ACA repeal bill nixed: What’s next for healthcare reform, employers?

With the fall of the AHCA find out what is next for employers in terms of healthcare from the great article at HR Morning by Christian Schappel.

The Republican’s best attempt to repeal the Affordable Care Act (ACA) to date has been axed. Where does that leave employers, and what can they expect next? 

For starters, it leaves employers with the ACA and everything that comes with it … the employer mandatethe reporting requirements … the whole enchilada.

In other words, any organizations that relaxed their ACA compliance efforts — believing the Republican’s American Health Care Act would repeal and replace Obamacare — could be exposing themselves to non-compliance penalties.

The more complicated question is: What happens next?

A piecemeal approach?

With this appearing to be the GOP’s best shot at repealing and replacing Obamacare (or at least parts of it) in one stroke, and the party failing to push its legislation through Congress, President Trump and House Speaker Paul Ryan (R-WI) appear resigned to the fact that the ACA will remain in place indefinitely.

“We’re going to be living with Obamacare for the foreseeable future,” Ryan said after announcing the GOP bill would not be voted on in the House.

Trump has even indicated that after this loss for the GOP, he wants the party to focus on other issues, like tax reform.

But that doesn’t mean health reform will be on the back burner.

It now appears that Republicans’ best course of action to implement reform changes would be to attempt to “fix” parts of the ACA that are deemed to not be working. And it could do that by including small healthcare provisions in other pieces of legislation, like future tax reform bills.

Trump and his fellow Republicans could also seek to offer concessions to Democrats in future legislation as a means to get members of the left to agree to include certain provisions of the American Health Care Act in future bills.

Example, Republicans are still expected to push hard for a rollback of the ACA’s expansion of Medicaid, and members of the GOP could seek to include rollback provisions in future tax reform legislation in exchange for proposing a tax reform plan Democrats would find more palatable.

How did we get here?

So why did the American Health Care Act fail, despite Republicans controlling the House, Senate and White House?

The answer starts with the fact that the GOP didn’t have the 60 seats in the Senate to avoid a filibuster by the Democrats. In other words, despite being the majority party, it didn’t have enough votes to pass a broad ACA repeal bill outright.

As a result, Senate Republicans had to use a process known as reconciliation to attempt to reshape the ACA. Reconciliation is a process that allows for the passage of budget bills with 51 votes instead of 60. So the GOP could vote on budgetary pieces of the health law, without giving the Democrats a chance to filibuster.

The problem for Republicans was reconciliation severely limited the extent to which they could reshape the law — and it’s a big reason the why American Health Care Act looked, at least to some, like “Obamacare Lite.”

Ultimately, what caused Trump and Ryan to decide to pull the bill before the House had a chance to vote on it was that so many House Republicans voiced displeasure with the bill and said they wouldn’t vote for it.

Specifically, here are some of what conservatives didn’t like about the American Health Care Act:

  • it largely left a lot of the ACA’s “entitlements” intact — like government aid for purchasing insurance
  • it didn’t do enough to curtail the ACA’s expansion of Medicaid
  • too many of the ACA’s insurance coverage mandates would remain in place
  • the Congressional Budget Office estimated that the bill would result in some 24 million Americans losing insurance within the next decade, and
  • it didn’t do enough to drive down the cost of insurance coverage in general.

See the original article Here.

Source:

Schappel C. (2017 March 29). ACA repeal bill nixed: what's next for healthcare reform, employers? [Web blog post]. Retrieved from address http://www.hrmorning.com/aca-repeal-bill-nixed-whats-next-for-healthcare-reform/


What it Takes to Make Good Decisions in the New World of Work

With many companies taking employee education and training into their own hands employers must be properly prepared for the changing future. Check out this great article from SHRM about what employers must do to keep pace in the ever evolving workplace by Ross Smith and Madhukar Yarra

We live in a world where phenomena such as the internet, globalization, social media, and mobility are accelerating change faster than ever before. Today’s digital age fed by big data is manifested in new businesses disrupting existing business models, which are remnants of the industrial era. These new models, typified by the Ubers, Amazons, Teslas, Airbnb’s and Facebooks of the world, are fossilizing the older generation of companies.

It is difficult for the education system to keep pace with this kind of change. The education system is a behemoth whose design is evolving to address the need for agility and speed. They change after the fact and therefore almost always take refuge in ‘best practices’. The MBA as we know it, has also fallen prey to this.

The MBA has been designed to provide a pool of mid-level managers for large corporations and questions arise about the future. Armed with an MBA, new hires walk into a large corporation with a desire to prove their worth through a strong knowledge of historical best practices. They may miss the value of ‘first principles’ thinking, and more often than not, face challenges to make an impact. Over time, this can create a disconnected or disillusioned workforce.

