on deductions ... for an individual with self-only coverage under a high deductible health plan is $3,400 ... [and for] family coverage under a high deductible health plan is $6,750.... For calendar year 2017, a 'high deductible health plan' is defined under Section 223(c)(2)(A) as a health plan with an annual deductible that is not less than $1,300 for self-only coverage or $2,600 for family coverage, and the annual out-of-pocket expenses (deductibles, co-payments, and other amounts, but not premiums) do not exceed $6,550 for self-only coverage or $13,100 for family coverage." (Internal Revenue Service [IRS])
[Opinion] U.S. Chamber of Commerce Statement to House Ways and Means Committee on the Tax Treatment of Health Care (PDF)
"[O]ver 175 million Americans are enrolled in employer-sponsored coverage.... We urge you to protect ERISA and employer-sponsored coverage. Second, we urge you to repeal the [ACA]'s 40% excise tax on high-cost plans and preserve the longstanding tax treatment of employer-sponsored coverage for employers and employees alike. There is no direct evidence that changing the tax treatment of these benefits will result in savings.... Finally, we believe that greater innovations in employer-sponsored coverage may continue to help to reduce health care spending." (U.S. Chamber of Commerce)
[Opinion] U.S. Chamber of Commerce Statement for House Subcommittee Hearing: 'Innovations in Health Care -- Exploring Free-Market Solutions for a Healthy Workforce' (PDF)
"[E]mployers have driven recent advancements in health care coverage through the adoption of workplace wellness programs, the implementation of private exchanges, use of the Accountable Care Organization (ACO) model, and the integration of telemedicine into plans. However, providing affordable health insurance coverage is becoming progressively more challenging with new restrictions on plan design and new requirements governing employer-sponsored coverage." (U.S. Chamber of Commerce)
What the $100m Uber Settlement Means to All Employers
"Quite simply, this deal is a game-changer. It provides a blueprint for a possible path towards peaceful coexistence with workers without the specter of a class action lawsuit hanging over your heads at all times.... [T]his deal further presages the possible emergence of a new third classification of worker that reflects the reality of working in the gig economy in the 21st century.... Government regulators and elected legislators will take notice of this proposed solution and could see it as a model for developing laws covering gig economy working relationships." (Fisher & Phillips LLP)
Healthcare Providers Changing Their Approach to Employee Health Plans
"Over 75% of respondents self-insure their employees' healthcare. Of those that do not currently self-insure their employees' health, 25% indicated it is somewhat or very likely that they will switch to a self-insured approach next year. Of those who self-insure their employees, 54% looked to a traditional payor to administer their self-insured plan, while 36% look to an independent third-party administrator (TPA). Those working with independent TPAs were significantly more satisfied[.]" (Valence Health)
Teleworkers More Likely to Pursue Wellness Options on Their Own Compared to Office-Based Counterparts
"While teleworkers are more likely to pursue wellness options on their own compared to their office-based counterparts, almost half of all full-time U.S. employees do not participate in wellness-related activities no matter where they work.... [A] lack of work life flexibility is not a barrier to wellness since almost all employees indicated they have some form of flexibility. However, training and guidance on how to manage that flexibility does positively influence employee wellness pursuits." (Flex+Strategy Group)
[Opinion] Reports of Obamacare's Demise Are Greatly Exaggerated
"UnitedHealthcare was initially cautious in its participation in the ACA marketplaces, but became more aggressive recently, offering coverage in 34 states in 2016. However, the company's plans were often not competitively priced, with UnitedHealthcare offering 1 of the 2 lowest premium plans in only 35% of the counties where it participated ... The company's inability to compete on price may be because its historical strength has been in the employer-based health insurance market, which values broad networks of doctors and hospitals. In the ACA marketplaces, narrower networks have been a primary way in which insurers keep costs and premiums low." (JAMA Forum)
Ryan Wants to End Obamacare Cost Protections for Sick Consumers
"U.S. House of Representatives Speaker Paul Ryan called on Wednesday for an end to Obamacare's financial protections for people with serious medical conditions, saying these consumers should be placed in state high-risk pools.... Ryan said existing federal policy that prevents insurers from charging sick people higher rates for health coverage has raised costs for healthy consumers while undermining choice and competition." (Reuters)
[Guidance Overview] Confirm Health Plan Coverage Meets Latest FAQ ACA Preventive Care Guidance
"On one hand, failing to design and administer their health benefit programs to comply with these and other rules and interpretations ... can trigger significant liability for insurers as well as group health plans and their sponsoring employers. On the other hand, group health plans and insurers that carefully design and administer their arrangements to comply with the guidance also can take advantage of opportunities to manage utilization and costs using the narrow windows of opportunity offered within the guidance. In either case, careful, well-documented efforts to verify compliance in response to the evolving guidance is important to prevent unanticipated violations and position group health plans, their sponsoring employers and fiduciaries and insurers to mitigate potential exposures in the event of a violation of existing or subsequently published guidance." (Solutions Law Press)
