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[Official Guidance] Text of CMS Final 2020 Actuarial Value Calculator Methodology (PDF)
25 pages. "The AV Calculator [XLSM] represents an empirical estimate of the AV calculated in a manner that provides a close approximation to the actual average spending by a wide range of consumers in a standard population. This document is meant to detail the specific methodologies used in the AV calculation." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
HHS Provides Recommendations to Reform the Health Care System
"[HHS] recommends increasing provider mobility by allowing easier transfer of board licensing across states. The out-of-state issue is particularly relevant for telehealth, since it would preclude physicians from practicing 'out of state' if the patient is calling in across state lines.... HHS also proposes loosening state regulation of network adequacy standards ... this would drive down cost but decrease choice.... HHS argues for more high-deductible health plans (HDHP).... HHS also supports having the government collect quality measures ... [and] recommends pivoting away from provider value-based purchasing system, as they are two burdensome, too crude, and sacrifice unmeasured quality for measured quality[.]" (Healthcare Economist)
The Health Care Priorities and Experiences of California Residents
"Making sure people with mental health problems can get the treatment they need was identified by 88 percent of Californians as an 'extremely' or 'very' important priority (including 49 percent 'extremely' important). At least three-quarters also see other health priorities as at least 'very important,' including making sure Californians have access to health insurance coverage ... lowering the amount people pay for health care ... lowering the price of prescription drugs ... making sure there are enough health care providers across California ... and making information about medical prices more available[.]" (Henry J. Kaiser Family Foundation)
The State of Employer-Sponsored Healthcare
"[K]ey areas of employer frustration: ... [1] Consolidated medical and pharmacy benefit manager vendor markets means less competition, resulting in higher prices for employers.... [2] Providers are incented to perform more services rather than improving the quality of care ... [3] Most large employers self-insure their health benefits programs, thereby bearing all of the cost escalation risk.... [4] The current prescription drug supply chain model lacks transparency ... [5] Employers perceive that market players (i.e., doctors, hospitals, pharmaceutical companies, insurers, and even brokers) are mostly vested in the status quo, making change slow and difficult." (Managed Healthcare)
How Employers Are Fixing Health Care
"Working closely with providers such as Geisinger, the Mayo Clinic, Johns Hopkins, and Virginia Mason ... [some employers] are crafting bundled payment arrangements that cover the cost of an employee's care for certain episodes from start to finish -- all the procedures, devices, tests, drugs, and services needed for, say, a knee replacement or a back surgery. They're also, in most instances, picking up the tab for any necessary travel, lodging, and meals for the employee and a caregiver, thus democratizing destination care programs that have historically been reserved as an executive perk." (Harvard Business Review)
Public-Option Proposal Would $774 Billion in Hospital Revenue
"The [KNG Health] analysis projected 40.7 million would enroll in such a public option starting in 2024, and about 90 percent of enrollees would come from those who have coverage in the nongroup market or through employer-sponsored insurance (ESI).... [O]nly 5.5 million of the 29 million people currently uninsured were projected to sign up for the public option. The Medicare-X plan was projected to cut healthcare spending by $1.2 trillion (or 7 percent) over the 10-year period from 2024 to 2033. The bulk of those savings would come from $774 billion in hospital spending reductions stemming from the use of Medicare rates instead of higher commercial insurance rates." (Healthcare Financial Management Association [HFMA])
Paying Patients to Switch: Impact of a Rewards Program on Choice of Providers, Prices, and Utilization
"For 131 elective services, patients who received care from a designated lower-price provider received a check ranging from $25 to $500, depending on the provider's price and service. In the first twelve months of the program we found a 2.1 percent reduction in prices paid for services targeted by the rewards program. The reductions in price resulted in savings of $2.3 million, or roughly $8 per person, per year. These effects were primarily seen in magnetic resonance imaging and ultrasounds, with no observed price reduction among surgical procedures." (Health Affairs; purchase required for full article)
Cadillac Tax Repeal on the Horizon?
