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Health plans - design


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HELP Committee Hearing: Examining Job-Based Health Insurance and Defining Full-Time Work
Recording of hearing held Jan. 22, 2015. Witnesses: Dr. Betsy Webb, Superintendent, Bangor School Department, Bangor, ME; Andrew F. Puzder, Chief Executive Officer, CKE Restaurants, Carpinteria, CA; Dr. Doug Holtz-Eakin, President, American Action Forum, Washington, DC; and Joe Fugere, Founder, Tutta Bella Pizzeria, Seattle, WA. (Committee on Health, Education, Labor and Pensions, U.S. Senate)
Who Maxes Out on Health Savings Accounts? (PDF)
"Overall, 15 percent of all accounts had received the maximum contribution.... HSAs with employer contributions were less likely than those without employer contributions to receive the maximum contribution. In 2013, 14 percent of HSAs with an employer contribution received the maximum contribution, compared with 20 percent of accounts without an employer contribution. Accounts belonging to individuals with distributions from their HSA for claims were more likely than those without such distributions to have received the maximum contribution in 2013." (Employee Benefit Research Institute [EBRI])
Statement by Caesar's Entertainment's CEO to Senate HELP Committee Hearing on Employer Wellness Programs
"Employer-sponsored wellness programs are an ensemble of information, support and incentives designed to help participants improve their health and receive greater value. In return for participation, employers provide better and more affordable care. Wellness programs are ideally suited to address the emergent epidemic in chronic diseases, which exact a terrible toll on people's lives, but are among the most easily preventable and manageable of conditions." (Business Roundtable [BRT])
State-Level Trends in Employer-Sponsored Health Insurance (PDF)
83 pages. "During the post-recession period (2008/2009 to 2012/2013), we found that ... fewer workers were employed in firms that offered [employer-sponsored insurance (ESI)], fewer employees were eligible for coverage, and fewer employees took up coverage when eligible. Part-time workers and those in small firms experienced the greatest declines in ESI coverage in the post-recession period, which occurred on top of existing lower rates of ESI coverage for those workers." (State Health Access Data Assistance Center)
Testimony of Catherine Baase, M.D. to Senate HELP Committee Hearing on Employer Wellness Programs (PDF)
"Success in engaging the business community, with appropriate actions as part of a broad societal strategy to improve health, is an imperative. To have optimal impact, employers need to have a comprehensive health strategy. The insight and business case for employer involvement in health has evolved. The health of employees and the communities in which the business operates have connection to multiple business/ employer priorities. It is possible to have a significant impact on the health of the employees through corporate health strategies and programs." (American Benefits Council)
11 Diverse Organizations File Amicus Briefs Supporting ACA in King v. Burwell
"At least 11 groups representing a diverse set of stakeholders filed briefs ... expressing the shared belief that Congress always intended to bring affordable health insurance to people in every state -- and that the language of the ACA reflects that intent.... Here's a quick look at some of the individuals and groups who filed, along with the constituencies who would suffer if the Supreme Court rules in favor of withdrawing premium tax credits in states with federally facilitated marketplaces." (Families USA)
[Guidance Overview] Recent Changes to Ohio Insurance Laws Bring Them Into Line with Federal Rules for Health Plans (PDF)
"Lowers to 26 (from [28] the age to which health insurance coverage must be extended, upon the request of the insured, under certain health policies or plans that provide coverage to an insured's unmarried dependent children ... Increases to 30 (from  25) the minimum number of hours that an eligible employee works in a normal work week for the purposes of the law governing small employer health benefit plans.... Increases the potential length of one-time, limited duration health insurance policies, from policies that are not longer than six months to policies that are less than 12 months." (Ohio Legislative Service Commission)
Health Insurers May Be Finding New Ways to Discriminate Against Patients
[A]advocates say ... some insurers are placing high-cost medications for chronic conditions into the highest-priced tiers of the drugs they cover, which would force patients to pay potentially thousands of more dollars out of pocket for essential medications.... A new analysis published in the New England Journal of Medicine suggests that is the case. Of 48 exchange health plans Harvard School of Public Health researchers analyzed, they identified 12 plans that appeared to discriminate against HIV patients." (The Washington Post; subscription may be required)
ACA Users Are No Sicker Than Those on Commercial Exchanges
"First year data showed that newly-insured members were scheduling PCP, women's health and preventive care visits at a much higher percentage than commercially-covered members. Prior to Obamacare, preventive visits were likely a low-priority for the uninsured, but now that these services are free under the new law, more enrollees are taking advantage of their ability to access care.... It's possible that over time, a correlation may emerge between preventive visits and increased referrals for specialty care, so these patterns will need continual monitoring." (William Gallagher Associates)
Is It Time to Update Your Cafeteria Plan?
