Concerns Rise Over Letting Employers Fund HRAs for Individual Health Plans

Employers, health insurers, regulators and hospitals are all raising concerns about the Trump administration’s rules issued last year that allow employers to fund health reimbursement arrangements (HRAs) that their workers can use to purchase health plans on the open market.

The Centers for Medicaid and Medicare Services, IRS and the Department of Labor issued the final rules in late 2019. They reverse one of the major pinch-points of the Affordable Care Act, which bars employers from paying employees to buy their own health insurance either on publicly run health insurance exchanges or on the open market.

The fine for breaching this part of the law is a hefty $36,500 annually.

The rules continue to receive pushback from small business groups, insurers, regulators and others, who say that employers who want to go this route are facing a bureaucratic nightmare.

And one of the biggest concerns is that employers will use the opportunity to move older and sicker workers from their group health plans to exchanges, in order to reduce the cost burden on their plans.

Complexity a major issue

The National Federation of Independent Business has said that small businesses that want to offer workers an HRA integrated with an individual-market health plan are facing a lot of complexity.

“NFIB recommends that your departments plan to release… a publication that explains in plain English, step-by-step, how small businesses can establish, administer, and comply with the rules,” the group wrote.

HRAs are tax-sheltered accounts funded employers that typically are offered to reimburse employees for out-of-pocket medical expenses. This rule expands how those HRAs can be used. HRAs have been tax-advantaged only if they are coupled with an ACA-compliant group health plan. They cannot be used now to pay premiums for individual-market health insurance.

Under the rule, employers could provide an HRA that is integrated with individual health insurance coverage. The rule does include provisions to prevent employers from steering workers or dependents with costly health conditions away from the employer group plan and toward individual coverage.

Employers also could offer a different type of HRA, funded up to $1,800 a year, that could be used by employees to pay premiums for short-term plans that don’t comply with ACA consumer protections.

Employers could not offer the same employees the choice of either a traditional group plan or an HRA-funded individual-market plan. But they could offer a group plan to certain classes of employees, such as full-time workers under age 25, and an HRA plan to other classes, such as part-time employees.

Fears many may be shunted from group plans

Other concerns that are being raised include those by the American Academy of Actuaries that self-insured employers, in particular, may use the rule to shunt less healthy employees out of their group health plans, which in turn could result in worsening the ACA individual-market risk pool.

The Federation of American Hospitals expressed concern that the proposal would shift people out of the employer group market into the less stable individual market, which offers thinner benefits and less support for consumers.

The conservative National Federation of Independent Business supports the new rule but is concerned that it will be a complex process to set this type of arrangement up, especially for small businesses.

The liberal Center on Budget and Policy Priorities said the proposal to let a special type of HRA be used to buy short-term plans could be challenged legally, because the ACA and the Health Insurance Portability and Accountability Act (HIPAA) prohibit group plans from discriminating based on health status, as short-term plans are allowed to do.

Employer Guide for Dealing with the Coronavirus

As the outbreak of the 2019 novel coronavirus gains momentum and potentially begins to spread in North America, employers will have to start considering what steps they can take to protect their workers while fulfilling their legal obligations.

Employers are in a difficult position because it is likely that the workplace would be a significant source of transmission among people. And if you have employees in occupations that may be of higher risk of contracting the virus, you could be required to take certain measures to comply with OSHA’s General Duty Clause.

On top of that, if you have workers who come down with the virus, you will need to consider how you’re going to deal with sick leave issues. Additionally, workers who are sick or have a family member who is stricken may ask to take time off under the Family Medical Leave Act.

Coronavirus explained

According to the Centers for Disease Control, the virus is transmitted between humans from coughing, sneezing and touching, and it enters through the eyes, nose and mouth.

Symptoms include a runny nose, a cough, a sore throat, and high temperature. After two to 14 days, patients will develop a dry cough and mild breathing difficulty. Victims also can experience body aching, gastrointestinal distress and diarrhea.

Severe symptoms include a temperature of at least 100.4ºF, pneumonia, and kidney failure.