The question then becomes - if emerging and disruptive business models no longer subscribe to historical best practices, and by extension, to business schools, as their source for leadership, where should they look? What is that institution or model that allows individuals to build decision making capabilities in today’s world?

The reliance on irrelevant frameworks, outdated textbooks, and a historical belief in “best practices” all run counter to how a leader needs to be thinking in today’s fast paced digital world.  There are no established best practices for marketing in a sharing economy or creating a brand in a digital world. The best practices might have been established last week. The world is moving fast, and leaders need to be more agile. Today, Millennials are leading teams, calling the shots in many corporations, which means that the energy created is one that leaves little time for rules and structures to effectuate and/or create impact. Making good decisions in today’s business world requires a new and different kind of thinking, and there are tactics that can help grow these new types of leaders.

Importance of questions: most leadership and business programs today evaluate and assess students based on answers, not the ability to ask good questions. Thoughtful and incisive questions lead to innovation and as business problems become more granular and interconnected, this skill will help leaders arrive at better decisions.

Experimentation over experts: Students are encouraged to seek “expert advice” rather than formulating their own hypotheses that can be tested as low cost experiments. While consulting with those who have walked the same path has its benefits, relying on the experiences of others may hinder growth, particularly when change is accelerating. The shift to globalization, digitization, social, and agile are changing rapidly, there is no “right answer”, so experimentation is a crucial skill.

Interdisciplinary perspective: Disciplines and industry sector models are glorified at a time when discipline barriers are being broken to create new ideas. A conscious intermingling of disciplines creates more fertile minds for innovative thoughts to occur.

In today’s management programs, outdated content and old-school delivery mechanisms are limiting  students and businesses alike. There is a dire need to help business and young talent alike embrace a new art of problem solving, essential for the realities of today.

Many companies are starting to take education and employee training into their own hands. The advent of online courses, MOOCs, and other innovative programs in employee education are supplementing traditional education.

HR professionals can learn from companies who have set up their own deep technical training programs. With the work they do to augment decision science skills, Mu Sigma University is a great example of a modern day tech company, building skills across technology, business, analytics, and design. The workforce is changing. Many traditional jobs are being replaced with automation, robots, cloud-based machine learning services, and artificial intelligence – while at the same time, the demand for high end engineering, analytics, business intelligence, data and decision science is booming. Many companies, such as Mu Sigma, are spinning up advanced technical training investments to ensure their employees are equipped for a rapidly evolving future.

See the original article Here.

Source:

Smith R. &  Yarra M. (2017 March 15). What it takes to make good decisions in the new world of work [Web blog post]. Retrieved from address https://blog.shrm.org/blog/what-it-takes-to-make-good-decisions-in-the-new-world-of-work


The Changing Landscape of Employee Benefits

Great article from our partner, United Benefit Advisors (UBA) about the changes coming to employee benefits by Pat McClelland

There is no denying our industry is changing rapidly, and it’s not about to slow down. Combined with disruptive advances in technology and evolving consumer expectations, we’re seeing consumer-driven health care emerge. Take, for example, the fact that employees now spend more than nine hours a day on digital devices.

There’s no doubt that all this screen time takes a toll.

  • Device screens expose users to blue light. It’s the light of the day and helps us wake up and regulate our sleep/wake cycle.
  • Research suggests blue light may lead to eye strain and fatigue. Digital eye strain is the physical eye discomfort felt by many individuals after two or more hours in front of a digital screen.
  • In fact, digital eye strain has surpassed carpal tunnel syndrome and tendonitis as the leading computer-related workplace injury in America1.

Employees are demanding visibility into health care costs and transparency in the options available so they can take control of their own health. Consumers are more knowledgeable and sensitive to cost, and as a result becoming very selective about their care.

Lack of preventive care

Preventive screenings are a crucial piece of overall health and wellness. In fact, the largest investment companies make to detect illnesses and manage medical costs is in their health plan. But if employees don’t take advantage of preventive care, this investment will not pay off. Only one out of 10 employees get the preventive screenings you’d expect during an annual medical visit2.

It's a big lost opportunity for organizations that are looking for a low-cost, high-engagement option to drive employee wellness.

How a vision plan can help

The good news is that the right vision plan can help your employees build a bigger safety net to catch chronic conditions early. It all starts with education on the importance of an eye exam.

Eye exams are preventive screenings that most people seek out as a noninvasive, inexpensive way to check in on their health; it’s a win-win for employers and employees.

