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Court Ruling Illustrates Importance of Clear and Concise Benefits Communication

"A recent court ruling granting class certification to individuals suing Blue Shield of California over its refusal to cover a procedure it considers experimental and investigational (E&I) speaks to the importance of both payers and employers making it very clear what it will and will not cover -- and where members and providers can check to see if a recommended procedure or supply falls into the 'E&I' category.... Payers and employers alike should carefully review their summary plan descriptions, contracts and websites to make sure E&I is described clearly and accurately, and that consumers and providers alike know exactly where to locate information." [Escalante v. California Physicians' Service dba Blue Shield of CA, No. 14-cv-03021 (C.D. Cal. July 14, 2015)]

GOP Funding Bill Proposes Cuts to CMS, DOL

"[T]he U.S. House Appropriations Committee released its draft fiscal year 2016 Labor, Health and Human Services (LHHS) funding bill, which includes substantial cuts to [CMS] and the [DOL]. The bill also appears designed to block several key provisions of the ACA.... Specifically, the bill: [1] Prohibits all funding for Center for Consumer Information and Insurance Oversight (CCIO) programs; [2] Eliminates the Health & Human Services' Agency for Health Research on Quality; [3] Bans use of funds to: [a] Support patient centered outcomes research (rescinding $100 million in funding for the Patient Centered Outcomes Institute (PCORI)), [b] Implement, further, enforce or advance the Navigators program, or [c] Carry out Title X of PHS -- the National Family Planning Program."

Dramatic Shift to Consumer-Directed Health Plans

"71 percent of employer health plans have individual, in-network out-of-pocket maximums (OOPMs) of $2,500 or more in 2015, up from 66 percent in 2014 and 58 percent in 2013.... ER copays increased 9 percent, reflecting the rising cost of hospital care as well as the cost-share increase between the plan and participants.... Across the board, out of network preventive service costs were higher with the exception of a routine mammogram."

ACA Reporting Readiness a Concern for Employers

"26 percent of small employers (less than 1,000 employees) are still undecided regarding whether they will implement a solution in-house or an outsourced solution to facilitate reporting, while 37 percent of large employers (5,000 or more employees) reported that they are in discussions with outsourced vendors currently, and 12 percent have not yet considered any solutions or do not know."

HHS Proposal Places Greater Emphasis on Summary of Benefits and Coverage

"For payers participating in the public marketplace, [CMS] is proposing to ... require individual payers to provide an SBC for 'plan variations,' which essentially are reduced cost-sharing options for essential health benefits, as part of the Qualified Health Plan (QHP) process.... [T]here have been rumblings that HHS, DOL and IRS are considering adding coverage examples beyond diabetes and child birth.... In addition, after three years of minimal change, there's a possibility that the SBC format could change for the 2016 plan year."

Supported State-Based Marketplace Model May Gain Traction

"The [supported state-based marketplace (SSBM)] is similar to the partnership model but allows for more state autonomy.... [A] primary point of difference between these two models is possession of final decision-making authority.... SSBM states will not be required to pay the 3.5 percent user fee for using Healthcare.gov in 2015.... SSBM states are provided full autonomy in setting the marketplace user fees and establishing a plan for sustainability, while partnership marketplaces are required to use the 3.5 percent premium assessment that is required by the FFM."

Health CO-OPs Stumble

"CO-OPs have blamed the weak enrollment figures on various obstacles during the first year, including: higher prices than some of the national payers, the administration's decision to allow people to renew noncompliant plans, and problematic health exchange interfaces. Disappointing enrollment figures are especially troubling given the $2 billion in federal loans supporting the CO-OPs."

Final ACA Rule Permits One-Month Orientation Period

"[In] some cases the employer may not be able to utilize fully both the one-month orientation period and 90-day waiting period without potentially becoming subject to an assessable payment under Code section 4980H, if those periods would cause the employer to not offer coverage by the first day of the fourth full calendar month of employment.... The departments anticipate that the cost impact of the rules will be limited as it is anticipated that the inclusion of an orientation period will not result in most employees facing a full additional month between being hired and obtaining coverage."

Growing Shift in the Health Plan Cost Burden from Employers to Employees

"Two-thirds of 2014 medical plans have individual, in-network out-of-pocket maximums of $2,500 or more. This is up from 58 percent of plans in 2013, and 49 percent in 2012. 42 percent of plans charge coinsurance for office visits, up from 35 percent in 2013. Emergency room (ER) visit co-pays have increased by roughly $3 per year since 2009, with a 2014 average of $113 per visit. The percentage of plans with high deductibles grew by 2 percent in 2014 from 23 percent to 25 percent."

Employers Remain Uncertain About Private Exchanges

"50 percent of employers have begun to evaluate new private exchange options, while 71 percent of employers are looking into adopting a self-insured model.... 50 percent of employers were unsure of how private exchanges would impact recruiting and/or retention, while 20 percent believed it would have a significant impact and 10 percent believed that there would be no impact. The majority (67 percent) of employers agree that private exchanges are a viable option, but that it will just be considered another offering in a suite of benefits choices."