Biden Administration Clamps Down on Short-Term Health Insurance

The Biden administration has rolled back regulations that allow Americans to stay on short-term health insurance plans for up to three years while still satisfying the Affordable Care Act’s individual mandate.

The new rules will limit these controversial plans to no more than four months and they require more disclosure on behalf of the insurers and agents that sell these plans to help consumers understand what they are buying.

These plans are not full-fledged health plans; they offer limited scope of coverage that caps insurance for many services, and they are not subject to ACA consumer protection rules that bar discrimination and guarantee coverage regardless of pre-existing conditions.

The ACA originally limited short-term plans to just three months to fill temporary gaps in coverage when someone is transitioning from one source of coverage to another. The Trump administration enacted new regulations that allowed people to stay on a plan for 12 months, with the option to renew for three years.

These plans have gotten a lot of bad press citing horror stories of people finding out their policies were virtually useless, leaving one man more than $43,000 in debt after his plan wouldn’t pay for his treatment after it deemed his cancer a pre-existing condition.

Critics say the plans are deceptively marketed and consumers are duped into buying health insurance that has stripped-down coverage. Proponents say that these plans serve a valuable purpose in helping people transition from one type of coverage to another.

Many people who have purchased these plans thought they were receiving comprehensive coverage but were surprised later when the insurance wouldn’t cover certain procedures or capped coverage.

Some common features of short-term plans are:

  • They often use health histories to determine who can get coverage.
  • They often exclude key service categories from covered benefits, such as maternity.
  • They can decline coverage due to pre-existing conditions.
  • They may limit or cap coverage both on a per-service or daily rate basis or in the aggregate (like capping total payments during the year at $100,000).
  • They are not required to cover the 10 essential health benefits that the ACA requires compliant plans to cover at no cost to the enrollee.

 

What the final rule does

The new regulations only apply to new plans that are launched on or after June 17, the day the final rule takes effect.

New plans that claim to be “short-term” health insurance will be limited to just three months, with renewal for a maximum of four months total, if extended.

Also, the final rule restricts how these plans may be marketed and requires new levels of disclosure. Plans will now be required to provide consumers with a clear disclaimer that explains the limits of what services they cover and how much they cover. 

It should be noted that the new rule does not affect fixed indemnity plans like critical illness, which pays a lump sum if someone is diagnosed with a covered illness. Other plans pay a pre-determined amount on a per-period or per-incident basis, regardless of the total charges incurred.

Plans might pay $200 upon hospital admission, for example, or $100 per day while a person is hospitalized to help with out-of-pocket costs.

Smallest Firms See Largest Health Insurance Hikes

A new report has found that small businesses that purchase their group health insurance online or through payroll vendors saw the largest premium hikes in 2022, significantly higher than those that went through brokers.

Overall rates for employers with 10 or fewer employees saw their family plan health insurance premiums jump 12% from 2021, compared to just 5.4% for all small to mid-sized businesses with up to 250 employees, according to the report by HR and benefits software company Ease.

The cost for individual group health plans increased 6.7% for the smallest SMBs, compared to just 4.3% overall between 2021 and 2022. As stated, the numbers for smaller companies were the most pronounced for those who buy their coverage online or via payroll vendors.

Meanwhile, employees’ share of premiums increased at a slower rate overall of 4.15% between 2021 and 2022, meaning that employers were not passing on the full increases in group health plan premiums to their staff.

Since 2018, individual premiums have increased by 21% while family premiums have increased by 18%. To put it into dollar signs, that’s an extra $104 for individuals and $231 for families each month for medical insurance.

The Ease report notes that those higher premiums are likely hurting those small employers more than larger SMBs with between 51 and 250 workers. The latter have seen an increase in health plan enrollment among their employees between 2018 and 2022, while those with one to 50 employees saw overall decreases. Overall, more than half of SMB employees opt out of their employer-sponsored coverage.

The HDHP effect

The report found that health maintenance organizations and preferred provider organizations continue to dominate the landscape in group health benefits for SMBs. While high-deductible health plan (HDHP) enrollment grew at an astounding 68% between 2021 and 2022, they only accounted for 6% of group health plan enrollment.

Some employers have gravitated towards HDHPs to reduce their and their employees’ overall premium spend, but these plans come at a cost: more out-of-pocket costs for workers.

