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Health plan costs - misc

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[Opinion] Medicare for All: The Two Issues It Must Confront
"The U.S. debate will center on two issues: the relatively high prices we pay for the drugs, devices, technologies, services and facilities we use, and the medical necessity for many services provided for which evidence shows no benefit. What happens to innovation if the federal government uses its muscle to ratchet down what it pays for services and who decides what's necessary or not? And what's the administrative expense necessary to managing our $3.4 trillion expenditure? ... The issue will be whether and how primary and preventive health will be elevated in a U.S. single payer model and how specialty and long-term care are impacted long-term." (Paul Keckley)
[Opinion] Why Bernie Sanders' Single Payer Health Care Plan Is a Total Disaster
"[I]mposition of a government health-care monopoly -- be it in the form of the Medicare fee-for-service system, the British National Health Service or the Canadian health system -- has certain economic features in common. First, such a system will rely on broad-based taxation, usually in the form of some sort of payroll tax.... Second, the program costs will surely outrun the official projections.... Third, the program will not be a model of simplicity." (The Heritage Foundation)
Employers Face 4.3% Increase in U.S. Health Benefit Cost in 2018, Highest Since 2011
"Average per-employee health benefit cost is predicted to rise by 4.3% in 2018, the highest since 2011, but the long-term trend remains stable. Employers are struggling to control cost for pharmaceuticals, which will rise more than 7% next year as spending on new specialty medications skyrockets. Following the failure of repeal and replace, the excise tax on high-cost plans will go into effect in 2020 -- and with the tax threshold rising at only about half the current rate of health benefit cost, many employers will be affected." (Mercer)
States Protect Consumers Against Balance Bills
"Beginning July 1st, California is the latest state to enact consumer protection against balance billing.... California is now one of 21 states with some form of consumer protection against balance billing. Unfortunately, many of these 21 states have protections for consumers only in limited situations such as emergency care or on certain types of health plans." (Hill, Chesson & Woody)
UNC Health Care Set to Merge with Carolinas Healthcare, But Is This Good for Consumers?
"Both systems emphasized that a merger will improve patient access, create efficiencies, provide better outcomes, and lower costs.... Leading healthcare policy experts from Duke, Carnegie Mellon, and Johns Hopkins have expressed doubts that a merger of this magnitude will result in any patient savings." (Hill, Chesson & Woody)
[Opinion] Private Employers Should Demand and Share Evidence from Payment Reforms
"Employers face a collective action problem in which they seek shared evidence about which payment reforms are working, but may not individually generate it or be in a position to share it.... Employers should seek rigorous and comprehensive evidence for the impact of payment reforms to facilitate comparison across alternatives and support good decision-making. If enough employers make these demands, plans will respond by better evaluating the payment reforms they administer and better communicating the results of those evaluations." (Suzanne Delbanco, Andrew Olson, and Mark McClellan, via Health Affairs)
Impact of CSR De-Funding on Market Stability (PDF)
14 pages. "Colorado is requiring issuers to apply the CSR load to all metal levels instead of just the Silver plans.... New York is largely unaffected by these changes as the populations that would qualify for the CSR 87% and 94% plans are covered under the state's Basic Health Plan.... Oregon has proposed to allow all issuers to increase their on- and off-exchange Silver rates by the same 7.1% in the event that CSRs are de-funded.... States such as Vermont and Massachusetts have merged individual and small group markets. The impact of CSR de-funding may extend to the small group market in addition to the individual market." (Wakely Consulting Group)
Reminder: Medical Loss Rebates to Employers Must Be Handled Properly
"[Certain] insurers must send rebates to individuals and employers by September 30.... Employers will need to determine how much, if any, of the rebate they can retain, use for plan operations or return to plan participants. Employers are plan fiduciaries and therefore must make prudent determinations in the best interests of the plan participants and beneficiaries. Many employers will take a conservative view and distribute the rebates to plan participants in proportion to the amount that they paid for their coverage, and some may even choose to distribute the entire rebate to plan participants, even if that is not mandated." (Willis Towers Watson)
In Health Care, a Good Price Is Hard to Find
"The underlying problem of our health care system -- beyond the corrosive partisan politics -- is its high cost. [The author has] long understood that the lack of price transparency is one reason our system stays so expensive. It was a surprise, though, to find out that this opacity is cemented by legally binding contracts." (Kaiser Health News)
Senators Introduce Legislation to Replace Obamacare with Block Grants to States for Health Care
"The Graham-Cassidy-Heller-Johnson (GCHJ) proposal repeals the structure and architecture of Obamacare and replaces it with a block grant given annually to states to help individuals pay for health care.... The block grant is run through CHIP and is subject to a mandatory appropriation. The grant dollars would replace the federal money currently being spent on Medicaid Expansion, Obamacare tax credits, cost-sharing reduction subsidies and the basic health plan dollars."