Employer concerns

OSHA — OSHA’s General Duty Clause requires an employer to protect its employees against “recognized hazards” to safety or health which may cause serious injury or death.

According to an analysis by the law firm Seyfarth Shaw: If OSHA can establish that employees at a worksite are reasonably likely to be “exposed” to the virus  (likely workers such as health care providers, emergency responders, transportation workers), OSHA could require the employer to develop a plan with procedures to protects its employees.

Protected activity — If you have an employee who refuses to work if they believe they are at risk of contracting the coronavirus in the workplace due to the actual presence or probability that it is present there, what do you do?

Under OSHA’s whistleblower statutes, the employee’s refusal to work could be construed as “protected activity,” which prohibits employers from taking adverse action against them for their refusal to work.

Family and Medical Leave Act — Under the FMLA, an employee working for an employer with 50 or more workers is eligible for up to 12 weeks of unpaid leave if they have a serious health condition. The same applies if an employee has a family member who has been stricken by coronavirus and they need to care for them.

The virus would likely qualify as a serious health condition under the FMLA, which would warrant unpaid leave.

What to do

Here’s what health and safety experts are recommending you do now:

  • Consider restricting foreign business trips to affected areas for your employees.
  • Perform medical inquiries to the extent legally permitted.
  • Impose potential quarantines for employees who have traveled to affected areas. Ask them to get a fitness-for-duty note from their doctor before returning to work.
  • Educate your staff about how to reduce the chances of them contracting the virus, as well as what to do if they suspect they have caught it.

If you have an employee you suspect has caught the virus, experts recommend that you:

  • Advise them to stay home until symptoms have run their course.
  • Advise them to seek out medical care.
  • Make sure they avoid contact with others.
  • Contact the CDC and local health department immediately.
  • Contact a hazmat company to clean and disinfect the workplace.
  • Grant leaves of absence and work from home options for anyone who has come down with the coronavirus.

If there is a massive outbreak in society, consider whether or not to continue operating. If you plan to continue, put a plan in place. You may want to:

  • Set a plan ahead of time for how to continue operations.
  • Assess your staffing needs in case of a pandemic.
  • Consider alternative work sites or allowing staff to work from home.
  • Stay in touch with vendors and suppliers to see how they are coping.
  • Consider seeking out alternative vendors should yours suddenly be unable to work.

Reference Pricing Can Reduce Medical Outlays, Costs

In an effort to coax health plan participants to use price-shopping behavior when deciding on where to have a procedure, more insurers are starting to roll out a system known as “reference pricing.”

With reference pricing, the health insurer imposes a limit on the amount it will pay for a particular procedure – a limit that is reasonable and allows access to care for patients. The price is usually a median or average price in the local market.

When a health plan participant selects a provider that charges less than the cap, they will receive the standard coverage with little or no cost-sharing.

But, if they decide to use a provider that charges more than the cap, the participant will have to pay the entire difference out of pocket. These excess payments do not count towards the patient’s deductible or the annual out-of-pocket maximum.

Use of reference-based pricing rose from 11% to 13% among large employers in 2015, according to a study by Mercer Benefits.

Proponents of reference pricing say that it can reduce health care spending because it encourages people to shop for better deals and, eventually, encourages hospitals to lower their prices.

Organizations that have implemented reference pricing report lower outlays for procedures.

CalPERS, the pension fund for California state employees, in 2011 began reference pricing and asked its preferred provider organization, Anthem Blue Cross, to research the average costs for hip and knee replacements among hospitals and develop a program that ensures sufficient coverage by those hospitals that meet a certain cost threshold.

The program set a maximum of $30,000 for these procedures.

The number of Anthem-CalPERS enrollees who chose a designated high-value hospital for their knee or hip replacement surgery increased from 50% between 2008 and 2010 to 64% in the first nine months of 2012, compared with little to no change among Anthem policyholders not enrolled in CalPERS.

Also, the average price for such procedures fell from more than $42,000 before the initiative to $27,148 in the first nine months of 2012.

The changes resulted in savings of about $5.5 million during the first two years of the reference pricing initiative, and the average cost to CalPERS for the procedures fell by 26%.