  • A comprehensive eye exam can reveal health conditions even if the person being examined doesn’t have symptoms.
  • The eyes are the only unobtrusive place in a person’s body with a clear view of their blood vessels.
  • And, an eye exam provides an opportunity to learn about the many options available to take control of their health and how to protect their vision.

By screening for conditions like diabetes, high blood pressure, and high cholesterol during eye exams, optometrists are often the ones to detect early signs of these conditions and put the patient on a quicker path to managing the condition. In a study conducted in partnership with Human Capital Management Services (HCMS), VSP doctors were the first to detect signs of3:

  • Diabetes - 34 percent of the time
  • Hypertension - 39 percent of the time
  • High cholesterol - 62 percent of the time

See the original article Here.

Source:

McClelland P. (2017 March 02). The changing Landscape of Employee Benefits [Web blog post]. Retrieved from address http://blog.ubabenefits.com/the-changing-landscape-of-employee-benefits


CBO estimate of AHCA impact on employer-sponsored benefits is off the mark

Does the implementation of the AHCA have you worried about your employee benefits? Take a look at this great article from Employee Benefit News about what the implementaion of the AHCA will mean for employers by Joel Wood.

In breaking down the Congressional Budget Office’s assessment of the proposed American Health Care Act, let’s look at the impact of the AHCA on employer-sponsored plans. The CBO estimates that 2 million fewer Americans will have employer-sponsored coverage in 2020, growing to seven million by 2027. Here’s CBO’s rationale:

  • The mandate penalties are eliminated, and thus many will drop.
  • The tax credits are available to people with a broader range of incomes than the Obamacare credits/subsidies
  • Some employers will drop coverage and increase compensation in the belief that non-group insurance is a close substitute.

These are valid points. The CBO experts are basing their estimates on sound economics and inside the constraints of their authority, and so of course we worry about any proposal that devolves employer-sponsored care. But, we also have to note that the CBO said much the same about the Affordable Care Act, which largely didn’t happen. And CBO notwithstanding, we at the Council of Insurance Agents & Brokers, too, feared something of a death spiral after the ACA was enacted.

The ACA’s employer penalties were very small in comparison to premiums, and it made sense that many would dump their plans, give their employees cash, and send them to the subsidized exchanges. Also, the subsidies were pretty rich — graduating out at 400% of the poverty line. That’s more than $90,000 for a family of four.

What we didn’t take into account in reference to the ACA were a number of things:

  • A core assumption of the ACA was that states would all be forced to expand Medicaid to 138% of the poverty line, and the exchange subsidies would kick in above that amount. The courts struck that down and 19 (all-red) states never adopted the expansion, creating a massive donut hole.
  • We underestimated how chaotic would be the rollout of Healthcare.gov.
  • We knew the exchanges would be a model of adverse selection, but a “bailout” of insurance carriers through the “risk corridor” program was supposed to keep them in the game. Republicans balked, sued, and the reinsurance payments have been so lacking that most of the exchanges are currently in a “death spiral” (as described by Mark Bertolini, CEO of Aetna).

So employer-sponsored health insurance has, well, thrived since the enactment of the ACA — perhaps in spite of it, not because of it.

If the CBO is correct and seven million people lose ESI over the next decade, that’s problematic. But it ignores other opportunities that are being created through the proposed GOP bill and Trump Administration executive actions.

Employers-sponsored opportunities
Republicans propose significant expansion of HSAs that will compliment higher-deductible ESI plans. They want work-arounds for state mandates on essential health benefits, even though their goal of “buying across state lines” can’t be realized through the tricky budget reconciliation process. And, ultimately, Republicans want to realize the potential for the ACA wellness provisions that have been eviscerated through years of EEOC/ADA/GINA conflicts. That would be a big win for employers.

The most important tradeoff between the “discussion draft” of a few weeks ago and the AHCA is that GOP House leaders junked their plan to tax 10% of employee contributions for ESI plans, in favor of pushing the Cadillac tax out five more years, to 2025.

Personally, I figure I’ve got another decade left in me to lobby for this industry, and that would get me eight years along the way. That’s a terrific tradeoff in my book, especially as Ways & Means Chairman Kevin Brady (R-Texas) emphasized he never intends for that tax to go into effect — it’s purely a budgetary gimmick. And, it’s a ridiculous “score” from CBO anyway. Everybody knows that no employer is going to pay that tax; they’ll work their plan design to get under the numbers.