Background materials:

(U.S. Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), Ron Johnson (R-WI) and former U.S. Senator Rick Santorum (R-PA))
[Opinion] American Academy of Actuaries Comment Letter to Senate HELP Committee on Stabilizing the Individual Health Insurance Market (PDF)
"[A]ctions that would help stabilize and improve the individual health insurance market include: [1] Continued funding of cost-sharing reduction (CSR) payments; [2] Effective enforcement of the individual mandate; [3] Enrollment outreach and assistance; [4] External stability funding (for instance, in the form of reinsurance); and [5] Avoiding actions that would increase uncertainty or threaten stability." (American Academy of Actuaries)
Senate Eyes Compromise in Insurance Subsidy Battle
"With some insurers already jumping ship because uncertainty about the future of the [ACA], lawmakers on the HELP Committee hope to vote on a bill by the end of this week intended to stabilize the individual markets. [Sen. Lamar Alexander (R-TN)] said his party and the Democrats are aligned on several key themes, including congressional approval of cost-sharing reduction payments.... Alexander said the two sides only agree in full on expanding copper plans, which could attract more people into the markets and spread risk out across insurance pools. The plans would cover less of the out-of-pocket costs in exchange for significantly cheaper premiums." (Courthouse News Service)
New Value-Based Insurance Model Aims to Turn High-Deductible Plans on Their Heads
"[H]igh-deductible health plans (HDHPs)] keep costs down by reducing the actuarial value of health plans -- meaning more of the cost burden is shifted to individuals ... HDHPs can encourage consumer behavior that is counterproductive, such as avoiding necessary medical care out of concern about costs ... MESA, on the other hand, is based on a reference-pricing model, which encourages consumers to choose service providers that offer high-quality care at a lower price. To aid that decision-making process, the model proposes a data analysis tool that will allow consumers to select providers based on quality and cost of care." (FierceHealthcare)
How Would Coverage, Federal Spending, and Private Premiums Change If the Federal Government Stopped Reimbursing Insurers for the ACA's Cost-Sharing Reductions?
14 pages. "[1] If insurers have enough time before the start of the plan year to incorporate their anticipated CSR costs into a surcharge placed on silver marketplace premiums ... silver premiums [would increase] by 23 percent in 2018.... [and] the federal government would spend 18 percent more on premium tax credits than it would have spent on tax credits and CSRs combined under current law, an additional $7.2 billion in 2018. [2] If insurers exit the marketplaces in response to the loss of CSRs ... nongroup premiums would rise by 37 percent. Eliminating the tax credits and CSRs would reduce federal spending on this assistance by $40.7 billion in 2018. [3] If lawmakers alter the ACA in response to the elimination of CSRs such that insurers are no longer required to pay CSRs to eligible enrollees, ... nongroup premiums would rise by 12 percent." (Urban Institute)
Governors Press Congress for Fast Bucks to Secure Obamacare Market in 2018
"A bipartisan succession of state governors and insurance commissioners told the [Senate Health, Education, Labor and Pensions (HELP) Committee] that there is no time for them to get their own reinsurance programs up and running in order to stabilize the market. What would help in the short term, they said, would be for the federal government to step in and do it -- temporarily.... Governors testified [on September 7, 2017] that reinsurance would lower premiums, thereby bringing young, healthy people into the risk pool and providing stability to the marketplace." (Kaiser Health News)
Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage?