"Senator Martin Heinrich introduced the Middle Class Health Benefits Tax Repeal Act of 2019 [S.684] in the Senate on March 6, which has already secured 23 co-sponsors (12 Republican, 11 Democrat). Comparable legislation [H.R.748] has been pending in the House since January 2019, with similar bi-partisan support (of the 238 co-sponsors, 110 are Republicans and 128 are Democrats)." (Mayer Brown)
[Opinion] Reducing Individual Market Premiums to Expand Access to Coverage and Care (PDF)
"The individual market ... should be strengthened to make coverage more affordable while protecting those with pre-existing conditions. To achieve this, BCBSA recommends that policymakers take three critical steps: [1] Revise federal assistance to help more people afford coverage; [2] Enact policies to lower costs and remove financial barriers to accessing care. [3] Improve outreach to encourage people to obtain and maintain insurance Taken together, ... these three actions would reduce the average individual market premium by 33 percent, while enabling an additional 4.2 million people to obtain ACA coverage." (BlueCross BlueShield Association)
[Opinion] Administration Considers Groundbreaking Regulation Forcing Healthcare Providers to Disclose Secret Industry Pricing
"Insurers and providers alike will have a bullseye on the Trump Administration and the officials responsible for implementing this rulemaking. And that is no small lobby, with pockets as deep as one-fifth of the entire U.S. economy. The cash cow of obfuscation, secret discounts, unknown prices and third-party payment would begin a rather strict diet very soon if this information were permitted to flow into the light of day." (Benefit Revolution)
Administration Weighs Publicizing Secret Rates Hospitals and Doctors Negotiate With Insurers
"Mandating public disclosure of the rates would upend a longstanding industry practice and put more decision-making power in the hands of patients. Hospitals and insurers typically treat specific prices for medical services as closely held secrets, with contracts between the insurers and hospital systems generally bound by confidentiality agreements." (The Wall Street Journal; subscription may be required)
As Hospitals Post Price Lists, Consumers Are Asked to Check Up on Them
"Most hospitals appear to be complying with the rule, according to hospital officials and a small sampling of websites. However, the feds acknowledge they are not yet enforcing the rule, industry groups are not monitoring compliance, many hospitals are burying the information on their websites, and debate continues about whether the price lists are creating more confusion than clarity among consumers." (Kaiser Health News)
Lawmakers United Against High Drug Prices Bare Partisan Teeth
"The Doggett-Brown proposal is based on a concept known as compulsory licensing, which would allow the government to use its power to issue patents as a lever if manufacturers are seen as not operating in good faith.... Republicans at the hearing maintained that this government market muscle would discourage research and development of new medicines and treatments, echoing industry representatives who say the strategy is not only costly but also doesn't always lead to a breakthrough." (Kaiser Health News)
[Opinion] Partnership for Employer-Sponsored Coverage Comments to Senate HELP Committee on Rising Health Costs
"Eliminating or capping the tax exclusion of employer-sponsored coverage for individuals has been seen as a way to raise federal revenue and/or offset the cost of other federal reforms or programs ... A cap on the exclusion does not address rising health system costs or utilization and will stifle private-sector innovation and delivery designs ... There is no one-size-fits-all employer health plan nor should the federal government enact or implement laws that stifle an employer's ability to develop benefits offerings that meet the needs of their specific workforce[.]" (Partnership for Employer-Sponsored Coverage [P4ESC])
Insurers Ask for More Than $2 Billion in Unpaid CSRs
"Following continued success in suing the federal government over unpaid cost-sharing reduction payments (CSRs) ... the insurers in a class action lawsuit estimate damages of $2.36 billion for both 2017 and 2018. A second case includes a request for about $71 million for 2017 and 2018. The amount for 2018 in a third case will be determined through the CSR reconciliation process this spring. No funds will be paid out any time soon; any payments would not be made until after the appeals process is completed." (Katie Keith, in Health Affairs)
Health of Employee Benefit Programs Can Be Make-or-Break Issue for Impending Merger or Acquisition
"Companies typically like to delay due diligence of employee benefits to maintain the confidentiality of the impending deal and because employee benefits may be perceived as being less material to the decision about whether to proceed or not. Unfortunately, this level of discretion can be costly, as employee benefit programs can deeply affect a potential deal, sometimes to the surprise of the acquiring company." (Milliman)
How Affordable Are 2019 ACA Premiums for Middle-Income People?