In those cases, Ease CEO and co-founder David Reid recommends pairing an HDHP plan with other voluntary benefit plans that can “insure” gaps in coverage, such as short-term disability plans and group supplemental health insurance plans called Gap plans. They are similar to the Medigap supplemental insurance plans millions of seniors purchase each year to fill in holes in Medicare parts A&B.

Gap plans can help by providing coverage when employees have not met their health care deductible. These plans may cover most inpatient and outpatient services that are covered by the underlying primary health care plan and applied to the deductible or coinsurance provision.

Plans differ and employers may choose a variety of coverage options, including varied inpatient and outpatient benefits. Deductibles can be added to the plan to manage premium costs.

Coverage can often be configured to be compatible with HDHPs using health savings accounts.

Importance of your broker

Reid said that the report’s findings illustrate the importance of employers working with brokers and consultants to purchase their employee benefits.

“[SMBs] getting good advice are using more innovative solutions that allow them to make their dollars go as far as a large corporation’s dollar-spend on benefits,” he told the trade publication BenefitsPro. “Those who are bypassing a consultant and purchasing benefits through, say, their payroll vendor are generally seeing fully insured, off-the-shelf plans that increase in cost more quickly.”

As your broker, we have access to plans from different carriers and can work with you to put together offerings that will best accommodate your employees.

Besides Health Insurance and 401(k)s, These Are the Benefits Employees Value Most

Besides health insurance and a 401(k) plan, other benefits that employees value highly are generous paid time off and flexible or remote work, according to a new survey.

But for the first time, the annual study by employee benefits provider Unum found that the younger generations are not on the same page with their older peers when it comes to what they value most in their benefits package.

“A multi-generational workforce is a huge benefit for companies,” said Liz Ahmed, executive vice president of People and Communications at Unum. “With the diversity of background, experiences, and thought employees bring, employers need to make sure there’s something in their benefits package for everyone’s different stage of life.”

Although the generations differ in their top three priorities, when opened to the top five, there is one common denominator: emergency savings.

Emergency savings

Sixty-four percent of employees surveyed said they do not have access to an emergency savings option through their employer. This benefit ranks third for boomers (25%), third for Gen X (32%) and second for Gen Z (37%).

Emergency savings plans can help prepare your employees for unexpected expenses — without dipping into retirement funds or using credit cards.

Employer-sponsored emergency savings accounts help workers save for financial emergencies by automatically deducting an amount from each paycheck and depositing it into a separate account. If they need to cover a bill or cash gets tight, they can draw from this fund to bridge a financial gap.

Also, with mental health support and resources high on the list for younger workers, employers may consider tapping an employee assistance program. EAPs are voluntary, work-based programs that offer free and confidential assessments, short-term counseling, referrals and follow-up services to employees who have personal and/or work-related problems.

You can use the following list as a general guidepost if you are considering adding voluntary benefits to your employee offerings.

These are the top 15 non-insurance benefits for U.S. workers:

  • Generous paid time off program
  • Flexible/remote work options
  • Paid family leave (for childcare or caring for an adult family member)
  • Mental health resources/support
  • Emergency savings
  • Professional development
  • Financial planning resources
  • Fitness or healthy-lifestyle incentives
  • ID theft prevention
  • Gym membership or onsite fitness center
  • Student loan repayment benefits
  • Pet-friendly offices
  • Personalized health coaching
  • Sabbatical leave
  • Dedicated volunteer hours.

A final thought

There are so many voluntary benefits to choose from that it’s important that you opt for ones that your employees actually want. A good way to gauge their interest is to conduct your own survey by asking them which benefits they would like to see and offering them a list to choose from.

Most Workers Make Bad Health Insurance Decisions

Even though the majority of workers receive health insurance coverage on the job, a new survey has found that many of them understand surprisingly little about their health plans and are leaving money on the table.

The “Health Insurance Literacy Survey” by Healthcare.com found widespread misunderstanding about how copays and deductibles work, and what premiums and benefits are.

Experts say that when people don’t understand their health insurance they may make poor coverage decisions, such as choosing plans that provide more benefits than they need, or too few.

Those poor choices can be costly in terms of the premiums they pay or what they pay in copays, coinsurance and deductibles out of pocket.

