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Health plans - design


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Employers Plan to Expand Use of Onsite Health Centers
"Nearly four in 10 (38%) large U.S. employers with onsite health facilities plan to add new centers over the next two years ... A majority of the 120 responding employers that already have onsite or near-site health facilities, or are planning to implement them, share these objectives for their centers: increase productivity (75%), reduce health care costs (74%) and improve convenient employee access to health care services (66%). Nearly all centers also offer a similar range of primary care services. Immunizations (99%), care for acute conditions such as upper respiratory and urinary tract infections (99%), and blood draws (95%) top the list." (Towers Watson)
[Guidance Overview] Late to the Party: EEOC Proposes Wellness Program Regs
"Discussed [in this article] are some of the typical wellness program designs and the issues raised for those programs under the EEOC Wellness Rules. One key concern under these rules is whether the program is part of an employer-sponsored group health plan. Also, the rules primarily cover programs that ask questions about a disability or require a medical examination.... [T]he EEOC Wellness Rules often will require changes [in order for the plan] to remain compliant with the ADA." (McGuireWoods LLP)
[Opinion] Midwest Business Group on Health Comment Letter to IRS on 'Cadillac Tax' (IRS Notice 2015-16) (PDF)
"The Cadillac tax is a unique revenue generating mechanism that presumably targets excessively generous employer-sponsored health insurance packages, thereby increasing incentives for the prudent and efficient use of care. The tax is not intended to work at cross purposes with the general concept of employer-sponsored insurance, undermine the overall movement toward consumer directed care or hinder an employer's ability to offer cost effective strategies for improving the health and wellbeing of their workforce. The regulatory implementation of Section 4980I must serve these narrowly tailored objectives." (Midwest Business Group on Health [MBGH])
Five Things You Need to Know About Medicare
"[1] Medicare is not a 'one size fits all' program.... [2] Medicare is not free! ... [3] Medicare does not cover all of your possible health care needs.... [4] You risk a possible penalty if you do not sign up for Medicare once you are eligible.... [5] There are special rules you need to know if you have health insurance through your employer at the time you are eligible for Medicare." (Women's Institute for a Secure Retirement [WISER])
Implications of Proposed Changes to the ACA in Response to King v. Burwell (PDF)
5 pages. "A temporary extension of premium subsidies would only delay the market disruption. Eliminating the individual mandate could threaten the viability of the health insurance market. Depending on the extent of other ACA changes, allowing for insurance to be sold across state lines could result in adverse selection, but also could increase competition. Allowing for association health plans (AHPs) also could raise adverse selection concerns." (American Academy of Actuaries)
[Opinion] Preventive Care Does Not Want to Be 'Free'
"Women are clearly not responding solely to financial incentives for screening. Under Obamacare's Essential Health Benefits, osteoporosis screening is only indicated as 'free' preventive care for women over 60 with certain risk factors. For women on Medicare (that is, most women 65 and older), screening is 'free'. And yet, the actual incidence is upside down." (National Center for Policy Analysis Health Policy Blog)
[Guidance Overview] Compliance Issues for Wellness Plans (PDF)
8 pages. "This [article] covers ... [1] State of the nation for employer-sponsored wellness plans; [2] Health Insurance Portability and Accountability Act's (HIPAA's) non-discrimination rules; [3] Americans with Disabilities Act (ADA); [4] Genetic Information Non-Discrimination Act (GINA); and [5] State law concerns." (Marsh & McLennan Agency LLC)
[Guidance Overview] New Agency FAQs May Require Changes to Health Plan Pharmacy Coverage of Preventive Care Services (PDF)
"A plan may use cost-sharing to encourage the use of generic pharmacy items rather than brand name items. But if a plan does impose cost-sharing or medical management techniques, it must have an accessible, transparent and expedient exceptions process. Also, if a provider recommends a particular contraceptive service or item based on medical necessity, the plan must defer to the provider's determination and cover it without cost sharing." (Buck Consultants at Xerox)
[Guidance Overview] FAQs 'Clarifying' Preventive Care Services in Fact Break Some New Ground (PDF)
"The new FAQs create some confusion about whether, and in what circumstances, group health plans and health insurance issuers may continue to use their definition of medical necessity. Historically, group health plans and health insurance issuers, and not attending providers, have defined medical necessity. The new FAQs can arguably be seen as part of a recent trend in the Departments' guidance to defer to providers, rather than to plans and issuers, in determining medical necessity." (Groom Law Group)
Antitrust Lawsuits Target Blue Cross and Blue Shield
"Blue Cross and Blue Shield health insurers cover about a third of Americans, through a national network that dates back decades. Now, antitrust lawsuits advancing in a federal court in Alabama allege that the 37 independently owned companies are functioning as an illegal cartel.... The suits, which name all of the Blue Cross and Blue Shield companies as defendants as well as the Blue Cross Blue Shield Association, have already survived the insurers' first major legal challenge." (The Wall Street Journal; subscription may be required)