"Marketplace enrollment among subsidized enrollees rose from 8.7 million in 2015 to 9.2 million in 2018. However, premiums increased significantly, and the number of unsubsidized enrollees in ACA-compliant plans has fallen over this same period from 6.4 million to 3.9 million.... [A]ffordability challenges are particularly acute for older adults with incomes just above the premium subsidy cutoff (400% of poverty), particularly in rural areas where premiums are highest." (Henry J. Kaiser Family Foundation)
Insurer Skips Doctors, Sends Checks Directly to Patients, Prompting Lawsuit
"The suit by Sovereign Health highlights part of an ongoing war between insurance companies and [health care] providers over payment and billing issues, one that puts the patient right in the middle of the fighting by sending payments straight to patients after they seek out-of-network care. Patients are supposed to send the money on to providers. Many times, they do; other times, they don't." (CNN)
Insurance Companies Win Important Ruling on Payment of ACA Cost-Sharing Reductions
"[T]he U.S. Court of Federal Claims held that ACA Section 1402 'sets forth an unambiguous mandate' that the government 'shall make' CSR payments to insurers. The Court further rejected the government's argument that Congress' failure to appropriate money for these payments in any way extinguished the obligation.... The Court likewise found that the statutory obligation created an 'implied-in-fact' contract between the government and insurers, further obligating the government to make the payments." [Community Health Choice v. U.S., No. 18-5C (Ct. Cl. Feb. 15, 2019)] (Faegre Baker Daniels)
Employers Striving to Sustain Competitive, Affordable Health Benefits
"[Employers] have tried and exhausted many tactics to contain healthcare costs, and are looking for other alternatives -- beyond putting their health plan out to bid to optimize network discounts and/or reduce fixed costs, such as Administrative Services Only (ASO) fees and stop loss premiums. [A] diagram shows a range of possibilities an employer can consider[.]" (Findley)
Paying Patients to Use Lower-Price Health Providers Can Result in Savings
"Examining a program that pays patients $25 to $500 for using a lower-price medical provider for each of 135 elective procedures, researchers found the effort led to a 2.1 percent reduction in the average price paid of all eligible services. The decrease in prices paid was greatest for MRIs (4.7 percent), ultrasounds (2.5 percent) and mammograms (1.7 percent)." (RAND Corporation)
Could 2019 Be the Year of MLR Rebates for ACA Issuers in the Individual Market? (PDF)
"For issuers projecting a favorable 2018 loss ratio, now is the time to consider the implications and strategies for 2019 and beyond. [1] Track and optimize QI expenses.... [2] Set 2020 premium rates with a potential MLR rebate in mind.... [3] Consider how the MLR is affected by long-term investments.... [4] Consider offering a 'premium holiday' to reduce member premiums while avoiding some of the tedious logistics of distributing M LR rebate checks.... [5] Ensure an expert is familiar with the details of the federal and state MLR guidelines so that reporting forms are appropriately and accurately filled out.... [6] Revisit risk contracts with the MLR in mind." (Milliman)
Surprise Billing Legislation: What Employers Need to Know
"Congress [is] beginning to take action to address the issue of surprise medical billing via the introduction of three bills. [1] Protecting Patients from Surprise Medical Bills Act ... [2] No More Surprise Medical Bills Act of 2018 ... [3] Reducing costs for out-of-network services act of 2018 ... All of [these] bills could affect the services offered by employers under their group health plans.... [T]he legislation could also impact the costs borne by the employer for certain services provided to employees." (Thompson Coburn)
[Opinion] Health Care Spending Is More Than Just the Parts You See
"To really understand how Medicare for All or any other big change in health care financing would affect them, people need to understand how they would impact their overall family health budgets. Few people think about the other health costs they pay: their taxes to support health care, or what their employers are paying towards premiums (which is depressing their wages)." (Drew Altman, via Axios)
State Approaches to Mitigating Surprise Out-of-Network Billing (PDF)
42 pages. "A key first step is removing the patient from the middle of disputes over surprise out-of-network billing and requiring insurers, providers, and/or regulators to resolve problems.... Protections ... should apply comprehensively across settings ... and not merely in emergency situations.... Minimize reliance on notice and consent exceptions ... Include means of enforcement ... [By] focusing regulation on health care providers, the policy approaches detailed in [this paper] are able to largely or entirely protect enrollees in self-insured health plans as well as those in fully-insured plans, while likely surviving any ERISA challenges." (The Brookings Institution)
[Guidance Overview] Deadline Nears for New San Francisco Minimum Healthcare Expenditure Requirements
"Starting in 2018 100% of employer expenditures must be irrevocable to count toward the minimum spending requirement -- that is, they must be payments that the employer has not retained and cannot recover, even if the employee leaves the job.... The annual reporting form ... which must be submitted by April 30 ... is usually available on the HCSO website around April 1. Employers can register with the city to receive an email notification when the form is available." (Buck)
Do Consumer-Directed Health Plans Plans Really Work?