Some of the key findings:

  • 26% of Americans surveyed say lack of health insurance understanding caused them to receive a higher-than-expected medical bill.
  • 41% were unable to correctly answer what “in-network” means. Understanding the meaning of in-network is crucial when choosing where to receive treatment and avoiding paying excessive fees for medical services when going out of network. Most health plans do not cover out-of-network care.
  • 59% don’t understand that low-deductible health insurance plans start paying out sooner than high-deductible health plans (HDHPs).
  • 22% incorrectly believe that if they think their medical expenses will be low in the coming year, they should choose a low-deductible plan.
  • 43% of those surveyed could correctly identify what a health savings account is, and 20% could not describe a single feature of these tax-advantage accounts.

What it costs them

The costs of choosing the wrong plan can be in the thousands of dollars per year, according to a 2021 analysis conducted by Trevor Collier and Marlon L. Williams, both associate professors of economics at the University of Dayton in Ohio.

Collier and Williams found that 97% of 2,300 employees studied would have been better off choosing a plan that had lower premiums, but higher cost-sharing for medical services. Despite that, 23% chose the higher premium plan anyway.

They calculated that the average cost per year of choosing the wrong plan was more than $2,000.

The study shows just how little many people know about their health insurance coverage. As their employer, you can help your employees make good choices about their health coverage.

What you can do

During your open enrollment meetings, you should go over some of the basics of coverage and explain that people who are not frequent health care users may be better off in high-deductible health plans, that have a lower premium in exchange for more out-of-pocket expenses.

Conversely, people who have chronic conditions are not good candidates for HDHPs.

Make sure to schedule a series of meetings in the run-up to open enrollment where you can go over the basics of how health insurance works. Get your human resources team to urge staff to schedule time with them if they have any questions.

Alleviating Health Insurance Burden on Employees a Top Priority: Poll

As the 2023 group health open enrollment season nears, more employers have heard concerns among their staff and are focusing on affordability and easier access to health care services, according to a new study.

Mercer’s “Health & Benefit Strategies for 2023” study, which surveyed more than 700 employers, found that more than two-thirds of businesses are planning to improve their health benefit options to better compete for talent.

The survey found that 70% of all large employers were planning benefit enhancements for 2023. While small employers are somewhat less likely to be planning enhancements, still more than half (53%) say that they are.

One in five employers said they would put a special emphasis on improving benefits for low-wage and unskilled workers, while two-thirds said they planned to focus on all employees. The biggest concern among employers is the increasing costs that employees have to shoulder for their health benefits.

Employers are starting to realize that a high-deductible health plan with an attached health savings account is not a good fit for all of their employees. In fact, the high-deductibles have been blamed for saddling an increasing amount of U.S. workers with more medical debt.

Tackling affordability issue

Businesses are taking different approaches to tackling the affordability issue, both on the front end in terms of premiums or the back end in the form of out-of-pocket expenses. Mercer found that:

  • 41% of employers said they’ve already introduced a low- or no-deductible plan option, while 11% said they are considering adding one.
  • 11% said they offer at least one plan with no employee premium-sharing (meaning the employees pay nothing for their coverage and the employer covers the entire monthly premium). Mercer found that these kinds of arrangements are more common among small employers, although more large employers are starting to offer them as well. Another 11% said they are planning on adding a free option.
  • 16% said they offer a narrow/high-performance network plan with low cost-sharing, and another 24% said they are planning on offering one for 2023.
  • 17% said they offer salary-banded health plan contributions (with lower-wage workers required to pay less for their share of premium than higher-wage colleagues). Another 15% said they plan to offer this type of arrangement for 2023. But employers need to be careful.
    Writes Mercer: “It’s important to be thoughtful about the possible consequences of implementing salary banding for the first time now. While charging lower-paid employees less is the goal, charging some employees more could have a negative impact on hiring at those levels.”

Find out what they want

But just improving benefits or adding benefits without consulting staff can backfire. It’s important employers understand their employees’ needs before embarking on changes to their benefits.

“When it comes to retaining talent, taking a standard approach to benefit design is almost guaranteed to come up short,” Mercer writes.

Mercer also notes that employees are more concerned these days about having the right lifestyle fit at their employer, so employers should take into account differences in their employees’ lifestyles.