Characteristics of the Population With Consumer-Driven and High-Deductible Health Plans, 2005-2014
"CDHP enrollees were less likely than those with traditional coverage to be between the ages of 21 and 34 in 2014, and more likely to be ages 45-54. CDHP enrollees were more likely than traditional-plan enrollees to be in households with $150,000 or more in income in every year except 2006, 2009 and 2010. They were also more likely to be in households with $100,000-$149,999 in income in most years. They were roughly twice as likely as individuals with traditional coverage to have college or postgraduate educations in nearly all years of the survey." (Employee Benefit Research Institute [EBRI])
Early Marketplace Enrollees Were Older and Used More Medication Than Later Enrollees
"Medication use may provide an early indicator of the health needs and access to care among Marketplace enrollees.... Among Marketplace enrollees ... those who enrolled earlier (October 2013-February 2014) were older and used more medication than later enrollees. Marketplace enrollees, as a whole, had lower average drug spending and were less likely to use most medication classes than the employer-sponsored comparison group. However, Marketplace enrollees were more likely to use medicines for hepatitis C and particularly for HIV." (Health Affairs)
West Coast Port Contract with Union Has Employers Covering 'Cadillac Tax'
"Under the [five-year] contract, the Pacific Maritime Association, a group of port terminal operators and shipping companies, will provide full health care benefits for members of the International Longshore & Warehouse Union, their dependents and retirees including full coverage with no premiums, no in-network deductibles or co-pays, $1 prescriptions and 100% coverage of hospital care." (The Wall Street Journal; subscription may be required)
Congress Could Revive Health Coverage Tax Credit
"Last week as part of a broader trade bill, H.R. 1314, the Senate agreed to renew the Health Coverage Tax Credit [HCTC] through the end of 2019.... Until its expiration [at the end of 2013], the HCTC paid 72.5% of health care premiums for eligible beneficiaries: individuals who lost their jobs due to foreign competition, and retirees age 55 through 64 whose pension plans were taken over by the [PBGC].... The House of Representatives is expected next week to begin consideration of the trade bill to which the renewal of the HCTC is attached." (Business Insurance; free registration required)
Measuring the Optimism, Outlook and Direction of America on Employee Benefits (PDF)
"88% of respondents feel optimistic about the future; 75% feel 'in control' of their lives today. Yet, regarding their financial futures, less than one in five feel very secure, and only 18% are confident they could cover their current expenses in the event of a major injury or illness.... Nearly 95% of employees agree they are more likely to enroll in benefits they feel familiar with and educated about.... About half (49%) of surveyed employees identified cancer as their top health concern. Yet, enrollment in benefits like critical illness and accident insurance remains low." (Lincoln Financial Group)
[Guidance Overview] EEOC Proposes Clarification of Application of ADA to Employer Wellness Program Incentives
"The Proposed Regulation clarifies that significant incentives may be offered to group health plan participants to encourage and reward participation in wellness programs without violating the ADA. However ... the Proposed Regulation imposes limits that would prohibit many employer wellness programs that the Joint Regulations currently permit and imposes a new notice requirement on employers." (Blank Rome LLP)
Individual Coverage Outpaces Small Business-Sponsored Health Insurance in California
"[E]nrollment in California's small business market in 2014 dropped by 11% to 2.1 million enrollees. Meanwhile, enrollment in the individual market increased by 47% to 2.18 million ... While there is no historical data for comparison, the numbers appear to mark the first time that the state's individual market has outpaced small business enrollment[.]" (California Healthline)
Quality Now Trumps Quantity in Stats on Uninsured
"For years, the Current Population Survey conducted by the U.S. Census Bureau overestimated the number of people without health insurance. Last year, the Census Bureau revised the survey to correct the error, which was likely caused by the way the government asked Americans about their coverage. The fix ... should produce more-accurate estimates. But responses obtained with the new methodology aren't compatible with responses collected using the previous approach, making it harder to examine uninsured rates over the years at a crucial moment -- as Americans try to gauge the success of the Affordable Care Act." (The Wall Street Journal; subscription may be required)
[Official Guidance] Text of Agency FAQs on ACA Implementation (Part XXVII): Limitations on Cost-Sharing, and Provider Nondiscrimination
Limitations on Cost Sharing under the Affordable Care Act

"In the final HHS Notice of Benefit and Payment Parameters for 2016 ..., HHS clarified that under section 1302(c)(1) of the [ACA], the self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or in coverage other than self-only.... [T]he Departments received questions regarding the application of the clarification to self-funded and large group health plans [and] are issuing the following FAQs ...

