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<< Older News  |  August 2, 2021

News

All News > Health Plan Costs

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Use Value-Based Payment to Resolve the Debate About Telehealth Payment Parity
Health Affairs Blog Link to more items from this source
[Opinion]
Aug. 2, 2021

"Some argue that telehealth requires less clinical effort and fewer overhead costs than in-person care, undercutting the case for payment parity.... Those who support payment parity believe it would help clinicians adopt and maintain telehealth as a way to support health care access and patient experience. Arguments on both sides would be strengthened by more high-quality studies."

Tags: Health Plan Costs  •  Health Plan Design  •  Teleheath

Joint Agencies Issue FAQs Regarding Plan Coverage for HIV PrEP Treatment
EPIC Link to more items from this source
[Guidance Overview]
July 29, 2021

"Health plans with policy years beginning on or after June 30, 2020, must cover PrEP as preventive care under the ACA.... The Final Recommendation gives information about whom the USPSTF determined to be at high risk for HIV acquisition.... The Departments' FAQs explain that plans must provide coverage without cost-sharing for PrEP drugs and items and services included as part of determining whether PrEP is appropriate for the individual and ongoing follow-up and monitoring."

Tags: Health Plan Costs  •  Health Plan Design

Legal Risk for Plan Sponsors Remains Following Challenges to Cross-Plan Offsetting
OneDigital Link to more items from this source
July 28, 2021

"Once standing was established, the Lutz court found the practice of cross-plan offsetting violated ERISA's duty of loyalty and ban on representing both sides in a transaction. More challenges to cross-plan offsetting will follow in the wake of these cases, leading to decisions on when and how the practice violates ERISA fiduciary duties."

Tags: HIPAA  •  Health Plan Costs

Editor's Pick CRS Report on Surprise Billing in Private Health Insurance: Overview of Federal Consumer Protections and Payment for Out-of-Network Services
Congressional Research Service [CRS] Link to more items from this source
[Guidance Overview]
July 27, 2021

50 pages. "This report provides an overview of private health insurance billing and describes federal requirements related to surprise billing. Table A-1 summarizes all deadlines and deliverables required in the No Surprises Act. Appendix B summarizes additional provisions of the No Surprises Act not explicitly summarized or referenced elsewhere in the report. Table C-1 summarizes the applicability of federal surprise billing requirements to different surprise billing situations." [R46856, Jul. 26, 2021]

Tags: Health Plan Costs  •  Health Plan Design

Research Suggests Urgent Care Centers Reduce Health Care Costs
AcademyHealth Link to more items from this source
July 27, 2021

"Across the six states studied, researchers found that the existence of an urgent care center in a zip code reduced the number of [emergency department] visits by about 17 percent.... [T]he authors estimate that urgent care centers save about $3.3 billion annually.... [T]his number does not consider other ways in which urgent care centers might offset those savings by, for example, encouraging new health care use or acting as a substitute for lower-cost primary care clinics."

Tags: Health Plan Costs

Surprise Billing Regs: Impact on Out-of-Network Providers
K&L Gates Link to more items from this source
[Guidance Overview]
July 27, 2021

"Intended to provide patients protection against unanticipated medical expenses, the IFR will remove the predominant methodology used by health plans to pay out-of-network providers under the [ACA]. For out-of-network providers, the IFR creates administrative complexity and can result in reduced reimbursement."

Tags: Health Plan Costs  •  Health Plan Design

Hospital Price Transparency: CMS Issues Proposed Rule to Increase Penalties for Larger Hospitals Violating Disclosure Requirements
Foley & Lardner LLP Link to more items from this source
[Guidance Overview]
July 23, 2021

"While the CMP for the smallest hospitals would remain unchanged, the annual penalty for noncompliance by the largest hospitals throughout a year would be $2,007,500.... CMS also has had reports that publicly available standard charge listing have not been as accessible as CMS intended or desired.... As a consequence, CMS proposes in the Rule that each hospital must ensure 'that the standard charge information is easily accessible, without barriers, including, but not limited to, ensuring information is accessible to automated searches and direct file downloads through a link posted on a publicly available website.' "

Tags: Health Plan Costs

CMS Proposes to Increase Penalties for Hospital Price Transparency Noncompliance
K&L Gates Link to more items from this source
[Guidance Overview]
July 23, 2021

"CMS noted that several early studies have indicated a high rate of hospital noncompliance with the Hospital Price Transparency Rule, which the agency said aligns with its sampling and reviews conducted to date as part of its enforcement efforts.... [The] Proposed Rule also proposes to update the list of activities that CMS deems to be access barriers to the machine-readable file and specifically to require that the machine-readable file is accessible to automated searches and direct downloads."