[Guidance Overview] HHS Sets New Requirements to Limit Surprise Medical Bills from Out-of-Network Providers
"[C]ertain QHP enrollees' cost-sharing amounts for essential health benefit services provided by out-of-network providers in an in-network setting will count toward an enrollee's in-network annual limitation on cost sharing. However, this requirement [1] will not apply if the QHP gives appropriate notice to the enrollee, [2] is slated to take effect in the 2018 benefit year but may see further modifications before then, and [3] is not intended to preempt any state laws on this issue." (Epstein Becker Green)
Proposals for Change in Prescription Drug Pricing: Transparency, Competition and Innovation (PDF)
"Pricing transparency reports ... Continued assessment of direct-to-consumer advertising requirements ... Reduce backlog of generic applications ... Foster competition for branded drugs ... Target exclusivity protections to truly innovative products ... Increase oversight of 'pay for delay' settlements ... Shorten the exclusivity period for biologics and promote policies to increase the uptake of biosimilars ... Expand research on treatment effectiveness and value ... [Require] drug manufacturers ... to conduct comparisons of new products to existing products ... Expand the availability of value -- based pricing." (The Campaign for Sustainable Rx Pricing)
[Opinion] Obamacare Disaster Will Be Obama's Enduring Domestic Legacy
"According to a 2014 McKinsey survey, about three-quarters of those in the exchanges were previously insured on commercial plans, either through their employers or the individual market. They were doing fine without taxpayer-subsidized insurance but were pushed into Obamacare. They now face rising premiums and smaller provider networks -- and as commercial insurers flee, they will increasingly be stuck in horrible, Medicaid-style plans. This is not what the president promised when he sold Obamacare to the American people." (The Washington Post; subscription may be required)
[Guidance Overview] New FAQs Cover ACA, Mental Health Parity Items
"[1] Disclosure of the calculation of out-of-network payments is now required ... [2] Clinical trial coverage clarifications ... [3] MOOPing up after reference-based pricing ... [4] Mental Health Parity and Addiction Equity analysis must be plan-by-plan ... [6] Playbook for authorized representatives requesting information about MHPAEA coverage." (Benefits Bryan Cave)
UnitedHealthcare's Departure from Marketplaces Could Impact Consumers' Costs, Access
"The company's departure could be felt most acutely in several counties in Florida, Oklahoma, Kansas, North Carolina, Alabama and Tennessee that could be left with only one insurer[.]" (Kaiser Health News)
New York Insurers to Change Coverage of Hepatitis C Drugs
"Seven health-insurance companies in New York will change their criteria for covering costly drugs that cure chronic hepatitis C under the terms of agreements with the office of State Attorney General Eric Schneiderman. The agreements ... require the insurers to cover hepatitis C medications for nearly all patients who have commercial insurance plans in the state.... [An] investigation showed a wide discrepancy in how companies cover these drugs and found some insurers largely covered only patients with advanced stages of the disease, the attorney general's office said. Five of the insurers denied from 30% to 70% of claims[.]" (The Wall Street Journal; subscription may be required)
About That Cadillac Tax
"There are two key practical issues with the tax: the indexing problem and the adaptation question. In [the authors'] opinion, these are serious enough issues to warrant continued caution before implementing the Cadillac tax." (Health Affairs)
Better Pay and Benefits Loom Large in Job Satisfaction
"Sixty percent of employees rated benefits as a very important contributor to job satisfaction, keeping benefits in the No. 3 position. But just over two-thirds (68 percent) of employees indicated that they were satisfied with their benefits." (Society for Human Resource Management [SHRM])
Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States
"[At] the average pre-treatment uninsured rate, the full ACA increased the proportion of residents with insurance by 5.9 percentage points compared to 3.0 percentage points in states that did not expand Medicaid. Private insurance expansions from the ACA were due to increases in both employer-provided and non-group coverage. The coverage gains from the full ACA were largest for those with incomes below the Medicaid eligibility threshold, non-whites, young adults, and unmarried individuals." (National Bureau of Economic Research [NBER])
[Guidance Overview] ACA FAQ 31 Provides New Insight for the Mental Health Parity and Addiction Equity Act and Other Group Health Plan Mandates (PDF)
"MHPAEA has several testing requirements tied to it to verify limits provided for under mental health or substance abuse can pass certain mathematical thresholds.... [S]ome vendors were testing MHPAEA against the data for their book of business. A Q&A seems to require the testing for plans at the specific plan level, not compared to the entire book of business.... In order to ensure compliance, each sub-vendor of the plan will also need to comply.... The recent Q&As also point out that medical necessity determinations tied to MHPAEA compliance can be requested from participants, potential participants or contracting provider upon request[.]" (Kinney & Larson)
More Marketplace Health Plans Ease Access to Some Expensive Drugs