CalPERS says that after it implemented reference pricing, some of the hospitals that charged more than the payment limit significantly reduced their prices for the procedure.

These price reductions have increased; the number of California hospitals charging prices below the CalPERS $30,000 reference limit rose from 46 in 2011 to 72 in 2015.

Limits of reference pricing

To be clear, reference pricing cannot be applied to all procedures.

It should only be used for procedures or products that health plan enrollees can shop for, and when they have time to compare choices based on price and quality. This can include:

  • Scheduled procedures like the aforementioned knee replacements
  • Ambulatory surgical procedures
  • Lab tests
  • Imaging
  • Pharmaceuticals

What it should not be used for:

  • Emergency procedures
  • Unique components of care that the patient can’t select independently, like a lab test during a visit to a doctor
  • Complex medical conditions

Trends Shaping Health Insurance and Health Care in 2020

As a new decade begins, the health insurance industry is on the cusp of making a leap towards improved, higher-tech management of health plan participants.

A recent paper by Capgemini, an insurance technology and consulting firm, predicts the following trends that will be taking shape in the health insurance industry and how they may affect businesses that are paying for their employees’ coverage.

1. Realigned relationships — Insurers are trying to shift risk between themselves and pharmaceutical companies in an effort to reduce drug outlays. The report says insurers are also working more closely with health care providers for early intervention in medical issues that may be facing participants. Addressing health issues early can reduce long-run treatment costs.

2. Fluid regulations — As we’ve seen, just because the Affordable Care Act became the law of the land, the regulations governing health care and health insurance have continued streaming out of Washington. If the last two years are any guide, this will continue to be the case. Also, the constitutionality of the ACA is now being litigated once again after an appeals court upheld a lower court’s ruling that the individual mandate is unconstitutional.

3. Increasing transparency — More stringent regulations, along with President Trump’s recent executive order to improve price and quality transparency, are forcing the health care industry and insurers to become more transparent in their pricing.

One of the biggest focuses is on the drug industry and the role of pharmacy benefit managers, the largest of which have been criticized for being opaque in their pricing, discounts and how they handle drug company rebates.

Also, insurers are increasingly providing detailed information regarding services covered under their health plans, claims processing and payments. Additionally, some insurers are helping enrollees to make more informed decisions before they use a health care service by providing digital tools to help them reduce out-of-pocket expenses.

4. Predictive analytics — Health insurers are using predictive analytics for risk profiling and early intervention for enrollees with health issues. Predictive analytics provide insurers with insightful assessments of potentially high-risk customers, in order to mitigate losses.

With advancements in technologies such as big data and connected devices, insurers now have access to vast amounts of customer data, which can be used to remind people it’s time for their check-ups, medications and other necessary medical services.

Insurers are using predictive analytics to identify and monitor high-risk individuals to intervene early and prevent further complications. This in turn can help reduce claims.

Congress Eliminates the ‘Cadillac’ and Other ACA Taxes

Congress before the new year passed legislation repealing the so-called “Cadillac tax” on generous group health plans, as well as two other taxes, finally putting to bed an issue that has plagued the Affordable Care Act since its inception.

Although it had not yet been implemented, employers didn’t like the Cadillac and labor unions came out against it as well. It was so unpopular that Congress voted twice to delay implementation, which was originally set to start in 2018. The latest start date had been pushed until 2022.

The Cadillac tax, an enacted but not yet implemented part of the ACA, is a 40% levy on the most generous employer-provided health insurance plans — those that cost more than $11,200 per year for an individual policy or $30,150 for family coverage. It was designed to only tax the portion of the premium that was above the threshold.

Effect of repeal on group plans

The tax would have been levied on health plans, which are legal entities through which employers and unions provide benefits to employees. It would have been paid by employers, but its impact on employees would be indirect and would have depended on how firms and health plan managers responded to the tax in offering and designing benefits.

None of these issues now need to concern employers offering group plans.