"The uninsured rate among 19-to-64-year-old adults was 14 percent in 2017, or an estimated 27 million people, statistically unchanged from one year earlier. Uninsured rates ticked up significantly in three subgroups: 35-to-49-year-olds, adults with incomes of 400 percent of poverty or more (about $48,000 for an individual), and adults living in states that had not expanded Medicaid. Half of uninsured adults, or an estimated 13 million, are likely eligible for marketplace subsidies or the Medicaid expansion in their state. Four of 10 uninsured adults are unaware of the marketplaces. Adults in marketplace plans with incomes below 250 percent of poverty are much more likely to view their premiums as easy to afford compared with people with higher incomes." (The Commonwealth Fund)
Employees Poised to Spend an Average of $5,200 on Health Care in 2018
"The average health care cost increase for U.S. employees is projected to be 7.2 percent in 2018, up from 6.9 percent in 2017. Average health care costs for U.S. employees (including employee premiums and out-of-pocket costs) are projected to be $5,248 in 2018, up from $4,895 in 2017. Employee premium costs are projected to be an average of $2,678 in 2018. This is 18 percent of the total health care cost, which is consistent with cost sharing percentages over the past seven years." (Wolters Kluwer Law & Business)
[Guidance Overview] Healthcare Reform Questions and Answers for Employers (PDF)
162-page compilation of Q&As covering all aspects of the ACA. Updated through Sept. 5, 2017. (Arthur J. Gallagher & Co.)
State Insurance Commissioners Talk Reinsurance, CSR Payments at Senate ACA Stabilization Hearings
"Some common themes emerged at the first of four hearings: [1] Continue funding cost-sharing reduction (CSR) payments -- and not just for one year. [2] Invest in reinsurance programs and set up high-risk pools. [3] Reverse cuts to navigator programs and funds for marketing the individual exchanges. [5] And give states more freedom to run health insurance programs, with or without federal help." (FierceHealthcare)
GAO Report: IRS Should Mitigate Limitations of Data to Be Used for the Age and Gender Adjustment for the Tax on High-Cost Health Plans
"Starting in 2020, the [ACA] is scheduled to impose a 40% tax on high-cost health plans when an employee's annual cost of coverage exceeds a certain dollar limit. The limit may be adjusted if an employer's workforce -- based on age and gender -- is likely to have higher than average health costs. The adjustment is to be made based on the costs of the federal employee BlueCross BlueShield Standard plan, but [GAO] found that an adjustment based on this plan's costs alone may not be effective due to the relatively high costs incurred by its young members." [GAO-17-661, published and released Sept. 6, 2017] (U.S. Government Accountability Office [GAO])
[Opinion] Getting Risk Adjustment Right Is Key Under Any Individual Market Scenario
"Risk adjustment is a vital tool in preventing community rating in the individual market from causing harmful risk selection against plans and insurers' consequent risk avoidance. Effective risk adjustment lets insurers compete based on efficiency, networks, medical management, and consumer value, instead of by avoiding uncompensated risks. It also ensures that carriers can offer different levels of coverage, even though plans with the most comprehensive coverage are likely to disproportionately attract unhealthy members." (Health Affairs)
How Below-the-Radar Mergers Fuel Health Care Monopolies
"Hospitals have gone on a doctor-buying spree in recent years, in many areas acquiring so many independent practices they've created near-monopolies on physicians.... How could this happen? Where are the regulators charged with blocking mergers that have been repeatedly shown to drive up the price of health care? The answer, in many cases, is that they're out of the game." (Kaiser Health News)
Regulatory Capital Strategies in an Evolving Health Insurance Landscape (PDF)
"A health plan's required capital depends on how it contracts with providers. An effective contracting strategy can have a favorable financial effect by reducing the amount of required capital. Reduced capital can increase return-on-equity (ROE) or create available capital for other purposes." (Milliman)
[Guidance Overview] IRS Releases ACA Affordability Rates for 2018
"For 2018, the required contribution percentage has decreased to 9.56% (from 9.69% in 2017). This means that if an employee's share of the premium for employer-provided coverage (in 2018) is more than 9.56% of his or her household income, the coverage is not considered affordable for that employee and the ALE may be liable for a penalty if that employee obtains a premium tax credit through an Exchange." (The Wagner Law Group)
What Employers Can Expect with the Return of the Health Insurance Providers Fee in 2018
"[A] moratorium was placed on the fee for the 2017 calendar year. This exclusion had the desired outcome for the insurers as the fee for 2017 was scheduled to be $13.9 billion. The Health Insurance Providers Fee is scheduled to return in 2018 and is estimated to cost $14.3 billion.... The return of the fee will add roughly 3% on fully insured plans to the overall premium costs which will be a pass-through fee from the insurance companies that will hit the total premium cost for employers." (Hill, Chesson & Woody)