Tags: Health Plan Administration  •  Health Plan Costs

Surprise! Tri-Agencies Meet Deadline with First Set of Surprise Billing Rules, with More to Come
Groom Law Group Link to more items from this source
[Guidance Overview]
July 23, 2021

"The IFR is largely focused on how the surprise billing protections apply to group health plans and health insurance issuers, as well as how the Qualified Payment Amount (QPA) is calculated. There are some rules related to the initial payment for surprise billing claims from providers and notices of denial, as well as provider-focused rules. The IFR generally hews closely to the CAA's provisions and provides some clarity regarding the calculation of the QPA amount."

Tags: Consolidated Appropriations Act, 2021   •  Health Plan Administration  •  Health Plan Costs  •  Health Plan Design

Guidance Reminds Health Plans to Check Up on Preventive Care Compliance
Jackson Walker Link to more items from this source
[Guidance Overview]
July 23, 2021

"Employer-sponsored group health plans ... need to check with their group health plan's insurer or third-party administrator on how all elements of PrEP are being handled. Employers should also verify that the contents of their group health plan's summary plan description, plan document, and other employee communication materials accurately reflect the coverage of PrEP and are compliant with the requirements by September 17, 2021."

Tags: Health Plan Costs  •  Health Plan Design

Another Blow to Cross-Plan Offsetting: Employers Should Take Note
HUB International Link to more items from this source
July 22, 2021

"Plan sponsors should recognize that 'opting out' eliminates an overpayment recovery tool. As a result, your plan may have a tougher time recovering future overpayments. More importantly though, proactively squelching the practice should avoid a costly ERISA lawsuit down the road." [Lutz Surgical Partners PLLC v. Aetna, Inc., No. 15-2595 (D.N.J. Jun. 21, 2021)]

Tags: Fiduciary Duties  •  Health Plan Administration  •  Health Plan Costs

Text of ASOP 28: Statements of Actuarial Opinion Regarding Health Insurance Assets and Liabilities
Actuarial Standards Board Link to more items from this source
[Official Guidance]
July 22, 2021

"Since the last update of this standard, changes have been made to ASOP No. 5, Incurred Health and Disability Claims, and ASOP No. 42, Health and Disability Actuarial Assets and Liabilities Other Than Liabilities for Incurred Claims, due in part to the changes imposed by the [ACA]. Some assets and liabilities that are included in the scope of the actuarial opinion have changed, and others have gained prominence. Therefore, this revision of ASOP No. 28 reflects these changes in actuarial practice."

Tags: Health Plan Costs

Initial No Surprises Act Regs Provide Some Clarity for Employer Plans
Ogletree Deakins Link to more items from this source
[Guidance Overview]
July 22, 2021

"Employers may want to note that the DOL will establish a process to administer complaints that health plans and insurers are violating the No Surprises Act rules. Though employees could file such complaints, it appears that providers would be more likely to use the new system. Options for the DOL under the new process include referring the plan or insurer for an investigation or for enforcement action."

Tags: Consolidated Appropriations Act, 2021   •  Health Plan Administration  •  Health Plan Costs  •  Health Plan Design

Massachusetts Sets 2022 Individual-Mandate Coverage Dollar Limits
Mercer Link to more items from this source
[Guidance Overview]
July 22, 2021

"The Massachusetts individual mandate ... requires state residents to maintain MCC or face a potential state tax penalty.... In addition, health plan reporting requirements compel plan sponsors (or their vendors) to determine whether the coverage they offer meets MCC standards.... the 2022 maximum MCC deductibles are $2,850 for individual coverage and $5,700 for family coverage. If the plan has a separate prescription drug deductible, those amounts for 2022 can't exceed $350 for individual coverage and $700 for family coverage."

Tags: Health Plan Costs  •  Health Plan Design  •  Local Regulation

The Sleeper Health Cost Policy
Henry J. Kaiser Family Foundation Link to more items from this source
[Opinion]
July 22, 2021

"Hospitals have been sitting on the sidelines happily watching policymakers go after drug costs. But drugs represent ten percent of health spending while hospitals represent thirty four percent. A more aggressive policy aimed at anti-competitive mergers and consolidation in the hospital industry would aim right at high hospital prices that drive up health spending."

Tags: Health Plan Costs  •  Health Plan Policy

Administration Issues Part I of Surprise Billing Rule
Morgan Lewis Link to more items from this source
[Guidance Overview]
July 21, 2021

"Along with the IFR, the Departments released model notices that group health plans and issuers (as well as providers and facilities) must make publicly available, post on a website, and include on each explanation of benefits and other related materials.... The regulations apply to group health plans and insurance issuers offering group or individual coverage, including grandfathered plans. The regulations do not apply to retiree-only plans; excepted benefits; short-term, limited duration insurance; health reimbursement accounts (HRAs); and other account-based group health plans (e.g., healthcare flexible spending accounts)."