The tax was eliminated as part of a $1.4 trillion year-end budget bill that President Trump signed in order to keep the government open. Here are all the ACA-related taxes that the legislation eliminated:

  • The Cadillac tax, which had been expected to raise $197 billion over 10 years.
  • Starting in 2021, the health insurance tax, which had been projected to raise $150 billion over the next decade, and
  • The 2.3% excise on the sale of medical devices, which had been expected to generate $25.5 billion in the next 10 years.

High-Deductible Plans Saddling Workers with Bigger Drug Outlays

A new study has found that high-deductible plans and increased use of coinsurance are exposing health plan enrollees to higher and higher pharmaceutical costs.

One of the big problems for many enrollees in high-deductible plans is that their outlays for drugs may not count towards their health plan deductibles and, if they are enrolled in separate pharmaceutical plans, they may have to pay the full list price until they meet their drug deductible, according to the “2019 Kaiser Family Foundation Employer Health Benefits Survey.”

The report warns of a growing crisis for American workers, more and more of whom are struggling with their health expenditures, be they premiums, deductibles, copays and/or coinsurance.

Workers in small firms face relatively high deductibles for single coverage and many also are saddled with significant premiums if they choose family coverage, according to the study.

The cost of group health insurance is growing at about 4% to 5% a year, reaching $7,188 for single coverage in 2019 and $20,576 for family coverage.

Workers in small firms on average contribute 16% of the premium for single coverage, compared with workers at large firms (19%), according to the report. But small-firm employees contribute 40% on average for family coverage, compared to 26% for staff at larger firms.

That said, 35% of covered workers in small firms are in a plan where they must contribute more than one-half of the premium for family coverage, compared to 6% of covered workers in large firms.

But premium contributions are only part of the story. Eighty-two percent of covered workers have a general annual deductible for single coverage that must be met before most services are paid for by the plan, and that average deductible amount is $1,655. But, the average annual deductible among covered workers with a deductible has increased 36% over the last five years, and by 100% over the last 10 years.

The hidden cost-driver

With all this as a backdrop, the cost of prescription drugs is one of the largest challenges facing group health plan enrollees, especially those who are enrolled in high-deductible health plans, whose out-of-pocket expenses for pharmaceuticals can be especially burdensome. It is the hidden cost-driver in the system.

The Kaiser survey found that about 90% of covered workers are enrolled in plans where the health plan deductible must be met before prescription drugs are covered. But, this number has been shrinking as group coverage pricing increases and employers shift more of the cost burden to employees.

There are a few ways that employees are taking on a significant load with their drug expenditures:

  • First, more workers are enrolled in plans that carve out prescription drugs, meaning that their expenditures on medication do not count towards satisfying their health plan deductibles. About 13% of employees are enrolled in a plan with a separate annual deductible that applies only to prescription drugs.
  • Many people with workers face out-of-pocket costs linked to prescription list prices regardless of the actual net, post-rebate costs. That’s because coinsurance percentages are computed based on the price negotiated between the pharmacy and the plan or pharmacy benefit manager. These negotiated prices are typically close to list prices.

    Even worse, patients pay the entire negotiated price when they are within a deductible and do not enjoy the benefits of rebates that the PBM may have negotiated with drug makers. Patients with these benefit designs do not benefit from rebates, though major brand-name drug makers sell their products at half of the list prices.
  • In the past, health plans had two- or three-tier benefit designs for drugs, mostly for generics and brand-name drugs, with lower copays and coinsurance for the lowest-tier medicines. But as prices have started increasing, many plans have four tiers and sometimes five (the specialty tier).

    The disappearance of two- and three-tier benefit designs have made out-of-pocket expenses especially high for specialty drugs. Plans place therapies for such chronic, complex illnesses as cancer, rheumatoid arthritis, multiple sclerosis and HIV on the fourth and specialty tiers of benefit plan, for which the enrollee has to pay a larger share.

Average Family Plan Cost Hits $20,000 for First Time; What Can You Do to Cut Costs?

A new study has found that the average annual premium for a group family health plan has exceeded $20,000 for the first time in 2019, up 5% from 2018.

The average premium for single coverage plans in 2019 is $7,188, up 4% from the year prior, according to the Kaiser Family Foundation’s annual report on employer coverage.