"The IRS has recently issued Notice 2014-55 which expands the circumstances under which a participant may make a mid-year revocation of his election to participate in an employer sponsored health plan and elect coverage under a plan offered on the Health Insurance Exchange.... The expansion of the modification rules does not apply to elections under flexible spending accounts.... For plan years beginning in 2015, the cap on salary reduction contributions has increased to $2,550.... All cafeteria plans should be reviewed to reflect the Federal recognition of same sex-marriages.... Finally, employers should consider allowing a $500 carry over for a health FSA for contributions that are not reimbursed in the plan year in which deducted (and any applicable grace period)." (Clifton Budd & DeMaria, LLP)
Industry Group to Back Results-Focused Healthcare Payments
"A coalition of some of the nation's largest health care systems and insurers vowed on Wednesday to change the way hospitals and doctors are paid -- placing less emphasis on the sheer amount of care being delivered and more on improving quality and lowering costs.... The private coalition includes, among others, Partners HealthCare, the powerful Boston health system that oversees Brigham and Women's and Massachusetts General hospitals; Ascension, the nation's largest Catholic and nonprofit health system; Aetna, a national for-profit insurer; and Health Care Service Corporation, which operates five state Blue Cross plans." (The New York Times; subscription may be required)
CBO Now Says 10 Million Will Lose Employer Health Plans Under ACA
"Thanks to ObamaCare, the CBO now expects that 10 million workers will lose their employer-based coverage by 2021. This finding stands in sharp contrast to earlier CBO projections, which at one point suggested ObamaCare would increase the number of people getting coverage through work, at least in its early years. The budget office has, in fact, increased the number it says will lose workplace coverage every year since 2011." (Investor's Business Daily)
Health Savings Accounts and Health Reimbursement Arrangements: Assets, Account Balances, and Rollovers, 2006-2014 (PDF)
"The average account balance was $2,077 in 2014, up from $1,356 in 2008. An increasing number of individuals have held their account for three or more years. One-quarter (27 percent) had held their account for three to four years, up from 19 percent in 2008. Thirteen percent had held their account five or more years, up from 4 percent in 2008." (Employee Benefit Research Institute [EBRI])
Second Circuit Affirms that Health Plan's Same-Sex Spouse Exclusion Does Not Violate ERISA
"On December 23, 2014, the U.S. Court of Appeals for the Second Circuit upheld the District Court's dismissal of plaintiffs' claims alleging that the same-sex spouse exclusion in the employer's self-insured medical plan violated Section 510 of [ERISA] and also dismissed plaintiffs' breach of fiduciary duty claim under Section 404 of ERISA.... Employers considering such an exclusion for their self-insured plans should note that the decision is expressly limited to consideration of the ERISA claims and both the District Court and Second Circuit declined to address whether the exclusion is constitutional or valid under any other federal or state law." [Roe v. Empire Blue Cross Blue Shield, No. 14-1759-CV (2d Cir. Dec. 23, 2014; unpublished)] (Benefits Bryan Cave)
[Guidance Overview] Proposed Regs Address Wraparound Coverage (PDF)
"[One] alternative could be of interest to employers who want to provide alternative coverage to part-timers and/or early retirees. Employers are not subject to ACA assessments for part-time employees or early retirees who receive subsidized marketplace coverage... [Another] alternative can be offered to full-time employees and could be of interest to small employers (under 50 full-time employees) who want to offer wraparound coverage to full-time employees and who are not subject to the employer shared responsibility requirements and assessments." (Buck Consultants at Xerox)
[Opinion] Ending Subsidies in Marketplace States Would Hurt Diverse Group
"Of those losing subsidies and becoming uninsured: 81 percent are full- or part-time workers; 62 percent live in the South; 61 percent are white, non-Hispanic; and 60 percent have incomes below twice the poverty line.... One reason why many of the people losing tax credits would end up uninsured is that they don't have an offer of employer coverage." (Center on Budget and Policy Priorities)
HHS Sets Goals and Timeline for Shifting Medicare Reimbursements from Volume to Value
"HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments." (U.S. Department of Health and Human Services [HHS])
Supreme Court Rejects Presumption of Lifetime Health Benefit Vesting, Calling for Analysis Under Ordinary Contract Principles
"Because the Court explicitly declines to apply ordinary principles of contract law to the contract before it, it is not so clear how the case will end up. The parties both argued strenuously that ordinary principles of contract law compelled a ruling in their favor, and nothing in the Court's opinion directly addresses what the court of appeals should do with that argument. But it is fair to expect the courts of appeals -- reading the 'tea leaves' of the Court's opinion -- to look carefully at the examples of misunderstood contract doctrine that the Court identifies. As it happens, all of those examples reflect incorrect interpretations that favored the employees." (SCOTUSblog)
Health Care Reform Developments in 2014, and What the ACA Will Bring in 2015 (PDF)
15 pages. Article titles: [1] Technology at Forefront of ACA-Driven Innovation; [2] Why Medicaid, HIX Plans Matter to Employers; [3] Well-being 2.0: Employers Sharpen Focus on Workforce Health; [4] The Eye of the Beholder; [5] If the ACA Is Broken, Can the GOP -- and Employers -- Fix It? [6] Health Reform Shaking Up the Market -- But Not as Expected; [7] Competitive Benefits, Consumerism Drive Change; [8] Key Differences in DB to DC Shift Seen on Health Side; [9] ACA's Spirit Can Be Seen Unfolding Across the Globe; [10] Health Benefits Still Far From a Steady State. (Mercer)
[Opinion] Moving Beyond Wellness ROI Toward Employment-Based Cultures Of Health: Part I
"Lewis et al. are to be acknowledged for fueling the need for a sharper focus on the core challenge at hand for employers: how best to improve the value of their health care investment -- that is, how to manage health care costs while improving employee health and productivity -- in ways that are sustainable. Incremental, inconsistent and, at times, maddeningly slow progress has been made. Employment-based wellness has been at the forefront, even as the need for quality improvement continues." (Health Affairs)
[Guidance Overview] Top Five Open Issues for the Cadillac Tax (PDF)
"Clarifying regulations, guidance and potential statutory changes between now and then will determine whether employers find the tax to be even more of an administrative burden than a financial one. This article discusses the top five open issues about the application of the tax and its administrative requirements, encouraging employers to use caution in making strategic decisions in advance of clarifying regulations and potential statutory change.... What Is 'Employer-Sponsored Coverage"? ... How Is the 'Aggregate Cost' Determined? ... How Will the 'Age and Gender Adjustment' Work ... Who Is a 'Coverage Provider"? ... When Is 40% Really 60%?" (Benefits Quarterly published by the International Society of Certified Employee Benefit Specialists [ISCEBS])
Striving for 'Well-Being' Amid the Wellness Backlash
"While wellness programs may prevent a few heart attacks here [and there] and make companies feel like they're improving health, [Al Lewis and Vik Khanna] argue that it is hard to justify the $10 billion wellness industry as it currently exists. They suggest that any savings employers are promised or see are more likely to be a result of the high deductible health plans so many companies have adopted in the last decade. To some extent, their arguments are vindicated by recent research." (Healthcare Payer News)
Onsite Clinics Can Reduce Costs, Improve Employee Productivity
"According to [a recent survey], the greatest return for clinic value is among employers who experience high emergency room use for non-emergency conditions, show high levels of lost time from unscheduled medical issues, or have covered populations that show low utilization of existing primary care, preventive screenings or condition management programs and services." (Wolters Kluwer Law & Business)
UnitedHealth's $43 Billion Exit from Fee-for-Service Medicine
"Value-based payments come in a variety of forms. They include: pay-for-performance programs, patient-centered medical homes and accountable care organizations, a rapidly emerging care delivery system that rewards doctors and hospitals for working together to improve quality and rein in costs. UnitedHealth said it is generating 1 percent to 6 percent in savings from its various value-based reimbursement approaches. Once rolled out by commercial and government insurers on a pilot basis, they are quickly becoming the norm." (Forbes)