Here’s what employers are doing to get the answers they need:

  • Employee surveys: 61%
  • Analysis of needs based on employee demographcis and personas: 46%
  • Input from employee resource groups: 35%
  • Focus groups: 26%
  • Other sources of information: 46%
  • Nothing: 6%

If you are pinched for resources, Mercer notes that offering your staff greater flexibility in their benefits and better targeting communications about their benefits can be the way to go.

Flexibility can be a simple as supporting a work-life balance and giving them the option for flexible hours so they can run errands or tend to family issues like dentist or pediatric care appointments.

Flexibility can encompass a wide range of benefits. Here’s what Mercer found that employers offer or plan to offer in 2023:

  • 66%: Flexible work schedules, such as flex time during the day or a four-day work week.
  • 78%: Option to work from home regularly, but not every day.
  • 9%: Option to work from home every day.
  • 12%: Lifestyle accounts — employer-funded accounts that employees can use for a variety of purposes.
  • 45%: Paid time off to volunteer.
  • 50%: Other benefits/policies to support work-life balance.

Gen Z, Millennials Grow Disillusioned with Their Health Insurance

Surprise bills and billing errors are driving growing dissatisfaction among Millennials and Gen Zers with their health insurance, a new study has found.

HealthCare.com‘s “2022 Medical Debt Survey” found that about one in four Gen Zers and Millennials with medical debt skipped rent or mortgage payments because of their debt. That’s compared with 21% for Gen Xers and 12% for baby boomers.

The study reflects the increasing burden that health insurers’ policies for out-of-network care and higher deductibles are having on Americans, particularly those who are the most recent entrants to the job market. Since they typically earn less than those who have more experience, Millennials and Gen Zers are more susceptible to hardships if they receive unexpected bills.

To help these generations of workers, consider offering them educational sessions on how to choose health plans, coupled with training on how to avoid unexpected health care bills by going to in-network providers, and how to shop around in advance for scheduled procedures.

Already facing outsized medical cost hits, an increase in billing mistakes and surprise bills is contributing to a dim view of health insurance among Millennials and Gen Zers. In fact, 68% of Gen Zers who have health insurance but still incurred medical debt said their health insurance plan didn’t cover the service they received (or they received services out-of-network).

Additionally, the study found that:

  • 39% of Millennials are unsatisfied with their health insurance options.
  • About three in 10 Gen Zers (31%) and Millennials (27%) with medical debt believe that their debt is the result of a billing error.
  • 48% of Millennials have received a surprise medical bill.
  • 35% of Millennials have received a mistaken bill or had a claim denied.
  • 26% of Millennials have medical debt.

Affordability of health insurance is also a big consideration. Some 54% of Millennials say their health insurance is somewhat or very affordable.

Millennials are also using their health insurance benefits differently than prior generations:

  • 48% say they have used an urgent care center in the past. These visits can often cost more than a typical visit, but not as much as going to the emergency room.
  • 35% have used telehealth services for physical ailments.
  • 26% have sought mental health services through telehealth platforms.
  • 27% have used discount pharmacy apps.

The takeaway

The key to improving your younger generation workers’ understanding of their health benefits and how best to use them is through education. It starts with perhaps having a special session during each open enrollment focusing on what type of health plans are best suited for their generation.

If you offer high-deductible health plans, educate your staff on the importance of putting money aside in health savings accounts so they have money to pay for those unexpected expenses.

They should also be educated in how to use their health insurance to avoid larger costs, and the ramifications of using providers not in their health plan’s network. The education should also cover the costs of going to an emergency room compared to scheduling an appointment with their doctor or going to an evening clinic at their office.

Health Insurance Considerations for Workers Who Move Out of State

One fallout from the COVID-19 pandemic has been an increase in the number of Americans who are working from home permanently.

With so many people being freed from the yokes of the office, many have chosen to move to other states for a variety of lifestyle or cost reasons. But while these arrangements can be a boon for workers, they can make it difficult when it comes to your workers’ group health insurance.

One of the main stumbling blocks is that most group plans are local or regional at best, as they contract with providers and hospitals in the area where an employer is located.

For employers that suddenly have staff now working far afield from their headquarters, securing health insurance coverage in other states can create headaches, particularly if they have contracted with a local or regional insurer.

And to make matters worse, some employees who are working remotely don’t bother telling their employers they are moving, which can render their coverage obsolete if they locate to a place out of their insurance policy’s coverage area.