"[CDHPs], paired with a health savings account (HSA) are trending higher among many employers with growth of 11.2% from 2017 to 2018. These plans with lower premium costs are coupled with a new philosophy which brings comparison shopping and savvy consumerism into the healthcare space.... It sounds good in theory, but does it really work? Some actuaries say yes." (HealthEquity)
2018-2027 Projections of National Health Expenditures
"National health expenditure growth is expected to average 5.5 percent annually from 2018-2027, reaching nearly $6.0 trillion by 2027... [CMS] projects the health share of GDP to rise from 17.9 percent in 2017 to 19.4 percent by 2027.... Spending growth for prescription drugs is projected to generally accelerate over 2018-2027 (and average 5.6 percent) mostly as a result of faster utilization growth." (Office of the Actuary, Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Changes Proposed by HHS Will Affect Employer-Sponsored Health Plans
"For 2020, ... the out-of-pocket maximums would be $8,200 for self-only coverage and $16,400 for family coverage (compared to $7,900 and $15,800 for 2019).... HHS is also proposing to allow health plans (both fully-insured and self-funded) to exclude brand name drugs from essential health benefits if a generic equivalent is available. Plans would still need to have an exception process that would allow individuals to access the brand drugs, if necessary." (HUB International)
Government Report Reveals CBO Was Scandalously Off in Obamacare Estimates
"In what was literally a footnote in its annual report on national health spending projections, actuaries for the [CMS] on Wednesday estimated that the elimination of the individual mandate would have a significantly smaller impact than the CBO has long estimated. Specifically, the CMS report revealed that 2.5 million more people would go without insurance in 2019 due to the repeal of the individual mandate's penalties, and the impact would be 'smaller' thereafter." (Washington Examiner)
National Health Expenditure Projections, 2018-27: Economic and Demographic Trends Drive Spending and Enrollment Growth
"National health expenditures are projected to grow at an average annual rate of 5.5 percent for 2018-27 and represent 19.4 percent of gross domestic product in 2027.... Prices for health care goods and services are projected to grow 2.5 percent per year, on average, for 2018-27 -- faster than the average price growth experienced over the last decade -- and to account for nearly half of projected personal health care spending growth." (Health Affairs; purchase or subscription required to view full article)
Insurance Brokers Get Paid More to Sell More, Fueling High Health Care Costs
"Human resource directors often rely on independent health insurance brokers to guide them through the thicket of costly and confusing benefit options offered by insurance companies. But what many don't fully realize is how the health insurance industry steers the process through lucrative financial incentives and commissions. Those enticements, critics say, don't reward brokers for finding their clients the most cost-effective options." (National Public Radio [NPR])
[Opinion] Plan Sponsors Siding with Insurers in Hospital Network Negotiations
"We have all lived through the negotiation process of the big bad insurance company informing the public that a certain hospital's status was changing to non-participating based on the egregious demands of the hospital for higher fees upon contract renewal.... [T]he plan sponsor community is now siding with many of the insurers in these disputes, resulting in approval for carriers to be combative in their negotiations and potentially remove a hospital system from their network." (Frenkel Benefits)
Public School Teachers Strike for Higher Pay Amid Growing Retirement, Benefit Costs
"While average inflation-adjusted teacher salaries have been relatively stagnant since 1990, benefits costs have risen from 16.8 percent of expenditures in 1990 to 23 percent of today's much larger expenditure base.... Almost every state increased teachers' retirement benefits in the booming 1990s. But the additional promises were not accompanied by responsible funding plans. Overfunded at the turn of the millennium, by 2003, teacher pension plans were collectively short by $235 billion. By 2009, pension debt had more than doubled, to $584 billion." (USA TODAY)
Health Assessments and Biometrics 101
"Besides providing a baseline for a population's health, screenings also: Help detect disease in its early and most treatable stages -- even before symptoms are recognized -- and provide a summary of a participant's health; Improve both health and financial outcomes by significant margins (37% of employers reported greater health risk improvement and 34% reported a lower healthcare claims trend).... Health screening at a primary care provider may cost between 2.1 and 3.2 times more than an on-site health screening." (Healthstat)
More Insurers Win Lawsuits Seeking Cost-Sharing Reduction Payments