The costs of high-deductible health plans are only slightly less than the average. The average premiums for covered workers in HDHPs with an attached health savings account are $6,412 for single coverage and $18,980 for family coverage.

Increasingly, workers are picking up a larger portion of the health care and insurance tab. In 2019, they are paying $6,015 on average in premiums for family coverage, or about 29% of the total tab. Workers with individual coverage contribute 17.3% toward the total premium.

Additionally, the average deductible for single coverage is $1,655 in 2019, which is unchanged from the year prior, however, the deductible is often higher for workers in small firms ($2,271) compared to large businesses ($1,412).

The average annual deductible among covered workers with a deductible has increased 36% over the last five years and 100% over the last 10 years, according to the report.

Also, 66% of workers have coinsurance and 14% have a copayment for hospital admissions. The average coinsurance rate for a hospital admission is 20%, and the average copayment is $326 per hospital admission.

Another survey by the Kaiser Family Foundation and the Los Angeles Times found that 40% of group health plan enrollees had difficulty affording health insurance or health care, or had problems paying medical bills.

And close to 50% said that they or a family member had skipped or postponed getting health care or prescriptions in the past year due to costs.

Easing the burden

There are steps you can take to ease the burden on both your company and your employees.

Consider plans with telemedicine – More and more employers (69% of firms with 50 or more workers) are offering health plans that cover the provision of health care services through telemedicine. Telemedicine can greatly reduce the cost of care in terms of price for medical visits, as well as the time involved for the employee to travel to the doctor. Telemedicine can include video chat and remote monitoring.

Utilizing retail health clinics – More health plans will pay for services rendered by retail clinics, like those located in pharmacies, supermarkets and retail stores. These clinics are often staffed by nurse practitioners or physician assistants and treat minor illnesses and provide preventative services. They can greatly reduce the cost of care for these kinds of visits outside normal hospital systems.

Plans with narrow networks – If a health plan can contract with fewer doctors and specialists, there is often less outlay for care. At this point, the jury is still out on exactly how much can be saved, but there are also drawbacks such as:

  • Disruption of provider relationships
  • Employee backlash
  • Reduced access or convenience for employees
  • Lack of specialists.

Tiered or high-performance networks – These networks typically group providers in the network based on the cost, quality and/or efficiency of the care they deliver and use financial incentives to encourage enrollees to use providers on the preferred tier.

Telemedicine Taking Off, Reducing Health Costs

One of the fastest growing parts of the health care system, and which touches significantly on group health plans, is telemedicine.

From 2016 to 2017, insurance claims for services rendered via telehealth ― as a percentage of all medical claim lines ― grew 53% nationally, faster than any other avenue of care, according to “FH Health Indicators,” a white paper published by the nonprofit FAIR Health.

Telehealth uses technology to provide remote care via video conferencing and other means and is proving to be more and more effective, especially for time-pressed individuals or people who live in rural areas where patients often have to travel great distances for care.

Elderly patients especially find it useful, since it eliminates the need for transportation.

But as telehealth gains traction, the focus is shifting away from the novelty of connected devices and new technology and more toward providing patients with top-notch care ― and giving providers, physicians and nurses alike the power to deliver it effectively. As it evolves, it is also a promising new trend in terms of reducing health care delivery costs.

Telehealth can reduce the cost of care by eliminating the physical barriers that prevent patients from managing their health. As more patients take advantage of digital services like remote patient monitoring, automatic appointment reminders, and remote physician consulting using live video and audio, patients can use these services to reduce the cost of care and improve their chances of early detection.

And that can reduce your overall group health plan costs, as well as out-of-pocket costs for your employees.

Tech firms are coming up with more efficient ways for patients to communicate with their doctors that save time and money, and reduce liability for doctors as well. For example, more and more health care practitioners are adopting an online patient portal as a direct link between the patient and the doctor.

Doctors, patients embrace online portals

The portal can easily be password-protected for each patient and streamline routine interactions from appointment-setting to refilling prescriptions ― and everything in between. 

For example, when it’s time to get a prescription refilled, the patient simply makes a request to his or her doctor, via the patient portal or even via a cell phone or tablet app that can be proprietary to the practice. The doctor checks the dosage and approves the request in a few clicks, and in seconds the information is sent directly to a pharmacy so the patient can pick up the prescription.