Q1. Does PHS Act section 2707(b) apply this requirement to all non-grandfathered group health plans? Yes.... Q2. Does the clarification of section 1302(c)(1) of the [ACA] apply for plan or policy years that begin in 2015? No. The Departments will apply this clarification only for plan or policy years that begin in or after 2016. Q3. Does the clarification of section 1302(c)(1) of the [ACA] apply to self-only coverage or other coverage that is not self-only coverage under a high-deductible health plan (HDHP) as defined at section 223(c)(2) of the Internal Revenue Code? Yes....

Provider Nondiscrimination

On April 29, 2013, the Departments issued FAQs which addressed, among other issues, provider nondiscrimination requirements under PHS Act section 2706(a).... The House Committee on Appropriations subsequently [directed CMS] to provide a corrected FAQ or provide an explanation. The Departments are issuing the following FAQs in response ...

Q4. What is the Departments' approach to PHS Act section 2706(a)? ... Until further guidance is issued, the Departments will not take any enforcement action against a group health plan, or health insurance issuer offering group or individual coverage, with respect to implementing the requirements of PHS Act section 2706(a) as long as the plan or issuer is using a good faith, reasonable interpretation of the statutory provision.... Q5. Does Q2 in FAQs About Affordable Care Act Implementation Part XV continue to apply? No. [It] is superceded by this FAQ[.]"

(Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])
The Rise of Healthcare Provider-Sponsored Health Insurance
"With the ACA's mandate to control healthcare costs, increasingly high deductibles and growing enrollment in ACA exchange plans, Medicaid managed care and Medicare Advantage, the insurance market is beckoning health systems. They might be able to offer a strong value proposition -- lower premiums, easier access, expanded primary care and more affordable medical bills.... Given the shift of healthcare resources to primary and preventive care, there are real, long-standing problems with the health insurance model that could be solved uniquely when the payer is owned by the provider business getting paid." (Healthcare Payer News)
Chronic Care Management Programs Have Become Standard for Health Plans
"[T]he study found that all plans, regardless of size, location, and ownership, offer programs to support members with chronic conditions. Plans typically identify those members based on claims and laboratory data, and then match them to appropriate interventions and resources based on need and risk. While internal evaluations suggest that these programs improve care and reduce cost, plans report difficulties in engaging members and providers, leading to the programs being underutilized." (RAND Corporation)
Four Words That Imperil Health Care Law Were All a Mistake, Writers Now Say
"How those words became the most contentious part of President Obama's signature domestic accomplishment has been a mystery.... The answer, from interviews with more than two dozen Democrats and Republicans involved in writing the law, is that the words were a product of shifting politics and a sloppy merging of different versions. Some described the words as 'inadvertent,' 'inartful' or 'a drafting error.' But none supported the contention of the plaintiffs, who are from Virginia." (The New York Times; subscription may be required)
Six Key Activities CFOs and CHROs Should Perform Together to Optimize Employee Benefit Programs
"Advanced Strategic Planning ... Collaborate to align HR and finance metrics with company objectives... Evaluate outsourced partnerships... Utilize technology to drive efficiencies... Measure... Educate and Value." (Grooms Benefit Solutions)
'Embedded' Out-of-Pocket Limits Might Be Required for 2016 Plan Years
"The interpretation appeared only in the preamble to the regulatory changes made by the Notice, and did not appear as an actual change to HHS' regulations. HHS stated in the preamble that the interpretation is a 'clarification' of existing rules. HHS later issued FAQs clarifying that the interpretation would apply to plan years starting in 2016. Aside from arguments about whether statements made in a preamble are binding on anyone, many would argue that HHS does not have authority to implement this provision with respect to employer plans." (Lockton)
D.C. Court of Appeals Won't Rehear Challenge to Contraceptive Coverage Accommodation