Remote employees who fail to inform their employers when they relocate could suddenly find themselves in an area with no access to their insurer’s preferred network and they could have their claims denied if they seek out medical care. To avoid this issue, consider instituting a policy that they have to inform you of any move to another state.

What you can do

If all of your staff are working in a single location, city or state, there are usually plenty of options for group health insurance. But if you now have people working out of state, you have choices to make for how to get them covered.

Many national insurance companies don’t have the same type of network in every state, and even among those that do, health care providers may not offer the most cost-efficient networks for out-of-state employees.

Some carriers offer national group health plans that are available to employees in most states. If you now find yourself with employees who are scattered around the country, a national plan helps you avoid having to comply with different state regulations and finding carriers with good networks in other states.

In these types of plans, all of the employees in your organization receive the same group benefits regardless of where they live and work, and they all have access to the same quality coverage.

But there are just a handful of carriers that offer this type of group coverage. Talk to us if you want to know more.

One option is to find local coverage for employees in specific locations, but if you don’t have many employees in that region, you may not be able to find preferable rates for their group coverage.

If that is too difficult, you can set up a taxable stipend that your employees could use to purchase their own health insurance. A stipend is a fixed amount of money paid to an employee in addition to their basic salary, designed to cover whatever extra costs the employer allows, such as health insurance, internet and other expenses.

The takeaway

As more U.S. companies have workforces spread across many states, health insurance needs to be on the top of the list of considerations.

The health insurance you choose will depend largely on your budget and coverage preferences, and what is available to your staff in the state they are working in.

2022 Health Insurance Outlook, Changes

As we enter 2022, there are a number of changes on the horizon that plan sponsors need to be aware of as they will affect group health plans as well as employees enrolled in those plans.

Some of the changes concern temporary rules that were implemented during the COVID-19 pandemic. In addition, new rulemaking is likely to be introduced in 2022 that will affect health plans, including non-discrimination rules for wellness plans and new rules governing what must be included on insurance plan ID cards.

Here’s a list of what to expect in 2022.

HDHP telehealth services — The CARES Act, signed into law in 2020 after the pandemic started, temporarily allowed high-deductible health plans to pay for telehealth services before an enrollee had met their deductible.

That comes to an end Dec. 31, 2021, and for plan years that start on or after Jan. 1, 2022, HDHPs must charge enrollees for telehealth services if they have not yet met their deductible.

Mid-year election changes — The Consolidated Appropriations Act of 2021 (CAA) and ensuing guidance from the IRS relaxed a number of rules that will come to an end for plans incepting on or after Jan. 1, 2022. These rules were all not mandatory and employers could choose whether to relax them or not.

Here are the rules that will sunset at the end of 2021:

  • Allowing employees who had declined group health insurance for the 2021 plan year to sign up for coverage.
  • Allowing employees who had enrolled in one health plan option under their group health plan to change to another plan (such as switching insurance carriers or opting for a silver plan instead of a bronze plan).
  • For health flexible spending accounts (FSAs), allowing participants to enroll mid-year, increase or decrease their annual contribution amount, or pull out of the plan altogether and stop contributing.
  • For plan years ending in 2020 and 2021, permitting employers to modify their FSAs to include a grace period of up to 12 months to spend unused funds from the prior policy year.
  • Allowing for a higher FSA carryover amount than the typical $500.

Any plans that allowed these changes would have to have been amended to reflect that, and for 2022 they’ll have to be amended to reflect reverting to the old rules that forbid such changes.

Affordability level falls — Under the Affordable Care Act, employers with 50 or more full-time or full-time equivalent workers are required to provide health coverage to at least 95% of their full-time employees. The ACA requires that the coverage is “affordable” for the worker, which is set as a percentage of their household income.

For 2022, the affordability level will be 9.61% of their household income, down from 9.83% in 2021.

Electronic filing threshold drops — Starting in 2022, employers with 100 or more workers will be required file their 2021 ACA-related tax forms with the IRS electronically, as a result of changes brough on by the Taxpayer First Act. That’s a change from the prior threshold of 250. This applies to forms 1094-C, 1095-C, 1094-B and 1094-B.

While the IRS has yet to release guidance for this change, it’s expected it will do so by the end of 2021.