Senate Hearing Discusses ACA Definition of 'Full-Time'
"Sen. Alexander started the hearing by citing a Hoover Institution study, which found that the 30-hour standard puts 2.6 million working-age Americans at risk of losing jobs and work hours. Alexander claimed many of these employees work in the hospitality, retail, and restaurant industries, and are disproportionately women. Dr. Doug Holtz-Eakin, President of the American Action Forum, testified that this number of workers at risk of having their hours reduced on account of the 30-hour definition was as high as 9.8 million." (Littler)
Federal District Court: Discounted Purchase of Individual Disability Policies by Several Employees Does Not Constitute Employer Plan Entitled to ERISA Pre-emption
"The court well understands why Provident wants to place the ERISA fence around Rosen's state law claims. It would be well worth the effort if Provident could meet its burden of proving that ERISA affords Rosen his only remedy, that is, outside of RICO.... Although Provident asserts that the various policies were issued under the same risk number, ... Provident provides no reason to give significance to this common risk number while conceding that the policies were individually underwritten ... These [and other] facts are incompatible with Provident's characterization of the policies as part of an 'employee welfare benefit program' and instead strongly suggest that the policies were separate and individual disability policies outside the embrace of ERISA. The decisions to buy policies were voluntary, and the policies were not touted by the employer." [Rosen v. Provident Life and Accident Ins. Co., No. 2:14-cv-0922-WM (N.D. Ala. Jan. 21, 2015).] Editor's note: the opinion's author is District Judge William M. Acker Jr., who has testified to Congress about his views on ERISA's application to disability claims.] (U.S. District Court for the Northern District of Alabama)
[Guidance Overview] Employer Guide for Compliance with the Mental Health Parity and Addiction Equity Act
49 pages. "This Guide was developed to provide a reference for employers who offer [mental health and substance use disorder (MH/SUD)] benefits as part of their health plans, informing them of certain key requirements of MHPAEA, the Final Rules, and other federal guidance provided to the industry and offering them a reasonable approach to MHPAEA compliance. It presumes a basic familiarity with the law and regulations and directs the reader to sources where more detailed information can be obtained and reviewed." (Milliman, Inc. in conjunction with the Partnership for Workplace Mental Health)
Supreme Court to Address Same-Sex Marriage: Effect on Employer-Sponsored Group Health Plans (PDF)
"In the context of employer-sponsored group health plans, such a decision by the Court would affect employees residing in a state that currently does not recognize same-sex marriage (and imposes a state income tax). In these states, the Court's decision ... would: [1] Eliminate the requirement for employers to impute state income tax in the amount of the employer's contribution toward a same-sex spouse's coverage, and [2] Allow employees to pay for the same-sex spouse's coverage on a pre-tax basis for state income tax purposes. The Court's decision may also lead to more state insurance mandates requiring fully insured plans to offer coverage to same-sex spouses on the same terms as opposite-sex spouses." (ABD Employee Benefits)
2015 Plan Selections by ZIP Code in the Health Insurance Marketplace
"The dataset provides the total number of health plan selections by ZIP Code for the 37 states that use the HealthCare.gov platform, including the Federally-facilitated Marketplace, State Partnership Marketplaces and supported State-based Marketplaces. These data reflect the total number of consumers who selected a plan or were automatically re-enrolled for the 2015 coverage year as of January 16, 2015.... A total of 13,725 ZIP Codes with at least 51 plan selections per ZIP Code are included in the table. These data account for 97 percent of the total 7.16 million overall plan selections in the 37 states as of January 16, 2015." (Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
ERISA Advisory Council Report: 408(b) Fee Disclosure Regs Should Be Applied to Pharmacy Benefit Manager Compensation