Tags: Consolidated Appropriations Act, 2021   •  Health Plan Administration  •  Health Plan Costs

DOJ's Recent Telehealth Enforcement Action Highlights Increased Abuse of COVID-19 Waivers
Health Law Advisor, Epstein Becker Green Link to more items from this source
July 21, 2021

"On May 26, 2021, the Department of Justice (DOJ) announced a coordinated law enforcement action against 14 telehealth executives, physicians, marketers, and healthcare business owners for their alleged fraudulent COVID-19 related Medicare claims resulting in over $143 million in false billing.... The cases announced by both the DOJ and CMS allegedly sought to exploit these expanded policies by submitting false claims to Medicare for telemedicine encounters that never actually occurred."

Tags: Health Plan Costs  •  Teleheath

Medical Debt in the United States, 2009-2020
JAMA Network Link to more items from this source
July 21, 2021

"This study provides an estimate of the amount of medical debt in collections in the US based on consumer credit reports from January 2009 to June 2020, reflecting care delivered prior to the COVID-19 pandemic ... In June 2020, an estimated 17.8% of individuals had medical debt (13.0% accrued debt during the prior year), and the mean amount was $429 ($311 accrued during the prior year)."

Tags: Health Plan Costs

Feds Call on Insurers to Fully Cover HIV Prevention Drug Prep Without Cost-Sharing
FierceHealthcare Link to more items from this source
[Guidance Overview]
July 20, 2021

"[DOL and HHS issued FAQs on July 19] directing most insurers to offer pre-exposure prophylaxis (PrEP) to beneficiaries at no cost. The guidance ... comes after HIV patient advocacy groups have found that insurance plans have been slow to offer preventative drugs without cost-sharing obligations.... [Insurers] have 60 days to come in compliance with the no cost-sharing requirement."

Tags: Health Plan Administration  •  Health Plan Costs  •  Health Plan Design

CMS Prepares to Make Noncompliance with Price Transparency Requirements Much More Expensive
Healthcare Financial Management Association [HFMA]; free registration required Link to more items from this source
July 20, 2021

"The $300 rate would remain for hospitals with 30 or fewer beds. The penalty would rise by $10 per day for each additional bed, with a maximum allowable penalty of $5,500 per day. In other words, hospitals would not be subject to an incrementally higher penalty for bed counts beyond 550. Thus, for hospitals that remain noncompliant for an entire year, the penalty would range from $109,500 to slightly more than $2 million."

Tags: Health Plan Costs

Large Self-Insured Employers Lack Power to Effectively Negotiate Hospital Prices
American Journal of Managed Care Link to more items from this source
July 20, 2021

"In most areas of the United States, self-insured employers lack market power to negotiate hospital prices. There is no evidence that greater employer market power is associated with lower hospital prices in the employer-sponsored insurance markets. Employer coalitions would need to enroll a considerable number of employers to have a sufficient market power to negotiate with hospitals. Self-insured employers may consider building purchase alliances with state and local government employee groups to enhance their market power and lower negotiated prices for hospital services."

Tags: Health Plan Costs

Text of CMS Updated 2022 Benefit Year Final HHS Risk Adjustment Model Coefficients (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
July 20, 2021

17 pages. "[T]his document announces some minor revisions to the 2022 benefit year final risk adjustment adult model coefficients. The reason for these revisions is to apply a constraint to the enrollment duration factors (EDFs) that was missing in the 2022 Payment Notice's risk adjustment model coefficients."

Tags: Health Plan Administration  •  Health Plan Costs

No Surprises Act: HHS Issues Interim Final Rule
OneDigital Link to more items from this source
[Guidance Overview]
July 20, 2021

"When does this rule apply? ... What plans are covered by the interim final rule? ... Major provisions of the interim final rule ... How is billing determined? ... What about cost sharing? ... What notices must providers and group or individual health plans give to patients?"

Tags: Consolidated Appropriations Act, 2021   •  Health Plan Costs  •  Health Plan Design

CMS Proposes Rule to Increase Hospital Price Transparency
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Guidance Overview]
July 20, 2021

"CMS proposes to increase the penalty for some hospitals that do not comply with Hospital Price Transparency final rule.  Specifically, CMS is proposing to set a minimum civil monetary penalty of $300/day that would apply to smaller hospitals with a bed count of 30 or fewer and apply a penalty of $10/bed/day for hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500." [See also: text of proposed regulations and a Fact Sheet.]

Tags: Health Plan Administration  •  Health Plan Costs

Insurer Filings Suggest COVID-19 Pandemic Will Not Drive Health Spending in 2022
Henry J. Kaiser Family Foundation Link to more items from this source
July 20, 2021

"This brief reviews initial 2022 premium rate filings for Marketplace-participating individual market insurers in 13 states and the District of Columbia.... [M]ost of these insurers expect health utilization patterns to return to pre-pandemic levels and therefore most are factoring in no additional costs or savings related to COVID-19 into their 2022 premiums. These insurers also tended to make similar assumptions about how COVID-19 would affect their group market costs."

Tags: Coronavirus (COVID-19)  •  Health Plan Costs


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