More guidance coming

The CAA created a number of new requirements that affect health insurance and coverage. Look for various government agencies, chiefly the Centers for Medicare and Medicaid Services, to provide new guidance on:

Insurance plan identification cards — Part of the CAA requires health plans and issuers to include information about deductibles, out-of-pocket maximum limitations and contact information for assistance on any ID cards issued to enrollees on or after Jan. 1, 2022.

Continuity of care requirements — The CAA also requires insurers to offer anyone who is a “continuing care patient” of a provider or facility the option to elect to continue to receive care for up to 90 days from the provider or facility, even when there’s a change in that provider’s contract status with a health plan that could normally result in a loss of covered benefits.

If certain conditions apply, this transitional care would be provided as if the contractual relationship with the provider had not changed.

Wellness program incentives — The Equal Employment Opportunity Commission is expected to issue new regulations on what kind of incentives are permissible for employer-sponsored wellness programs. The main focus is on incentives and if they are discriminatory to some workers.

Alternative Group Plan Funding Gets a Second Look

Watching their group health plan premiums climb higher with each passing year, some employers start looking into alternative funding strategies in hopes they can get a better handle on their employees’ health costs.

While group plans are the standard, larger employers have typically had more options for funding their group health coverage. But now even small and medium-sized employers – even companies with fewer than 100 employees – can benefit from alternative funding approaches.

There are three main types of alternative funding strategies that are available to employers:

  • Captives
  • Private exchanges
  • Full and partial self-funding.

Captives

With a captive, multiple employers pool their resources and share the risk in providing health insurance to their employees. It is essentially a self-insured pool built into a captive insurance company (an insurer that is owned by the entity that created it). The captive has staff that will administer the health plan.

Captives are also multi-year agreements, so once an employer commits to make it worth their investment, they need to stick with it for a period of time.

Group captives will often have a specific funding mechanism that is broken down into four layers:

Layer 1: The employer is responsible for the first $25,000 of any claim made by one of its employees.

Layer 2: All employers involved in the captive will share the costs of that claim if it exceeds $25,000, up to $250,000.

Layer 3: For claims that cost more than $250,000, the captive will secure reinsurance coverage to cover amounts above that level. This reinsurance is also called “stop-loss” insurance.

Layer 4: Another layer of protection known as “aggregate stop-loss” coverage protects each employer in the captive for the total claims of their employees, ranging from 115% to 125% of expected claim costs in a year.

Private exchanges

Typically, businesses using a private exchange will offer employees a credit that can be applied toward the purchase of a health plan. Employees can then access a variety of health plans through an online portal and can chose and enroll in plans that meet their needs.

Private exchanges are run by insurance carriers or consultancies, and plans on the exchange are regulated as group coverage. Employees shopping on these exchanges are not eligible for the Affordable Care Act’s tax credits or cost-sharing subsidies.

Most employers currently using private exchanges are large; therefore, most private exchange plans are regulated as large-group coverage and are not part of the ACA’s single risk pool. However, to the extent that smaller employers participate in private exchanges, they are subject to the ACA’s small-group rating regulations and risk-pool requirements.

One of the main features of private exchanges is that they enable employees to comparison-shop among multiple health insurance plans.

Self-insuring

There are many different types of self-insurance, from minimum-premium or risk-sharing arrangements to a fully self-funded plan, in which the employer is responsible for all claims.

Employers can choose from:

Retrospective premium arrangements – The insurer will credit back a portion of the unused premium to the employer (typically as a credit for the following year). This is often used in a fully insured arrangement.

Minimum premium arrangements – The employer pays fixed costs (administration charges, stop-loss insurance and network access fees) and claim costs up to a maximum liability each month.

Partial self-funding -The employer takes on more liability and pays fixed costs (administration, network access, stop-loss premiums and some fees and taxes). It’s partial self-funding because the employer will purchase individual stop-loss insurance, which caps the employer’s liability on any given claim to a certain amount, say $50,000.

That way, the employer is self-insuring most of their employees’ medical needs, but is protected in case some of those claims become catastrophic.

Full self-funding – This is like partial self-funding except that there is no stop-loss insurance and the employer is responsible for all costs that are not shared by its employees.  This kind of arrangement is usually only available to large employers.

The takeaway

These alternative funding approaches are what is available now. But the industry is innovating to making health care and insurance more affordable for all involved.

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.