"In 2012, the [DOL] issued regulations requiring providers to disclose direct and indirect compensation to pension plans (Section 408(b)(2) Regulations).... [T]he Council recommends that the Department should consider making Section 408(b)(2) Regulations applicable to welfare plan arrangements with [pharmacy benefit managers (PBMs)], and thereby deem such arrangements reasonable only where PBMs disclose direct and indirect compensation, including compensation paid among related parties such as subcontractors, in a manner consistent with current Section 408(b)(2) Regulations. The Council also recommends that the Department should consider issuing guidance to assist plan sponsors in determining whether to and how to conduct a PBM audit of direct and indirect compensation." (Advisory Council on Employee Welfare and Pension Benefit Plans)
Time to Take Another Look at Stop-Loss Insurance
"Purchasing stop-loss insurance is a complicated process. Premium rates are obviously important in comparing policies, but trustees must also understand what their stop-loss insurance policies cover before they can make informed decisions regarding the best-value coverage that will help meet their objectives. This [article] reviews the basics of stop-loss insurance ... and how plan sponsors can use it to better manage the added risk and increased cost to plans that have made plan design changes to comply with the Affordable Care Act. It also looks at recent innovations and best practices for purchasing stop-loss insurance." (Segal Consulting)
[Guidance Overview] Wellness Programs Under Attack: Is Yours Legal?
73 slides from presentation to the Association of Corporate Counsel, Mid-America Chapter. Includes a detailed discussion of recent EEOC court challenges to employer wellness programs, ADA and GINA implications, and HIPAA "health factor nondiscrimination" considerations. (Utz & Lattan, LLC)
Health Insurance, Profit Sharing, Paid Vacation ... and Egg-Freezing?
"Importantly, the [EEOC] has announced that it will focus on 'pregnancy-related limitations' as part of its current strategic enforcement plan. Though it is early to say what impact the egg-freezing benefits will have at companies that have already decided to offer this benefit, the EEOC may not view the development as entirely positive." (Seyfarth Shaw LLP)
Healthcare Reform: Plan Eligibility Rules Need to Be Clearly Written
"Leaving existing plan documents and other materials (e.g., employee handbooks) to define health insurance eligibility with something vague like 'full-time employees: employees who regularly work 30 or more hours per week,' is only inviting trouble. You will no doubt have employees (with attorneys) who could make plausible arguments that they 'regularly' work 30 or more hours a week and can point to your existing written documents as evidence they should have been offered health insurance. Without clearly setting out new eligibility rules, it will be a much steeper uphill battle for the employer to defend itself." (Fisher & Phillips LLP)
Healthcare.gov Quietly Sharing Personal Data
"The government's health insurance website is quietly sending consumers' personal data to private companies that specialize in advertising and analyzing Internet data for performance and marketing ... There is no evidence that personal information has been misused. But connections to dozens of third-party tech firms were documented by technology experts who analyzed HealthCare.gov ... A handful of the companies were also collecting highly specific information. That combination is raising concerns." (Associated Press)
What's the Next Frontier in Health Reform? (PDF)
"Four key goals for reforming the health care system: [1] Securing health coverage for all ... [2] Ensuring that health coverage means access to needed care: creating a more equitable distribution of providers, ensuring that provider networks deliver meaningful access to care, and making dental coverage universally available [3] Transforming our health care system to provide care that is appropriate, high-quality, equitable, and patient-centered: paying for quality -- not quantity -- of care... [4] Reducing health care costs and making care more affordable: stopping uncompetitive provider consolidations, reducing high prescription drug costs, and making information on health care cost and quality transparent." (Families USA)
[Guidance Overview] Large Penalties Await Employers Who Reimbursed Certain Employee Health Insurance Premiums in 2014