"The plaintiffs objected to [the HHS accommodation], as they believe it makes them complicit in the provision of contraceptive coverage ... The dissenters would have held that the government must accept this belief, and that its failure to do so substantially burdens the religious beliefs of these organizations. The concurring judges ... asserted that this is not a question of religious belief, but rather a legal question as to how the law operates." [Priests for Life v. HHS, No. 13-5368 (D.C. Cir. May 20, 2015)] (Timothy Jost, in Health Affairs)
GAO Report: Medicare Results from the First Two Years of the Pioneer Accountable Care Organization Model
"GAO was asked to review the results of the Pioneer ACO Model and CMS's oversight of the ACOs. In this report GAO [1] describes the financial and quality results for the first two years of the model and [2] examines how CMS oversees and evaluates the model.... GAO analyzed ACOs' expenditures, spending benchmarks, the amount of shared savings and losses, and payment amounts for shared savings or losses. GAO also reviewed relevant laws, regulations, and documents describing CMS's oversight and evaluation role and interviewed CMS officials about the agency's oversight and evaluation activities." (U.S. Government Accountability Office [GAO])
The Titanic Redux (PDF)
"We've all heard the phrase, 'Doing that is like rearranging the deck chairs on the Titanic.' The point of the phrase is to call out the disproportionality of action taken in the face of a really big problem. And so it may be when we consider three heavily promoted health care cost management techniques: [1] Consumerism / High Deductible Health Plans, [2] the Defined Contribution Approach to determining the amount of employer health plan subsidies, and [3] Private Exchanges." (Chelko Consulting Group)
[Opinion] Coalition Letter to Senators Supporting Small Group Expansion (S. 1099) Legislation (PDF)
"[We] applaud your introduction of legislation (S. 1099) maintaining the current definition of a small group market as 1-50 employees, and giving states the flexibility to expand the group size if the market conditions in their state necessitate the change.... Repealing the ACA-mandated expansion and returning to the historical role of state determination would allow flexibility and ensure a broad array of coverage options and mitigate dramatic premium increases. Expanding the small group market to include groups up to 100 at this time would reduce choice for this segment of the market.... [E]xpanding the small group market to include all groups with up to 100 employees would have an immediate impact on premiums due to new rating rules, required Essential Health Benefits, and minimum actuarial value and cost sharing requirements." (Society for Human Resource Management, U.S. Chamber of Commerce, and 17 other trade associations)
'Cadillac Tax' a Major Roadblock to Consumer-Driven Health Plans (CDHPs) and Affordable Health Care (PDF)
A two-page flier describing the Cadillac Tax, how it is assessed, and its impact on consumer-driven health plans. (Employers Council on Flexible Compensation [ECFC])
The Impact of Same-Sex Marriages on Benefit Plan Administration
"If the Court concludes that same-sex couples have a fundamental right to marriage or that states must recognize same-sex marriages lawfully performed out-of-state, then health plans that define a spouse as a member of the opposite sex will need to be amended to cover lawfully married same-sex spouses. In addition, employers would no longer be able to cherry pick the types of spousal benefits they provide and would have to make available the same benefits to same-sex married couples that they currently offer opposite-sex married couples." (Bloomberg BNA)
[Guidance Overview] Philadelphia Paid Sick Leave Law Takes Effect (PDF)
"The new law requires employers with at least 10 employees to provide paid sick leave and smaller employers to provide unpaid leave.... As Philadelphia's sick leave ordinance took effect, the state legislature was considering preempting local leave laws. The state Senate has already passed a bill (SB 333) that would apply retroactively to January 1, 2015 to prevent Pennsylvania municipalities from imposing their own sick leave requirements on businesses." (Buck Consultants at Xerox)
[Guidance Overview] ACA FAQs Address Coverage of Preventive Services
"FAQ XXVI clarifies that if a provider recommends a particular type [of contraception] as medically necessary for an individual, the group health plan must defer to the professional's determination. Medical necessity considerations include the severity of side effects, differences in permanence and reversibility of contraceptives, and an individual's ability to appropriately use the item or service." (The Wagner Law Group)
[Guidance Overview] Where There's Smoke There's Questions: Designing Compliant Wellness Programs That Target Tobacco Use