Administration Acts to Move Beyond Troubled Navigator Program
"The administration today announced planned action to reduce funding to a program within the so-called 'Affordable Care Act' that has repeatedly fallen short of its purpose. Obamacare's data shows that many of their navigators have been paid handsomely, yet have not delivered in enrolling the number of patients they promised." (Energy and Commerce Committee, U.S. House of Representatives)
After Years of Erosion, Mid-Size and Some Small Employers Added Health Coverage in 2016 (PDF)
12 pages. "[O]ver the last year ... there is evidence of what may be a rebound in employment-based coverage offer rates among firms with 10-999 employees. More specifically, from 2015-2016: [1] For employers with 10-24 employees, those offering health benefits increased from 48.9 percent to 49.4 percent. [2] For employers with 25-99 employees, those offering health benefits increased from 73.5 percent to 74.6 percent. [3] For employers with 100-999 employees, those offering health benefits increased from 95.1 percent to 96.3 percent. For these employers, this trend actually began a year earlier, when the offer rate increased from 92.5 percent in 2014 to 95.1 percent in 2015." (Employee Benefit Research Institute [EBRI])
How to Keep ACA Stabilization Narrow
"[W]hen people read headlines or hear about 'premiums soaring' in the ACA marketplaces, most Americans -- 76% -- they think they are hearing about their own premiums, even though the vast majority of Americans are not in the individual insurance market and are not affected.... In fact, the rest of the health system where most Americans get their coverage looks very different from the non-group market." (Drew Altman, via Axios)
How Price Transparency Can Lower Healthcare Costs
"Drug prices are expected to increase by 9.9 percent this year ... One of the main causes of frustration among consumers is in their inability to see a clear rationale for why prices are rising and what exactly they are paying for.... With the changing climate in healthcare policy, price transparency has come to the forefront as people consider how to manage their medical spending. Price transparency can help drive down healthcare costs in by increasing pressure on providers to control costs and ensure that patients receive the highest quality of care possible for the price they pay." (Jeffrey Sanginiti, for HFMA)
[Guidance Overview] The Affordability Test Is More Restrictive on Employers in 2018
"[F]or the first time, the affordability threshold has decreased in 2018 all the way back to 9.56 percent. The significant drop in the affordability threshold compared to 2017 places employers who are toeing the line of the affordability threshold in danger of being subject to a potential section 4980H(b) penalty if the price of coverage is not reduced for self-only coverage." (Accord Systems, LLC)
[Guidance Overview] California's Surprising New 'No Surprise' Health Care Billing Law (PDF)
"Despite its nickname, the law includes many surprises: it is the first law to impose pricing terms on private health care providers, dictating that [individual health professionals (IHPs)] who are not contracted with their patients' health care service plans and insurers must accept discounted rates as payment in full.... In essence, the law permits health plans and insurers to pay discounted rates to IHPs without a bargained-for exchange of benefits. Thus, payers now have no incentive to contract with IHPs." (King & Spalding)
Massachusetts Governor Signs Bill with Employer Assessments for MassHealth
"The law calls for higher employer medical assistance contributions (EMACs) from all employers with at least six employees in Massachusetts. It also imposes a new assessment on employers with workers currently receiving benefits from MassHealth or from the MA Health Connector, the Commonwealth's [ACA] exchange. The higher contributions and new assessments will take effect January 1, 2018, and continue through 2019[.]" (Willis Towers Watson)
More Are Insured Under ACA, But Have More Out-of-Pocket Costs
"Those most likely to choose a high-deductible plan are also the least able to afford unexpected medical costs: low-income Americans.... [T]hey're more likely to choose coverage with high out-of-pocket costs because those plans generally have a lower monthly premium.... [A]bout half of the estimated 20.5 million Americans who gained coverage under the ACA did so through their state's expansion of eligibility for Medicaid[.]" (
Multinational Pooling: Save Money While Improving Employee Benefits
"[S]aving money without compromising the quality of the healthcare benefits you offer your staff can be challenging. One effective way of achieving this is by implementing a multinational pooling strategy, which ... can produce average premium savings of 15%. It involves combining your group's insurance contracts for employee benefits in different countries under one financing arrangement. Not only will this create savings through leveraging scale, it will also help you to assess your employee benefits risks on a regional or global basis." (Willis Towers Watson)
How to Launch an Employee Compensation, Bonus or Benefits Plan Internationally