The patient doesn’t have to get the doctor on the phone or bug the staff for a moment with the doctor, and the doctor doesn’t have to do additional paperwork or get on the phone with the pharmacy to call in the prescription after already having spoken with the patient on a separate call. The result is tremendous time savings ― and ultimately, cost savings for both the doctor and patient.

Online portals also facilitate communication between doctors and patients between appointments. If a patient has a question or clarification that does not warrant an additional office visit, the doctor or staff can quickly respond in an instant, without playing phone tag, and without having to route calls to busy doctors who can’t always be on the phone.

Physicians can also leverage these portal technologies to send lab results and images directly to the patient using a secured and encrypted link, and to make clinical summaries easily available online. When the doctor adds new information to the file, such as a lab report, the portal system can be programmed to automatically send an e-mail alert to prompt the patient to log onto the portal.

For all the technology though, we still have a way to go in implementing it. According to a recent study in the Journal of General Internal Medicine, 57% of respondents said they want to use their doctor’s website to review their medical records, but only 7% of those polled reported having made use of that technology to access their own information online.

A study from the Annals of Internal Medicine found that 77% to 87% of individuals who used their physician’s portal to open at least one note, and who completed a post-intervention survey, said that the process helped them be more in control of their health care.

Court Rules ACA Individual Mandate Unconstitutional

The U.S. Fifth Circuit Court of Appeals has upheld a lower court’s decision that the individual mandate portion of the Affordable Care Act is unconstitutional because the penalty was set to zero in 2017.

However, the fate of the entire law is still in play after the court remanded the question of whether that means the entire ACA should be declared void back down to the district court.

Proponents of abolishing the ACA say that its lack of a “severability provision” means that if any element of the ACA is found unconstitutional, the entire law must go. However, that would likely create chaos for the health insurance marketplace.

Two of the three judges on the court on December 18 upheld a lower court’s decision that the individual mandate is not constitutional because it cannot be construed as a tax.

The judges wrote: “The individual mandate is unconstitutional because it can no longer be read as a tax, and there is no other constitutional provision that justifies this exercise of congressional power. On the severability question, we remand to the district court to provide additional analysis of the provisions of the ACA as they currently exist.”

The decision prolongs the court process and ensures that the future of the landmark health care law remains uncertain.

There is much at stake in this case. If the entire law is thrown out by courts, it would reverberate through the health care industry, including insurance providers and hospitals, and put the coverage of millions of Americans at stake.

The decision would affect people who buy coverage in the individual market and those with coverage through Medicaid expansion, Medicare and from their employers.

The ruling that the individual mandate is unconstitutional will be appealed to the U.S. Supreme Court by the 20 Democratic states that are now defending the ACA in this court fight against republican states that filed the suit to abolish the law on the grounds that it is unconstitutional.

Some background

The ACA individual mandate provision ― or “individual shared responsibility” provision ― initially required many people to own what the government classifies as solid major medical coverage, or else pay a penalty. Congress passed a tax bill in 2017 that included a provision setting the penalty at zero.

ACA critics challenged the mandate through a case that reached the Supreme Court in 2012.

In a ruling on that case, the Supreme Court held that a federal law that blocks challenges to new taxes protected the individual mandate provision, because the penalty was a tax.

Critics of the provision say that, now the new tax law has set the individual mandate penalty at zero, the individual mandate is no longer a tax and can no longer benefit from the legal protection accorded to federal taxes.

The takeaway

Because of this ruling, the lower court will likely start hearings on whether the entire law should be thrown out based on the elimination of the penalties for not securing coverage.

The other part of the ruling, that the individual mandate is unconstitutional, is destined for appeal to the Supreme Court. It’s unlikely that it would be heard in 2020 and that the issue about the fate of the rest of the law will take years to wind its way through the courts.

Happy New Year!

May this year bring new goals, new achievements, and a lot of new inspirations for life. Wishing you a year fully loaded with happiness! Cheers to a prosperous 2020!

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