"[1] Is it acceptable to design a program where employees who use tobacco may avoid a higher insurance premium (or surcharge) only by quitting tobacco use? No.... [2] Are there any limits to the 'reasonable alternative standard' an employer can require for tobacco users to obtain the reward? Yes.... [3] Is it acceptable to design a program that restricts participation in certain health benefit options to employees who are tobacco-free (i.e., maintain a tobacco-free 'threshold' requirement for participation in certain health plans)? Generally, no.... [4] Does it matter whether an employer characterizes the different treatment of employees who use tobacco (and refuse to complete an alternative standard) and tobacco-free employees as a penalty or a reward? No." (Verrill Dana LLP)
Republican Proposals for King v. Burwell Ruling
"Top Republican legislators are pondering how to respond should the Supreme Court rule that the federal ObamaCare subsidies are illegal in 37 states (the states that didn't establish their own health insurance exchanges).... [T]hese subsidies trigger the individual and employer mandates in those states, meaning this ruling could significantly impact the way ObamaCare works. Here are a few Republican proposals for how to respond in this scenario[.]" (Health Care Lawsuits, a project of the Independent Women's Forum)
[Guidance Overview] EEOC Proposes Wellness Program Rule
"While the standard in the Proposed EEOC Rule for determining whether a program is reasonably designed to promote health is similar to the standard articulated in the FAQ guidance, the HIPAA Wellness Rule standard applies only to health-contingent programs while the standard in the Proposed EEOC Rule applies to all wellness programs, including participatory programs.... The Proposed EEOC Rule provides that offering a reasonable alternative standard and giving notice to the employee of that alternative as part of a health-contingent program under the HIPAA Wellness Rule would likely fulfill an employer's obligation to provide a reasonable accommodation under the ADA. The EEOC goes on to note, however, that the ADA requires employers to provide reasonable accommodations for participatory programs even though the HIPAA Wellness Rule does not require participatory programs to provide reasonable alternative standards." (Hodgson Russ LLP)
[Guidance Overview] Applicability of the Embedded Maximum Out-of-Pocket Limit to Large Group and Self-Funded Plans (PDF)
"Despite the lack of clarity on this issue, it appears that the Departments do intend to require large group and self-funded plans to comply with the 'embedded MOOP' requirements implemented in the [2016 Notice of Benefit and Payment Parameters]. The Departments are primarily relying on the cross-reference in section 2707(b) of the Public Health Service Act to extend the embedded MOOP requirement to large group and self-funded plans." (Groom Law Group)
31 Million People Were Underinsured in 2014; Many Skipped Needed Health Care and Depleted Savings to Pay Medical Bills
"While people buying coverage on their own are still more likely to be underinsured than those with employer coverage (37% vs. 20%), the share of people with employer insurance who are underinsured has doubled since 2003, when it was 10 percent.... 11 percent of people with employer plans and 24 percent with individual market plans had high deductibles in 2014, up from 2 percent and 7 percent respectively in 2003. People in small firms with insurance through their jobs were more likely to have a high deductible than those in larger firms (20% vs. 8%)." (The Commonwealth Fund)
[Opinion] Galen Institute Testimony to House Oversight Subcommittee Hearing Examining the Use of Administrative Actions in the Implementation of the ACA
"The Galen Institute has been chronicling changes made to the Affordable Care Act since it was enacted in 2010, and we count at least 50 changes -- 31 of them made by the administration. In addition, there have been 17 changes passed by Congress and signed into law by President Obama, and two changes made by the Supreme Court.... [This testimony] will discuss [1] examples of actions by the administration that are clearly contrary to the statute; [2] failed and successful congressional actions to provide legal authority to changing the law; and [3] additional changes only now being uncovered." (Galen Institute)
Senator Cassidy Introduces King v. Burwell Alternative
"Senator Bill Cassidy (R-LA) has introduced the Patient Freedom Act, in anticipation of the Supreme Court deciding for the plaintiffs in King v. Burwell ... If a state wants to restore the Obamacare tax credits, it would be free to do so by establishing a state-based exchange.... It would be an obvious choice to take Dr. Cassidy's other option: Receive the federal dollars and use them in a way that empowers patients, rather than the federal government. Having made that choice, the state can then take one of two paths. It can either choose individual tax credits deposited in patients' Health Savings Accounts (HSAs) or per capita block grants." (National Center for Policy Analysis Health Policy Blog)