"On February 14 and 15, two judges at the Court of Federal Claims held that insurers are entitled to unpaid cost-sharing reduction (CSR) payments. One of these lawsuits ... is a class action for unpaid CSRs, meaning the decision applies to the 91 insurers who are part of that class.... In some cases, these insurers are entitled to unpaid CSRs from both 2017 and 2018, even though many insurers opted to use 'silver loading' to make up for unpaid CSRs." (Katie Keith, in Health Affairs)
Is a Health Insurance Captive Right for You?
"What is a group captive and how does it work? ... What provider network is used in a captive arrangement? ... What is the cost to the employer? What about the employee? ... What are the protections for the employer from severe high claimants? ... Is the Captive Premium expensive? ... How do I go about joining a captive and is there a capital contribution? ... How are wellbeing programs worked into this type of insurance? ... What are the benefits to participating in a captive as opposed to traditional health insurance?" (CBIZ)
2019 ACA Compliance Overview: Cost-Sharing Limits
"Review your plan's out-of-pocket maximum to make sure it complies with the ACA's limits for the 2019 plan year ($7,900 for self-only coverage and $15,800 for family coverage).... For 2019, the out-of-pocket maximum limit for HDHPs is $6,750 for self-only coverage and $13,500 for family coverage.... [C]onfirm that the plan will coordinate all claims for EHBs across the plan's service providers or will divide the out-of-pocket maximum across the categories of benefits, with a combined limit that does not exceed the maximum for 2019." (Strategic Benefit Services)
2017 Health Care Cost and Utilization Report for Americans Covered by Employer-Sponsored Insurance (PDF)
23 pages. "In 2017, per-person spending reached $5,641, a new all-time high for this population.... Average prices increased 3.6% in 2017. Year-over-year price growth decelerated throughout the five-year period, rising 4.8% between 2013 and 2014 and slowing to 3.6% in 2016 and 2017.... The overall use of health care services changed very little over the 2013 to 2017 period, declining 0.2%.... Out-of-pocket spending per-person increased 2.6% in 2017." [Also available: data download in .CSV file format, HCCI's updated analytic methodology, and a State-level interactive tool.] (Health Care Cost Institute [HCCI])
Healthcare Spending for Employer Plans Hits Record
"Healthcare spending has outpaced gross domestic product growth over the last five years, reaching an all-time high in 2017 ... People are essentially paying more for the same amount of care.... The share of U.S. physician practices owned by hospitals or systems increased from 27% to 48% from 2011 to 2016 ... That led to a 9% price increase in specialist outpatient procedures and a 5% hike in primary-care outpatient procedures[.]" (Modern Healthcare Online; free registration required)
10 States with Highest, Lowest 2017 Employer Healthcare Spending
"Alaska saw the highest average annual healthcare spending for individuals with employer-sponsored insurance in 2017, while Hawaii saw the lowest, according to an interactive state tool from the Health Care Cost Institute." (Becker's Hospital Review)
Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance: Out-of-Pocket Costs
"This project assessed changes in opioid use disorder (OUD) treatment utilization and expenditures in the employer-sponsored private health insurance market during 2007 and 2014. These years mark periods before and after implementation of major federal legislation enacted to increase insurance coverage and expand access to coverage of behavioral health care, the introduction and expanded use of new opioid treatment medications, and other initiatives to expand substance use disorder treatment access." (Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
Use of Medication-Assisted Treatment for Opioid Use Disorders in Employer-Sponsored Health Insurance: Final Report
"This project assessed changes in Opioid Use Disorder (OUD) treatment utilization and expenditures in the employer-sponsored private health insurance market at two timepoints, 2006-2007 and 2014-2015, that mark the periods before and after implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA), the [ACA], the introduction and expanded use of new opioid treatment medications, and other initiatives to expand substance use disorder treatment access." (Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
Hospital Price Transparency: Making It Useful for Patients
"Crude versions of price transparency like the release of hospital chargemaster lists are unlikely to help patients get more value for their health care dollars.... Here are core elements of effective price transparency that Congress, the Trump administration, and private payers could consider in crafting policies that will effectively empower patients to be better purchasers." (The Commonwealth Fund)
Why Aren't More Employers Implementing Reference-Based Pricing Benefit Design?