"Geographical differentials in remuneration arise out of market forces and laws. Wage rates run highest in rich, developed economies with high standards of living. And employee benefits dovetail with local laws.... Yet in recent decades business drivers have pushed multinationals to align or harmonize certain pay, bonus and benefits offerings internationally ... [T]oday's cross-border project teams and instantaneous internal communications motivate employers to extend certain compensation and benefits offerings across borders." (Littler)
Review of CMS Proposed 2018 Risk Adjustment Changes to CSR Plans (PDF)
"Wakely reviewed CMS' proposed 2018 risk adjustment changes to cost-sharing reduction (CSR) plans and modeled the impact of the changes based on collected 2016 data. [The] modeling with national data shows that relative risk will decrease around 10% for the 87% and 94% CSR plans while all other plans' relative risk will increase at varying levels to offset the changes to CSR plans." (Wakely Consulting Group)
Solving Healthcare's Revenue Cycle Challenges Using Technology-Enabled Communications
22 pages. "Managing overdue payments is one of the top challenges facing healthcare organizations. Patients are struggling to pay medical bills, and more than half of patients are delaying payments. High insurance deductibles and confusion regarding insurance coverage are the primary reasons patients delay healthcare payments.... Healthcare providers can maximize reimbursements by prioritizing chronic disease management." (West)
The ACA's Transitional Reinsurance Program (PDF)
"This report provides an overview of ... the transitional reinsurance program.... [The] report [1] provides background information on reinsurance and the ACA risk-mitigation programs ... [2] describes the components of the transitional reinsurance program, as well as implementation of and experience with the program ...[3] discusses questions regarding the scope of HHS's authority to administer the transitional reinsurance program, including those raised by a 2016 [GAO] report." [Report R44690, Aug. 23, 2017] (Congressional Research Service)
Self-Funded Medical Plan Can Enforce Subrogation Interest in Wrongful Death Settlement
"Following his death, [the participant's sister] brought a wrongful-death action against the Duluth Clinic for allegedly negligent treatment [and eventually] settled her claim with the Clinic.... [The settlement agreement] denied that the Fund is entitled to any portion of the settlement proceeds ... [and] acknowledges that the Fund has asserted a lien and/or subrogation claim for certain medical expenses and ... represents that she will satisfy the Fund's subrogation rights, if any. However, [she] did not reimburse the Fund ... [The court] explained that under the terms of the Plan, the Fund had a subrogation interest in 'any ... recovery' from the Clinic for [the participant's] medical expenses. Thus, the Fund could recover whatever [the sister] recovered for the medical expenses in her settlement, whether or not [she] ultimately could have recovered those expenses at trial." [Mackey v. Johnson, No. 16-1886 (8th Cir. Aug. 22, 2017)] (Roberts Bartolic)
Trump's Threats on Health Law Hide an Upside: Gains Made by Some Insurers
"[T]he continuing churn among insurers and the anxiety pervading the industry -- stirred largely by President Trump's predictions of collapse and threats to withhold critical government payments to insurers -- have obscured an encouraging fact: Many of the remaining companies have sharply narrowed their losses, analysts say, and some are even beginning to prosper." (The New York Times; subscription may be required)
Stabilizing the Individual Health Insurance Market (PDF)
23 pages. "Market stabilization proposals currently under consideration include [1] appropriating and paying for the enhanced benefits insurers provide to low-income insureds through cost sharing reductions; [2] strong enforcement of the individual mandate; [3] external funding of $15 billion per year; and [4] the elimination of the 9010 HIT fee.... [The authors] find that the cited market stabilization provisions, combined, would increase enrollment by roughly 2 million individuals, reduce average premiums by more than 20 percent, and cost relatively little, when considering federal outlays for CSR spending and APTCs." (Oliver Wyman)
ACA Cost-Sharing Reductions: A Momentary Reprieve and Ongoing Doubts
"Although stakeholders in the CSR debate -- including healthcare insurance companies that participate in the ACA exchanges and insureds who obtain health insurance coverage through the exchanges -- gladly accepted the one-month reprieve from the threat of CSR de-funding, anxiety continues and will continue until the Trump Administration reveals its long-term policy regarding future funding of CSR payments on an ongoing basis." (Sheppard Mullin)
Analysis of the 2014-2016 ACA Reinsurance and Risk Adjustment Results
"Health Care Service Corporation (HCSC) led the country in Reinsurance receipts from HHS over the three years of the program.... Anthem, Humana, Aetna, and Blue Shield of California rounded out the top five Reinsurance recipients.... [F]our out of the top five [recipients of Risk Adjustment payments] were also on the list of top recipients of Reinsurance payments.... With the exclusion of UnitedHealthcare, the top recipients of Risk Adjustment funding received amounts that were well above the industry average of $14.47 per member month." (Mark Farrah Associates)
CBO Responds to Congressman's Questions about Objectivity and the Agency's Estimates of the Effects of the American Health Care Act