[Opinion] Rising Deductibles Will Make Underinsurance Worse
"[S]ince 2003, the category with the most comprehensive coverage -- employer-provided coverage -- has doubled the rate of underinsurance increasing from 10% to 20%. The greatest contributing factor has been the increase in the use of high deductibles." (Physicians for a National Health Program [PNHP])
Promoting Wellness Takes More Than Incentives
"Employers that did not use incentives reported lower participation rates -- a median of just 20 percent of employees. With the use of incentives, median participation rates increased to 40 percent. Employers offering rewards of more than $100 reported participation rates of 51 percent, compared with 36 percent for those with smaller rewards. Employers offering comprehensive programs reported participation rates of 59 percent, and participation in these programs was less sensitive to the types of incentives provided." (Society for Human Resource Management [SHRM])
[Official Guidance] Text of OPM Final Regs: Federal Employees Health Benefits Program -- Subrogation and Reimbursement Recovery
"[OPM] is issuing a final rule to amend the Federal Employees Health Benefits (FEHB) Program regulations to reaffirm the conditional nature of FEHB Program benefits and benefit payments under the plan's coverage as subject to a carrier's entitlement to subrogation and reimbursement recovery, and therefore, that such entitlement falls within the preemptive scope of the FEHA Act. FEHB contracts and brochures must include, and in practice already include, a provision incorporating the carrier's subrogation and reimbursement rights, and FEHB plan brochures must contain an explanation of the carrier's subrogation and reimbursement policy." (Office of Personnel Management [OPM])
Aetna Fined for Violating Autism Coverage Law
"Aetna Life and Health Insurance will pay up to $4.5 million to settle claims they failed to cover diagnosis and treatment of autism spectrum disorders. [Missouri] Gov. Jay Nixon announced the settlement Tuesday, which includes the state's largest fine ever for insurance law violations.... In the settlement, Aetna admitted that it failed to offer autism coverage in some cases.... Aetna also admitted it violated the autism mandate in 2012 and paid a $1.5 million fine under a settlement agreement, which required it to undertake a full and complete audit to ensure compliance. Aetna admitted it did not perform the full compliance audit." (Courthouse News Service)
Essential Health Benefits: List of the Largest Three Small Group Products by State, Updated May 19, 2015 (PDF)
"This document provides information to facilitate States' selection of the benchmark plans that will serve as the reference plan for the essential health benefits (EHB). Using data from HealthCare.gov and States, this document provides a list of the three largest small group insurance products ranked by enrollment in the first quarter of 2014 for each State. In addition, we are providing a list of the three largest nationally available Federal Employee Health Benefit Program (FEHBP) plans, which is another benchmark option under 45 CFR 156.100(a). We are also providing the single largest Federal Employees Dental and Vision Insurance Program (FEDVIP) dental and vision plans respectively, based on enrollment in the first quarter of 2014." (Center for Consumer Information and Insurance Oversight [CCIIO], Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
California Pressured to Explain Why It Revoked Blue Shield Not-for-Profit Status
"The California Franchise Tax Board decided in August that Blue Shield of California, the state's third-largest health insurer, no longer qualified for exemption from state taxes as a not-for-profit company. The decision was noted in government records but the public didn't hear about it until March this year when a newspaper reported the change.... Blue Shield of California covers about 3.4 million people, making it the state's third-largest health insurer behind not-for-profit Kaiser Permanente and for-profit Anthem. Blue Shield, with about 5,000 employees, reported $13.6 billion in revenue last year." (Kitsap Sun)
Achieving Medication Adherence Through Value-Based Health Plan Design (PDF)
"Five main features of value-based insurance design plans were found to be associated with higher rates of medication adherence: [1] Plans that provide more generous coverage; [2] Plans that target high-risk patients; [3] Plans that offer wellness programs; [4] Plans that do not offer disease management programs; [5] Plans that make the benefit available only for medication order by mail." (Robert Wood Johnson Foundation)