"The major barriers to [reference-based pricing (RBP)] adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices." (American Journal of Managed Care)
This Valentine's Day, 'Know Your Numbers' by Heart
"Heart disease is the nation's leading cause of death, in both men and women. According to the American Heart Association, nearly 80 percent of cardiac events can be prevented, yet most people don't know the important personal health data that is critical to determining your risk.... Having your personal information is key to understanding your current risk." (Grooms Benefit Solutions)
Senate Committee Hearing: How Primary Care Affects Health Care Costs and Outcomes
Feb. 5, 2019. Includes video and written testimony by: [1] Joshua J. Umbehr, M.D., Atlas MD; [2] Sapna Kripalani, M.D., Vanderbilt University Medical Center; [3] Katherine Bennett, M.D., University of Washington School of Medicine; [4] Tracy Watts, Mercer. (Committee on Health, Education, Labor and Pensions, U.S. Senate)
[Guidance Overview] Text of IRS FAQs on the Premium Tax Credit
Updated Feb. 8, 2019. Topics: [1] Basics [2] Eligibility; [3] Computing the Amount; [4] Reporting, Claiming and Reconciling. (Internal Revenue Service [IRS])
Health Care Spending in the U.S. and Taiwan
"[This article offers] some insights on health spending in the single payer health system of Taiwan as a sharp contrast to the high-spending US system, focusing on the role of prices and administrative costs in the two systems. These two factors play a central role in containing health care costs in Taiwan and help make the system economically and politically sustainable.... [I]nternational data on prices of health care services and goods [show] how the US is truly exceptional among nations in that sphere." (Tsung-Mei Cheng, in Health Affairs)
[Guidance Overview] Is the Proposed Expansion of HRAs a Game Changer for Employers? (PDF)
"The proposed regulations may especially be useful for small and medium-sized companies that want to be able to define the costs that they are willing to pay towards employee health insurance coverage by using HRAs with a fixed annual employer contribution and that have a small enough workforce to satisfy some of the consistency requirements of the proposed regulations." (Epstein Becker Green, via Bloomberg Tax Management Compensation Planning Journal)
Drivers of U.S. Mortality Improvement (PDF)
13 pages. "Experts from inside and outside the insurance/retirement industry were invited to participate in a daylong Expert Panel Forum discussion to provide input about drivers of U.S. mortality improvement for the short and long term. The issues addressed included: [1] What are going to be the key drivers of U.S. mortality? [2] How will key drivers of mortality interact? [3] How might factors discussed change mortality rates for different age groups, most noticeably below and above age 65?" (Society of Actuaries)
Estimates of the Impact of Eliminating Rebates for Reduced List Prices at Point-of-Sale for the Part D Program (PDF)
10 pages. "[T]he average beneficiary would have a premium increase of about 8%, and average beneficiary cost sharing would be reduced by about 9.5%.... [T]he net effect for beneficiaries is a 2% reduction in out-of-pocket expenses.... [A]pproximately 30% of non-low income beneficiaries will see a net savings ... [T]he other 70% of non-low income beneficiaries will on average experience a net increase in out of pocket expenses.... [T]he drug spend level threshold at which the non-low income beneficiary begins to experience a net savings will occur at an annual spend of $2,200 to $2,500." (Wakely Consulting Group, for Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
See Health as a Resource, Not as a Problem
"The next frontier of health investment will require shifting from a predominant focus on health as a state of illness to health as a state of high capacity and overall well-being.... Despite our long-term fixations on these externals, staggering financial expenditures, and unending calls for change in the medical industry, our current approach to health will never lead to high health and high well-being.... High health and high well-being arise when people engage in practices that optimize their physical, mental, emotional, purpose and life direction dimensions." (High Health Network)
How CBO and JCT Analyzed Coverage Effects of New Rules for Association Health Plans and Short-Term Plans (PDF)
20 pages. "To estimate the effects of the new rules for AHPs and short-term plans, CBO and JCT analyzed the incremental increase in coverage in both types of plans that will result from the rules ... The agencies followed several steps in completing their analysis, beginning with a comparison of estimated premiums for the new plans with those for the lowest-cost insurance otherwise available to individuals and small employers." (Congressional Budget Office [CBO])
Will the Cadillac Tax Generate Revenue?