"[W]hile the reimbursement of a more-than 2% shareholder has always been treated as wages to the shareholder ... it was not subject to payroll taxes ... Starting in 2014, however, in order for an employer to avoid the penalty the payments cannot be tied to the employee's premiums, and thus there must be no evidence of a 'plan.' As a result, the payments to the shareholders should now also be subject to payroll taxes. [The author] also of the opinion that because there can be no 'plan' under the meaning of Notice 2008-1 if the S corporation wishes to avoid the $36,500 annual penalty, the shareholder will no longer be permitted to deduct the premium on page 1 of Form 1040, but rather must take an itemized deduction on Schedule A, where it will be subject to a 10% of adjusted gross income floor[.]" (Forbes)
Risk Adjustment and Shared Savings Agreements (PDF)
"[This article discusses] the role of risk adjustment in shared savings agreements, the uncertainties involved in its potential impact, and steps that can be taken to maximize its performance in shared savings agreements. These steps can help both providers and payors have increased confidence in the process, optimizing participation and motivation by all players." (Milliman)
[Guidance Overview] CRomnibus Provisions Include Expatriate Health Plans / ACA Funding
"The act provides expat health plans with relief from the PPACA, requires additional PPACA disclosures and defunds some PPACA provisions.... The administration's 2016 budget submission must identify all funds spent by CMS on the public insurance exchanges." (Towers Watson)
[Guidance Overview] Employer Offer of Healthcare Coverage: The Multiemployer Plan Problem
"[T]he interim guidance now provides that an employer is treated as offering coverage for all employees for whom it is required to contribute to the multiemployer plan, even those full-time employees who never satisfy that plan's eligibility rules and therefore are never offered coverage. So employers who are making contributions to the plan (who arguably never have control over the plan's eligibility rules) are protected as long as they are making contributions. The fact that the plan may not actually provide coverage does not mean the employer has failed to offer the coverage." (Fox Rothschild LLP)
Half of Large Employers Are Unprepared to Fully Comply with ACA
"While the majority of large employers (70%) handle ACA compliance internally, the study revealed that these employers do not feel fully prepared to manage several critical compliance requirements, including Exchange notices (62%), ACA penalties (60%) and annual health care reporting (IRS Forms 1094/1095-C) (49%)." (ADP)
[Opinion] More Than a Third of American Workers Don't Get Sick Leave, and They're Making the Rest of U.S. Ill
"Nationally, nearly 4-in-10 private sector workers -- 39 percent -- do not have access to any sick leave at all. Zero. Zilch. None.... [T]hat amounts to 43.5 million workers who may be compelled by financial reasons to come into the office when they're sniffling, sneezing, barfing, and generally feeling under the weather, making the rest of us ill in the process.... 88 percent of private sector managers and financial workers have access to paid leave, more than double the rate among service workers (40 percent) and construction workers (38 percent)." (The Washington Post; subscription may be required)
[Guidance Overview] Proposed Rule Changes Include Limited Wraparound Coverage as 'Excepted Benefits' (PDF)
"The proposed regulations provide the ability to offer limited wraparound coverage if their benefits wrap around either: [1] 'Eligible individual health insurance' plan (e.g., a plan purchased through an exchange), or [2] A Multi-State Plan (i.e., a specific type of plan offered in the Exchange). These two mutually exclusive options on the use of wraparound coverage are outlined in [a table in this article], with the requirements to be an 'excepted benefit' listed in [a second table]." (Cheiron)
Stage Is Set: Predicting State and Federal Reactions to King v. Burwell (PDF)
11 pages. "If Congress chooses not to take corrective action following a [U.S. Supreme Court] ruling in favor of King, contingency plans for maintaining access to insurance subsidies will fall to the states.... [E]ach contingency option will vary on the time necessary for implementation, costs necessary to reach compliance and state political obstacles to overcome. Not all of these options tenably ensure continuous subsidy distribution without some disruption." (Leavitt Partners)
Will Multistate Health Plans Be Agents for Competition or for Consolidation? (PDF)