[Opinion] American Bankers Association HSA Council Comment Letter to IRS on 'Cadillac Tax' (PDF)
"[T]his ability to use your own money as you see fit is what constitutes ownership and ownership has to mean something; it can't be the case that the excise tax rules lump HSAs into the same category as every other product, because HSAs are the only product where someone other than the employer owns a portion of the dollars being counted.... [T]he IRS has the necessary discretionary authority to characterize employee contributions to the employee's HSA, even if facilitated by the employer through Section 106 authority, as 'excludable' without also being included in the definition of 'applicable coverage' precisely because employers don't own any of the money in an employee's HSA." (American Bankers Association Health Savings Account Council)
[Opinion] ECFC Comment Letter to IRS on 'Cadillac Tax' (Notice 2015-16) (PDF)
"The Agencies should confirm in final guidance that limited scope vision and/or dental coverage is exempt from the Excise Tax when self-funded; confirm the application of this exemption to consumer-directed benefit arrangements (FSAs and HRAs); and expand application of the exemption to exclude any HSA-compatible (i.e., limited purpose) FSA or HRA.... [T]he guidance should clarify that employer contributions to an HSA are not included in the Excise Tax determination unless the HSA is a group health plan ... The guidance should clarify that voluntary supplemental excepted benefit coverage should not be included (even when funded on a pre-tax basis) unless the arrangement would be part of a Section 5000 group health plan.... Salary reduction contributions to consumer-directed arrangements FSAs and HSAs should not be counted for purposes of determining the Excise Tax." (Employers Council on Flexible Compensation [ECFC])
Uninsured Rate for Americans Ages 50-64 Dropped 31 Percent Since December 2013 (PDF)
"[T]he share of Americans ages 50 to 64 without health insurance fell by nearly a third, from 11.6 percent to 8.0 percent, between December 2013 and December 2014. Overall, the number of 50- to 64-year olds with health coverage increased by approximately 2.2 million between December 2013 and December 2014.... The 27 states that chose to expand Medicaid eligibility as of December 2014 saw the largest drop in the uninsured rate among the 50- to 64-year-old age group, from 9.8 percent in December 2013 to 5.5 percent in December 2014. States that did not expand their Medicaid programs saw a smaller decrease in their uninsured rate among this age group, from 13.8 percent to 11.0 percent." (AARP Public Policy Institute and Urban Institute)
[Guidance Overview] Crediting Employees for Hours of Service When No Work Is Performed, and Keeping Employees on Your Health Plan When They No Longer Work
"[This article looks] specifically at what an employer must count as an hour of service during an employee's measurement period to ascertain whether that employee is, in fact, a full-time employee. Once full-time status is confirmed in any given situation, [the authors address] the conditions of employment that would require that an employee remain covered under your health plans." (Benefit Revolution)
[Guidance Overview] The ACA's 'Toyota Tax'
"If you are an employer, you might ask, 'How do we determine the value of the coverage that we are providing?' The answer is: That's a great question ... It appears that the final regulations are likely to require an employer to look at the coverage in which the employee is enrolled (rather than the cheapest available), and then use rules similar to those that apply for determining the 'applicable premium' for COBRA to determine the cost of that coverage." (McAfee & Taft)
Change to Mammogram Guidelines Could Lead to Coverage Shift
"Millions of women could lose access to free mammograms under changes to breast cancer screening guidelines that influence insurers ... [This] analysis is based on an update to breast cancer screening recommendations proposed by the U.S. Preventive Services Task Force, a group of medical experts whose work guides health care standards and policy. The public comment period on the proposal expires Monday." (National Public Radio)
Federal District Court Finds Retiree Health Plan's Lifetime Limit Did Not Violate the ACA