"This letter provides additional details about ... [1] The steps CBO takes to ensure that its work is objective, impartial, and nonpartisan; [2] The benchmark to which the AHCA was compared and how the percentage of people insured today relates to CBO's estimates of the number under the AHCA and under that benchmark over the next decade; and [3] Why CBO and [JCT] did not provide an estimate of the average effect on premiums for people living in states that would obtain waivers from requirements for both essential health benefits and community rating under the AHCA." (Congressional Budget Office [CBO])
Retiree Health Costs Surge
"The estimate for retiree health care spending rises to an average of $275,000 per couple, excluding long-term care expenses. This is an increase of $15,000 from 2016. Health care continues to be one of the largest expenses in retirement.... And that applies only to retirees with traditional Medicare insurance coverage, and does not include costs associated with nursing home care." (Fidelity)
Wellness Programs Boost Employee Health, Productivity
"The researchers compared data for employees that participated in the health plan to employees at a different plant from the same company who weren't offered the wellness program.... Participating employees' productivity jumped by between 6 percent and 11 percent compared to those who didn't participate in the program, with the largest gains for those who improved their health. When further quantified, that figure equaled a 76 percent return on investment for the company after introducing its wellness program." (Wolters Kluwer Law & Business)
If CSRs Cease, 'Silver-Gapping' Could Benefit Some
"The subsidies are based on the cost of second-highest silver plan, and if discontinuing the CSRs leads insurers to raise premiums on only those silver plans, there could be unintended consequences. The government could end up paying more through the premium tax credit, a refundable credit that helps eligible individuals and families cover the premiums for their health insurance." (HealthLeaders Media)
2017 Benefits Strategy and Benchmarking Survey: Medical Benefits (PDF)
"Medical and drug coverage is the cornerstone of benefit offerings and key to talent recruitment and retention for nearly two-thirds (63%) of employers. Ninety- two percent (92%) agree their health benefits provide access to quality medical services, and the majority (61%) also believe employees are satisfied with their options. Seventy-one percent (71%) see these benefits as competitive within their region, industry or both." (Arthur J. Gallagher & Co.)
[Guidance Overview] IRS Updates Amounts Used to Calculate 2017 Obamacare Individual Individual Shares Responsibility Tax Penalties
"[IRS] set the monthly national average premium for qualified health plans that have a bronze level of coverage offered through Exchanges at $272 per individual and the maximum monthly national average premium for qualified health plans with a bronze level of coverage offered through Exchanges at $1,360 for a shared responsibility family with five or more members.... Taxpayers who are not enrolled in the necessary health coverage to meet the Obamacare health coverage mandate should evaluate their shared responsibility tax penalty exposure and weigh whether it makes more sense to enroll in qualifying health coverage or prepare to pay the tax." (Solutions Law Press)
Small Business Healthcare: How Employees Are Faring (PDF)
"When looking at average annual cost per employee, small businesses actually cut a better deal even compared to their largest counterparts.... Copays, deductibles, and HSA funding (when offered) are generally in line with average employers.... Small businesses are passing nearly 6.6 percent more of the costs for single coverage and nearly 10 percent more of the costs of family coverage on to employees -- and that number increases to 17.8 percent and over 50 percent more respectively when you compare small employers to their largest counterparts.... Small businesses also have higher out-of-pocket maximums, particularly for families." (United Benefit Advisers, LLC [UBA])
The Frustration of Out-of-Network Billing
"When a member receives an unexpected balance bill, most often the member places the blame on the insurance plan and feels like they've been cheated. Members rarely see that the provider is overcharging for a particular service." (Frenkel Benefits)
[Official Guidance] Text of IRS Rev. Proc. 2017-48: Monthly National Average Premium for Bronze Level QHPs, for Purposes of Determining Maximum Individual Shared Responsibility Payment (PDF)
"This revenue procedure provides the monthly national average premium for qualified health plans that have a bronze level of coverage and are offered through Exchanges for taxpayers to use in determining their maximum individual shared responsibility payment ... For purposes of Section 5000A(c)(1)(B) and Section 1.5000A-4, the monthly national average premium for qualified health plans that have a bronze level of coverage and are offered through Exchanges is $272 per individual ... For purposes of Section 5000A(c)(1)(B) and Section 1.5000A-4, the maximum monthly national average premium for qualified health plans that have a bronze level of coverage and are offered through Exchanges is $1,360 for a shared responsibility family with five or more members." (Internal Revenue Service [IRS])
What Does Formal Health Insurance Do, and for Whom?