25 pages. "The [Multi-State Plan (MSP)] Program provides the Office of Personnel Management with new authority to negotiate and implement multistate insurance plans on all health insurance exchanges with in the United States.... [T]he MSP Program may lead to further consolidation of the health insurance industry despite the program's stated goal of increasing competition by means of health insurance exchanges. The MSP Program arguably gives a competitive advantage to large insurers, which already dominate health insurance markets.... [T]he MSP Program's failure to produce increased competition may motivate a new effort for a public health insurance option." (Mercatus Center, George Mason University)
Startup Health Insurance CO-OP Collapses In Iowa
"CoOportunity Health was the second largest co-op in the country in terms of membership, and one of the largest in terms of the federal funding it received.... The largest insurer by far in the state was and still is Wellmark. But Wellmark decided not to offer any plans on Iowa's health exchange, leaving just CoOportunity and one other insurer -- Coventry -- offering plans on the exchange throughout the state.... Not only were the patients sicker, but CoOportunity's leaders initially thought they would enroll about 12,000 people in Iowa and Nebraska. They got about ten times that[.]" (National Public Radio)
2014 Industry Trends Among Employer-Sponsored Health Plans
"[T]he average total cost per employee in 2014 was $9,504, of which the average employer cost was $6,276 and average employee contribution, $3,228. Government (Public Administration) health insurance plans have the highest average cost per employee at $11,329 (17.5% higher than average), with the lowest employee contribution of $2,040, which is 45% less than the average employee. Surprisingly, this already low contribution is an astounding 39.7% lower than two years ago when public employees contributed $3,051." (United Benefit Advisors)
Three Predictions for Private Exchanges: Version 2015
"The consumer learning curve will spike upward.... Employers and brokers will graduate from 'Private Exchange School' and start to deploy.... Benefits shopping technology will trailblaze, especially for self-funded plans." (The Institute for HealthCare Consumerism [IHCC])
Coming Soon to a Workplace Near You: 'Wellness or Else'
"Among the two-thirds of large companies using such incentives to encourage participation, almost a quarter are imposing financial penalties on those who opt-out ... For some companies, however, just signing up for a wellness program isn't enough. They're linking financial incentives to specific goals such as losing weight, reducing cholesterol, or keeping blood glucose under control. The number of businesses imposing such outcomes-based wellness plans is expected to double this year to 46 percent[.]" (Reuters)
Navigating the Unfriendly Skies of ERISA Reimbursement (PDF)
"After a recent Supreme Court decision, employee-benefit plan participants under [ERISA] who receive a tort recovery from a third party may face a steeper climb to protect their settlement. Learning a few strategies can alleviate some of that turbulence." (Trial)
2014 Current Population Survey Annual Social and Economic Supplement: Research Files Now Available for Downloading
"The 2014 Current Population Survey Annual Social and Economic Supplement included redesigned questions for income and health insurance coverage.... Included in these files: Public use microdata files for the approximately 30,000 addresses that received the redesigned income questions.... Public use microdata file with estimates of current health insurance coverage for the approximately 30,000 households eligible to receive the redesigned income questions." (U.S. Census Bureau)
[Guidance Overview] ACA Employer Mandate Now in Effect; Employers Beware of Whistleblower Liability
"To date, no DOL administrative tribunal has recognized a whistleblower claim based upon an adverse employment action caused by an employer's alleged failure to comply with Title I of the ACA. Indeed, an administrative law judge dismissed just such a complaint on December 19, 2014, because the mandate was not in effect at the time of the alleged protected activity or adverse employment action." [Porter v. Housing Authority of Columbus, Georgia, 2015-ACA-00001, Decision and Order Granting Respondent's Motion for Summary Decision (ALJ, Dec. 19, 2014)] (Ford & Harrison LLP)
[Opinion] NHeLP Comment Letter to CMS on Draft 2016 Letter to Issuers in Federally-Facilitated Marketplaces
10 pages. "[We] have serious concerns regarding the lack of transparency in the proposed monitoring and review process. According to the Draft Letter, the results of the review will be shared with the states and issuers. We strongly urge HHS to make the results of its compliance reviews publicly available. Consumers and other stakeholders should be able to review and evaluate for themselves QHP performance based upon HHS' compliance reviews." (National Health Law Program [NHeLP])