"[F]or five classes of drugs -- two used to treat cancer, two for HIV and one class of multiple sclerosis drugs -- fewer plans in 2016 placed all the drugs in the class in the top specialty drug tier with the highest patient cost-sharing requirements or charged patients more than 40 percent of the cost for every covered drug in the class." (National Public Radio)
Health Care Access and Affordability Among Low- and Moderate-Income Insured and Uninsured Adults Under the ACA
"Low- and moderate-income adults with Marketplace coverage are no more likely to report problems paying medical bills or have high out-of-pocket costs than those with employer-sponsored insurance (ESI). Low- and moderate-income adults with Marketplace coverage are as satisfied with their health plans as those with ESI in terms of premiums charged, but are less satisfied with their choice of providers and the protection their plans provide against high medical bills." (Urban Institute Health Policy Center)
Telemedicine: A Game Changer for Senior Healthcare
"While healthcare for retirees once meant repeated trips to the doctor's office, many are now able to receive high-quality medical services without leaving the comfort of home. And it's all because of telemedicine. This high-tech patient care model is quickly gaining traction as a means for lowering costs while improving healthcare quality -- particularly among aging populations." (American Journal of Managed Care)
[Opinion] Should We Change the Tax Break for Employer-Sponsored Health Insurance?
"The tax break results in an estimated $250 billion less tax paid to the government for fiscal 2016. Fifty-seven percent of the U.S. population under the age of 65 receive coverage through an employer, but many economists have long argued that the third-party payer system has contributed to high health-care costs in this country. In addition, the tax break is not enjoyed by many people who have to buy their own health insurance." (Bloomberg BNA)
[Opinion] The End of Employer-Based Healthcare?
"[What Mark Bertolini, CEO of Aetna, is saying] is that health insurance is going to become a direct to consumer retail purchase. The provider systems will be the risk takers not the insurance companies. And there is a movement in Washington to eliminate the health insurance deduction at the employer level in exchange for lowering the corporate tax rate." (Joe Markland)
[Opinion] American Academy of Actuaries Comments to CMS on HHS-Operated Risk Adjustment Methodology Discussion Paper (PDF)
"[T]here is reason to question whether the market characteristics that underpin the MarketScan data accurately reflect the characteristics of enrollees in the reformed individual and small group markets. We note several individual market dynamics that are not present in commercial large group markets and could impact partial year enrollee costs ... However, at this time, it may be more important to focus on revising the risk adjustment methodology to address partial year enrollment based on the data available. If EDGE data can be used at a later date to calibrate HCC weights, then further adjustments to the partial year enrollment approach could be considered." (American Academy of Actuaries)
[Opinion] Confronting Consolidation (PDF)
"Aetna, Humana, Anthem, Cigna, they're all in merger/acquisition mode. Pharmaceutical manufacturers continue to merge ... Just two PBMs now control two thirds of the employer-sponsored prescription drug market.... So where does all this healthcare consolidation leave your corporate health plan? Probably not in a good place when it comes to patient access, provider choice, price competition and appropriateness of treatment.... [H]ow are plan sponsors going to protect themselves and their plan members from the increasing market power of the major healthcare players? ... Enter the U.S. Federal Trade Commission (FTC), whose role it is to protect consumers from anti-competitive practices." (Chelko Consulting Group)
Some Firms Save Money by Offering Employees Free Surgery
"Lowe's home improvement company, like a growing number of large companies nationwide, offers its employees an eye-catching benefit: certain major surgeries at prestigious hospitals at no cost to the employee. How do these firms do it? With 'bundled payments,' a way of paying that's gaining steam across the health care industry, and that Medicare is now adopting for hip and knee replacements in 67 metropolitan areas, including New York, Miami and Denver.... Lowe's comes out ahead, even after paying for the patient's travel[.]" (Kaiser Health News)
[Opinion] Health Plan Industry's Worst Nightmare: Employers Realizing They Are Actually the Insurance Company
"The continued hyperinflation of premiums would accelerate the employer realization that they need to take matters into their own hands and disintermediate health plans. A growing number of employers are doing exactly that. This situation begs the question, 'what do health plans do that couldn't be done better by an algorithm?' " (Dave Chase, in Forbes)
[Guidance Overview] Colonoscopies, Mental Health Parity, and More at Issue in Latest ACA FAQs
"The Departments' discussion of MHPAEA-related disclosures ... is notable for its expansive and potentially onerous listing of documents and plan information that must be provided on request to current or potential participants, beneficiaries, or contracting providers.... In the Departments' view, these disclosure obligations are a product of not only the MHPAEA and its final implementing regulations, but also: [1] ERISA's requirement that instruments under which the plan is established and operated be furnished to participants and beneficiaries with 30 days of request, subject to penalties ... [and] [2] The DOL claims procedure regulations and related ACA changes involving internal claims and appeals and external review." (Practical Law Company)
Can the ACA Employer Health-Insurance Mandate Be Avoided by Reducing Employees' Hours?