"Health insurance confers benefits to the previously uninsured, including improvements in health, reductions in out-of-pocket spending, and reduced medical debt. But because the nominally uninsured pay only a small share of their medical expenses, health insurance also provides substantial transfers to non-recipient parties who would otherwise bear the costs of providing uncompensated care to the uninsured. The prevalence of uncompensated care helps explain the limited take-up of heavily-subsidized public health insurance and the evidence that many recipients value formal health insurance at substantially less than the cost to insurers of providing that coverage." (National Bureau of Economic Research [NBER])
Too Few Patients Shop Around
"In a survey of nearly 3,000 adults younger than 65, about half of the roughly 1,900 who said they spent money on medical care in the previous year reported that they knew in advance what their costs would be.... More than 90 percent said they believed that prices vary greatly among providers, and 71 percent said that the amount they spent out-of-pocket was important or very important when choosing a doctor. Yet most respondents said they didn't comparison shop or even ask how much they would owe in copayments or other cost-sharing expenses before they turned up for an appointment." (Kaiser Health News)
The 'Rxisk' of Adjustments in 2018 ACA Risk Adjustment (PDF)
11 pages. "[CMS] is adding a new prescription drug category classification system to the 2018 risk adjustment model. Starting in 2018, a condition will be identified through a Hierarchical Condition Category with associated medical diagnosis codes, a prescribed medication, or both -- each one affecting the final risk member score differently. This paper approximates the likely CMS mapping based on the publicly available information to date." (Milliman)
Does the Trump Administration Control the Fate of the ACA?
"[HHS has] announced that it would make September cost-sharing reduction payments ('CSR Payments') to health insurance carriers that offer eligible plans on the public insurance exchanges.... It remains unclear whether HHS will cease making these CSR Payments after September, a move that would have major ramifications for insurance markets as well as the federal deficit." (Trucker Huss)
Impact of CSR De-Funding on Market Stability (PDF)
14 pages. "[M]embers receiving subsidies (premium tax credits and/or CSRs) or members in non-Silver plans will be largely unaffected by the premium changes due to the CSR de-funding. However, members in standard Silver plans and not receiving subsidies may experience a large rate increase if they stay in their current plans in 2018. These members may buy down to Bronze, drop coverage, or purchase a Silver plan off-exchange ... [T]he incentives for healthy members to buy Bronze and unhealthy members to buy Gold/Platinum may be increased.... The CSR load may vary by issuer based on their CSR market share and the morbidity of that CSR membership relative to the market." (Wakely Consulting Group)
Massachusetts Employers Face $200 Million Increase in Health Care Costs Under MassHealth Amendments
"The Act temporarily increases existing employer fees and imposes new fines on employers that together are expected to raise about $200 million. Despite this new revenue, the Act leaves a significant shortfall in projected MassHealth revenues. In light of this budget shortfall, future changes to these rules are all but inevitable. The new law applies in 2018 and 2019, and it sunsets December 31, 2019." (Mintz Levin)
White House: Federal Government to Make CSR Payments This Month
"The government will make this month's [cost-sharing reduction] payments to insurers ... a White House official said Wednesday.... The subsidies are snared in a legal dispute over whether the Obama health care law properly approved the payments to insurers. Adding to the confusion, other parts of the law clearly direct the government to reimburse the carriers." (Associated Press, via Insurance News Net)
CMS Releases Hospice Comparison Website
"The site displays information in a ready-to-use format and provides a snapshot of the quality of care each hospice facility offers to its patients.... By ensuring patients have the information they need to understand their options, CMS is helping individuals make informed healthcare decisions for themselves and their families based on objective measures of quality." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])

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