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My conclusions at this moment in time, thus, are:

  • Have we won the war among GOP leaders with respect to “hands off” of ESI while trying to solve the death-spiral problems in the individual/exchange marketplace? Not yet. We won a battle, not a war. Sadly and frustratingly, too many Republican leaders have bought into the elite conservative/libertarian economic intelligentsia that pure consumerism should drive healthcare, and that ESI is an “historic accident.” As our friend Ed Fensholt at Lockton always says, “Penicillin was an historic accident, too, but look how that turned out.”
  • Was former Speaker John Boehner right recently when he said that there’s no way you can get to the requisite 51 votes in the Senate right now with this current AHCA construct? You bet he was right. If you do the House plan and defund Planned Parenthood, you lose votes of pro-choice Republicans in the Senate. If Ryan and Trump relent to the Freedom Caucus on hacking the Medicaid expansion in 2018 instead of 2020, they’ll lose votes of Republicans in Medicaid-expanded states. In any event, they probably lose the votes of Ted Cruz (R-Texas) and Ben Sasse (R-Neb.) and a number of other Republicans who view the AHCA as “Obamacare Lite” and demand a more straightforward repeal.
  • Was Paul Ryan (R-Wis.) right when he said this on Face the Nation recently? “Look,” he said, “the most important thing for a person like myself who runs for office and tells the people we’re asking to hire us, ‘This is what I’ll do if I get elected.’ And then if you don’t do that, you’re breaking your word.” You bet he’s right. Republicans ran on this. They voted 60 times in the House to repeal the ACA. If they can’t do this, they can’t do tax reform, they can’t do 12 appropriations bills. Their margins for error (21 votes in the House; two in the Senate) are almost impossibly narrow, and the press hates this bill. But I wouldn’t pronounce this effort dead, by a long stretch.

Sometimes, when lobbying blank-faced Republican leaders on the importance of ESI, I feel like the old BB King lyric: “Nobody loves me but my mother, and she could be jivin’, too.”
But because of, or in spite of, current legislative efforts that are dominating the headlines, I feel relatively well-poised for ESI to continue to be the means through which a majority of Americans receive the health insurance they like and they want to keep. Our job is for them to keep it. Notwithstanding lots of obstacles, we will.

See the original article Here.

Source:

Wood J. (2017 March 21). CBO estimate of AHCA impact on employer-sponsored benefits is off the mark [Web blog post]. Retrieved from address https://www.benefitnews.com/opinion/cbo-estimate-of-ahca-impact-on-employer-sponsored-benefits-is-off-the-mark


ACA replacement proposal leaked: Some of the finer points for HR

Does the repeal of the ACA have you worried? Checkout this great article about some of the changes that will come with the repeal of the ACA by Jared Bilski.

A draft of the Republicans’ Affordable Care Act (ACA) replacement bill that was leaked to the public is likely to look a lot different when it’s finalized. Still, it gives employers a good indication of how Republicans will start to deliver on their promises to “repeal and replace” Obamacare. 

It should come as no surprise to employers that the GOP replacement bill, which was obtained by POLITICO, would scrap a cornerstone of the ACA — the individual mandate — as well as income-based subsidies and all of the laws current taxes (at least one replacement tax is included in the legislation).

According to the discussion draft of the replacement bill, it would offer tax credits for purchasing insurance; however, those credits would be based on age instead of income.

For example, a person under the age of 30 would receive a credit of $2,000. A person over the age of 60, on the other hand, would receive double that amount.

Some of the other highlights of the leaked legislation include:

End of ACA essential health benefits

Obamacare’s essential health benefits mandates require health plans to cover 10 categories of healthcare services, which include:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services
  6. Prescription medications
  7. Rehabilitative and habilitative services and devices
  8. Lab services
  9. Preventive and wellness services and chronic disease management, and
  10. Pediatric services, including oral and vision care.

Under the bill, individual states would make the decisions about what types of services plans must cover — beginning in 2020.

A Medicaid expansion overhaul

The Medicaid expansion under Obamacare that has covered millions of people will be phased out by 2020 under the GOP bill. The replacement proposal: States would receive a set dollar amount for each person.

There would also be variations in the funding amounts based on an individual’s health status. In other words, more money would be allocated for disabled individuals, which is a huge departure from the open-ended entitlement of the current Medicaid program.

Pre-existing conditions, older individuals

One of the most popular elements of the ACA would apparently remain untouched under the GOP bill: the Obamacare provision that prohibits health plans from discriminating against people with pre-existing conditions.

However, the legislation does take aim at older individuals. The GOP would allow insurers to charge older people up to five times more for healthcare than younger individuals. The current ACA limits that difference to three times as much.

The bill does aim to remedy this discrepancy by providing bigger tax credits for older people.

Taxes get axed

There is a slew of taxes built into the ACA — the manufacturer tax, and taxes on medical devices, health plans and even tanning beds — and the Republican bill would repeal those taxes.