"Though the Marin case calls into question whether an employer can lawfully manage the hours of its workforce in light of the increased costs of providing healthcare coverage under the ACA, it is important to note that the district court's refusal to dismiss the case does not provide an answer.... [E]mployers should carefully review, before distribution, all communications to employees regarding decisions to modify work schedules. This case demonstrates how such communications may bolster an employee's claims of discriminatory intent." (McGuireWoods LLP)
Cigna/Anthem Not Exiting Obamacare, Unlike UnitedHealth
"UnitedHealth's decision to exit most health exchanges by 2017 ... would on the surface seem like a death knell for the [ACA]. However, other insurers have more to gain by staying put, and some are doing just that. Cigna, which currently offers plans on the public exchanges in seven states for 2016, has plans to expand.... Aetna declined to comment on UnitedHealth's decision ... However, in February Aetna's CEO Mark Bertolini ... said, 'We continue to have serious concerns about the sustainability of the public exchanges.' " (Fox Business)
Medicare Delays Plans for New Star Ratings on Hospitals After Congressional Pressure
"60 senators and 225 members of the House of Representatives [had] signed letters urging CMS to delay releasing the star ratings.... CMS told Congress it would delay release of the star ratings on its Hospital Compare website until [at least] July.... Mortality, readmissions, patient experience and safety of care metrics each accounted for 22 percent of the star rating, while measures of effectiveness of care, timeliness of care and efficient use of medical imaging made up 12 percent in total." (Kaiser Health News)
[Guidance Overview] Section 1332 Waivers for State Innovation and Medicaid
"Section 1332 [of the ACA] ... allows states to request waivers of Marketplace requirements in order to implement 'State Innovations' in the Marketplace. For example, a state might use an innovation waiver to expand the minimum coverage requirements for health plans... The ACA sets out four basic 'guardrails' for use of section 1332 authority. The December 2015 [CMS] Guidance elaborates on these limits: [1]The section 1332 project must cover a number of people comparable to existing coverage.... [2] The section 1332 project must not reduce affordability of coverage.... [3] The section 1332 project must provide benefits at least as comprehensive as existing benefits.... [4] The section 1332 project must be deficit neutral for the Federal budget." (National Health Law Program [NHeLP])
CFOs Say Employee Health Is Strategic Business Investment, But More Tools Needed to Evaluate Its Return
"For many CFOs, attracting, retaining, and motivating performance trumps lowering costs.... There is also a focus on improving individual health through helping enrollees be better health care consumers and better manage their health with wellness programs, linking premiums to certain lifestyle factors, and offering financial incentives for wellness programs.... [O]nly 6% of CFOs are measuring a return on these investments in their health benefits and only 23% measure any outcome at all." (Grooms Benefit Solutions)
Responses to Court's Proposal for Zubik v. Burwell Still Show a Gap
"The final round of briefs in reaction to the Court's own idea for a possible compromise have now been filed ... [T]he non-profits said that the government was clinging too much to the idea, objectionable to them, that they must take a specific step to gain a separation from the process of providing contraceptives, and the government said that the degrees of separation that the non-profits demand from the source of contraceptives simply would not work in the real world of health insurance and state laws governing plans." (SCOTUSblog)
[Official Guidance] Text of DOL ACA FAQs, Part 31: Certain Preventive Services, Mental Health Parity, and Women's Health
12 questions and answers covering: [1] Coverage of Food and Drug Administration (FDA)-approved contraceptives; [2] Rescissions; [3] Out-of-network emergency services; [4] Coverage for individuals participating in approved clinical trials; [5] Limitations on cost-sharing under the [ACA]; [6] Mental Health Parity and Addiction Equity Act of 2008; and [7] The Women's Health and Cancer Rights Act. (Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
Express Scripts Countersues Anthem in Contract Dispute
"Express Scripts said it made five separate proposals to Anthem between June 2015 and March 2016 that would have reduced Anthem's costs by a range of $2 billion to $2.8 billion during the remainder of the contract. Express Scripts said its proposals included 'billions of dollars in additional value' if Anthem agreed to implement more restrictive prescription drug benefits, such as narrower drug formularies and pharmacy networks, to gain better rebates from drugmakers and pricing from pharmacies." (The Wall Street Journal; subscription may be required)

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