"The court was not persuaded by the plaintiff's argument that Congress repealed ERISA's retiree plan exception by implication when it enacted the ACA. The court reasoned that under ERISA's retiree plan exception, the provision cited by the plaintiff involving conflicts between the ACA's changes to the PHSA (as added to ERISA) and ERISA's pre-ACA group health plan requirements, did not apply to retiree-only plans." [King v. Blue Cross and Blue Shield of Illinois, No. 3:13-CV-1254-CAB-JMA (S.D. Cal. May 13, 2015)] (Practical Law Company)
[Opinion] U.S. Chamber of Commerce Comments to IRS on Section 4980I: Excise Tax on High Cost Employer-Sponsored Health Coverage (Notice 2015-16) (PDF)
"We urge Treasury and the IRS to carefully promulgate rules that only impose the tax on the plans that Congress intended -- the excessively generous group health plans -- and not group health plans that merely provide the minimum required level of coverage.... [As] the law was being enacted, an analysis by the Joint Committee on Taxation estimated that only a small subset of plans would be affected by the tax. Instead, roughly 30 percent of all employers will be subject to the tax in 2018 and between 50-60 percent will be hit in 2022." (U.S. Chamber of Commerce)
[Guidance Overview] HHS Guidance Reinforces Application of Self-Only Cost-Sharing Limitation to Family HDHP
"Issuance of this FAQ guidance seems to reinforce HHS's position, but some have questioned whether this interpretation applies to all plans -- or only to fully insured plans intended to be offered as qualified health plans (QHPs) in the individual or small group market. Support for narrower application arguably may be found in the structure of the guidance (which begins by explaining how the embedded limit is reflected in the application for QHPs), as well as its language (which appears to focus on 'issuer' compliance more than the March FAQ), combined with removal of the March FAQ from the HHS website." (Thomson Reuters / EBIA)
EEOC Proposed Rules on Wellness Incentives Welcomed After Prior Enforcement Actions
"Despite the uncertainty that exists between the HIPAA and ADA rules, employers continued to add incentives in 2014 to encourage participation in health-related programs -- or even to reward employees for meeting their health goals. But the practical implications of the EEOC proposal that limits incentives to 30% may be minimal. Most employers use incentives that are well below the maximum, and very few employers intend to increase incentives to the maximum." (Mercer/Signal)
[Opinion] Business Roundtable Comment Letter to IRS on Excise Tax on High Cost Employer-Sponsored Health Coverage
"We strongly believe that the impact of this tax will have broader implications than first anticipated by the Joint Tax Committee (JTC) and have been provided information that as many as 25 percent of employers' plans may be subject to the tax.... [T]he regulatory structure must acknowledge three variables that restrict employers' ability to avoid the tax. First, there are certain mandatory benefit offerings in the law that cannot be avoided. Second, there are geographic and age variations in various employer plans that make avoidance more difficult. Third, employers use and value the flexibility allowed under ERISA to design, offer and administer unique plans to their employee population." (Business Roundtable [BRT])
[Opinion] ERIC Urges IRS to Consider Impact to Employers and Employees When Addressing the 'Cadillac Tax'
"ERIC ... recommends that the IRS and Treasury: [1] Provide a two-year transition period ... [2] Narrow the definition of the types of health benefits that are subject to the tax ... [3] Create a safe harbor that treats plans fairly across the country and does not penalize plans with a large number of older workers or who ... live in a region of the country with high medical costs." (The ERISA Industry Committee [ERIC])
The Road to Healthcare Benefit Taxation
"If PPACA's Cadillac Tax remains in place as it is currently written, this [graphic provides a] snapshot of how it will eventually tax more and more of your health plan over time." (Milliman, via Benefit Revolution)
Feds Say That In Screening Colonoscopies, Anesthesia Comes With No Charge
"Although the health law made it clear that the colonoscopy itself must be free for patients, it didn't spell out how anesthesia or other charges should be handled. That lack of clarity allowed insurers to argue at first that if polyps were identified and removed during the colonoscopy, the procedure was no longer a screening test and patients could be billed. In 2013, regulators clarified that patients couldn't be charged for polyps removed during a screening colonoscopy because it was an integral part of the procedure. With this week's guidance, the government has made it clear that consumers don't have to pick up the tab for anesthesia during a colonoscopy either." (Kaiser Health News)

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