"In May 2018, [CBO] estimated that the tax would generate $168 billion in tax revenue from 2022 to 2028. The Joint Tax Committee (JCT) and CBO assume that when employers reduce the comprehensiveness of health benefits to avoid the tax that they will in turn increase worker taxable wages such that total compensation is unchanged. Shifting the composition of compensation toward a higher proportion of taxable wages will translate into additional tax revenue. Repealing the tax would mean finding $168 billion (or the equivalent in today's dollars) in new tax revenue." (Employee Benefit Research Institute [EBRI])
The Impact of the ACA: Evidence from California's Hospital Sector
"[A] substantial share of the federally-funded Medicaid expansion substituted for existing locally-funded safety net programs.... [T]he expansion produced a substantial increase in hospital revenue and profitability, with larger gains for government hospitals.... [The authors] do not detect significant improvements in patient health, although the expansion led to substantially greater hospital and emergency room use, and a reallocation of care from public to private and better-quality hospitals." (National Bureau of Economic Research [NBER]; purchase required for full document)
[Guidance Overview] San Francisco Increases Healthcare Costs and Requirements for Employers in 2019
"As of 2019, San Francisco employers with 20-99 employees worldwide must spend $1.95 per hour, and those with 100 or more employees worldwide must spend $2.93 per hour. Businesses with less than 20 employees remain exempt from the [health care security ordinance (HCSO)]. The 2019 'Exemption Threshold' (minimum amount for managerial, supervisory, and confidential employees to be exempt from the HCSO) has increased to $48.46 per hour or $100,796 per year." (ReedSmith)
New Year Brings Hospital Pricing Transparency
"[T]he amounts posted are the 'full price' amounts, sometimes referred to as 'rack rates' or the 'chargemaster' ... [A]lmost no one actually pays these prices.... Insurance companies and third-party administrators negotiate discounts ... [C]onsumers who are covered by insurance may only pay a portion of these rates through copayments or coinsurance.... [E]ven uninsured consumers may negotiate discounts ... [In] many cases, the items or services listed are given highly technical, often confusing names. Even an experienced health care professional may have trouble understanding them." (HUB International)
[Guidance Overview] Draft 2020 Letter to Issuers and Actuarial Value Calculator
"CMS will maintain the same approach in 2020 as it did in 2018 or 2019 in areas that include plan ID crosswalks, licensure and good standing, service areas, network adequacy, discriminatory benefit design, quality reporting, prescription drug benefit offerings, cost-sharing reduction variations, data integrity review, consumer support tools and related issues, and the summary of benefits and coverage. Where the 2020 draft letter differs from the 2019 letter, it generally does so by incorporating changes contained in the proposed 2020 payment rule." (Katie Keith, in Health Affairs)
[Guidance Overview] The ACA's Employer Shared Responsibility Provisions (PDF)
26 pages. "This report begins with an overview of how employers determine whether they are considered an ALE before outlining the [employer shared responsibility provisions (ESRP)]. It then discusses the two types of ESRP penalties and introduces administrative aspects of the ESRP. This report also includes two appendixes that contain definitions of terms as used in the report and a summary of how various worker classifications are considered for ALE determinations and under the ESRP." [Report R45455, Jan. 9, 2019] (Congressional Research Service [CRS])
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