Popular Southern Grocery Chain to Offer Same-Sex Health Benefits
"More gay and lesbian married couples living in conservative Southern states can get health benefits -- so long as they work for Publix. The grocery chain is one of the largest in the south, with stores in three states that ban same-sex marriage: Alabama, Georgia and Tennessee. Starting in January, even employees in those states can enroll their spouses in the company's health and dental plans -- as long as they were married in a different state." (CNNMoney.com)
[Guidance Overview] Expatriate Plans Exempted from Many ACA Provisions
"Although the exemption is extensive, expatriate plans must continue to meet certain ACA requirements.... [1] The employer mandate continues to apply, but the coverage provided by an expatriate plan will be deemed to be minimum essential coverage for purposes of complying with the mandate (and for purposes of the individual mandate). [2] Reporting requirements relating to the employer and individual mandates will apply, although electronic distribution of applicable forms will be permitted without participant consent. [3] The Cadillac tax, scheduled to take effect in 2018, will apply to certain foreign nationals working in the United States. [4] If the expatriate plan covers dependents, it must generally provide coverage up to age 26." (Ballard Spahr LLP)
[Opinion] What Happened in Vermont: Implications of the Pullback from Single Payer
"From the outset, [Vermont Gov. Peter Shumlin's] team embraced an Accountable Care Organization payment strategy that would enroll most Vermonters in large hospital-based, HMO-like organizations that would be overseen by a 'designated entity' -- presumably Blue Cross. To-date, ACOs have shown little or no overall cost savings, have increased administrative costs, and have driven hospitals to merge and gobble up physician practices.... The plan never envisioned including all Vermonters in a single plan, instead retaining multiple payers." (Physicians for a National Health Program [PNHP])
Twelve Things to Know About Health Care Reform for 2015 (PDF)
"[1] Beware of Excise Taxes.... [2] One-year delay for some small employers.... [3] Fiscal year plans.... [4] Section 6055 and 6056 reporting.... [5] Tracking hours of service.... [6] Applicable large employer status... [7] Transitional reinsurance fee for self-insured plans.... [8] PCOR fee for self-insured plans.... [9] W-2 reporting of the cost of coverage.... [10] Skinny plans and minimum value... [11] Cafeteria plan election changes.... [12] Health FSA limit." (Hinkle Law Firm LLC)
Medical Debt Among Insured Consumers: The Role of Cost Sharing, Transparency, and Consumer Assistance
"The average annual deductible ... under job-based health plans exceeded $1,200 for an individual in 2014. For non-group health plans sold on new health insurance marketplaces, deductibles are even higher.... [C]onsumers were often surprised to learn how much they owed for care they thought would be covered by insurance.... Greater transparency in the details of health insurance plans cannot eliminate medical debt, but [it] can help consumers distinguish plan differences to make more informed choices and to plan ahead financially." (Henry J. Kaiser Family Foundation)
The Potential Effect of Eliminating the ACA's Tax Credits in Federally Facilitated Marketplaces (PDF)
"Enrollment in the ACA-compliant individual market, including plans sold in the marketplaces and those sold outside of the marketplaces that comply with ACA regulations, would decline by 9.6 million, or 70 percent, in federally facilitated marketplace (FFM) states. Unsubsidized premiums in the ACA-compliant individual market would increase 47 percent in FFM states. This corresponds to a $1,610 annual increase for a 40-year-old nonsmoker purchasing a silver plan." (RAND Corporation)
ACA Considerations in Mergers and Acquisitions
"The acquirer will need to consider potential operational issues following the transaction, especially those that relate to the determination of full-time employee status for purposes of the ACA employer mandate rules.... [If] the acquirer and the target each use different measurement methods for determining full-time employee status, difficulties may arise in applying those methods following the closing of the transaction." (Drinker Biddle)

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