But those taxes help cover the cost of the ACA. So to make up for the shortfall that would result in killing those taxes, the GOP is floating the idea of changing the tax treatment of employer-based health insurance. As employers are well aware, employer-sponsored health plan premiums currently aren’t taxed. Under the GOP proposal, this would be changed for some premiums over a certain threshold — although the specifics of such a change remain murky.

Such a move would surely be met by fierce opposition from the business community. In fact, major employer groups are already preparing to fight such a proposition.

See the original article Here.

Source:

Bilski J. (2017 March 01). ACA replacement proposal leaked: some of the finer points for HR [Web blog post]. Retrieved from address http://www.hrmorning.com/aca-replacement-proposal-leaked-some-of-the-finer-points-for-hr/


Employers embrace new strategies to cut healthcare costs

Are you looking for a new solution for cutting your healthcare cost? Take a look at the great article from Employee Benefits Advisor about what other employers are doing to cut their cost healthcare cost by Phil Albinus.

As employers await a new health plan to replace the Affordable Care Act and consensus grows that high deductible health plans (HDHPs) are not the perfect vehicle for cutting healthcare costs, employers are incorporating innovative strategies to achieve greater savings.

Employers are offering HSAs, wellness incentives and price transparency tools at higher rates in an effort to cut the costs of their employee health plans. And when savings appear to plateau, they are implementing innovative reward plans to those who adopt these benefits, according to the 2017 Medical Plan Trends and Observation Report conducted by employee-engagement firm DirectPath and research firm CEB. They examined 975 employee benefit plans to analyze how they functioned in terms of plan design, cost savings measures and options for care.

The report found that 67% of firms offer HSAs while only 15% offer employee-funded Health Reimbursement Arrangements. As “use of high deductible plans seem to have (at least temporarily) plateaued under the current uncertainty around the future of the ACA, employer contributions to HSAs increased almost 10%,” according to the report.

Wellness programs continue to gain traction. Fifty-eight percent of 2017 plans offer some type of wellness incentive, which is up from 50% in 2016. When it comes to price transparency tools, 51% of employers offer them to help employees choose the best service, and 18% plan to add similar tools in the next three years. When these tools are used, price comparison requests saw an average employee savings of $173 per procedure and average employer savings of $409 per procedure, according to CEB research.

“What was interesting was the level of creativity within these incentives and surcharges. There were paycheck credits, gift cards, points that could be redeemed for rewards,” says Kim Buckey, vice president of client services at DirectPath. “One employer reduced the co-pays for office visits to $20 if you participated in the wellness program. We are seeing a level of creativity that we haven’t seen before.”

Surcharges on tobacco use has gone down while surcharges for non-employees such as spouses has risen. “While the percentage of organizations with spousal surcharges remained static (26% in 2017, as compared to 27% in 2016), average surcharge amounts increased dramatically to $152 per month, a more than 40% increase from 2016,” according to the report.

Tobacco surcharges going down “is reflective of employers putting incentives in, so they are taking a carrot approach instead of the stick,” says Buckey.

Telemedicine adoption appears to be mired in confusion among employees. More than 55% of employees with access to these programs were not aware of their availability, and almost 60% of employees who have telemedicine programs don’t feel they are easy to access, according to a separate CEB survey.

Employers seem to be introducing transparency and wellness programs because the savings from HDHPs appear to have plateaued, says Buckey. She also noted recent research that HSAs only deliver initial savings at the expense of the employee’s health.

“With high deductible plans and HSAs, there has been a lot of noise how they aren’t the silver bullet in controlling costs. Some researchers find that it has a three-year effect on costs because employees delay getting care and by the time they get it, it’s now an acute or chronic condition instead of something that could have been headed off early,” she says.

“And there is a tremendous lack of understanding on how these plans work for lower income employees, [it’s] hard to set aside money for those plans,” she says.

Educating employees to be smarter healthcare consumers is key. “What is becoming really obvious is that there is room to play in all these areas of cost shifting and high deductible plans and wellness but we can no longer put them in place and hope for the best,” she says. We have to focus on educating employees and their families,” she says. “If we are expecting them to act like consumers, we have to arm them with the tools. Most people don’t know where to start.”

She adds, “we know how to shop for a TV or car insurance but 99% of people don’t know where to start to figure out where to shop for prescription drugs or for the hospital where to have your knee surgery. Or if you get different prices from different hospitals, how do you even make the choice?”

When asked if the results of this year’s report surprised her – Buckey has worked on the past five – she said yes and no.

Given that the data is based on information from last summer for plans that would be in effect by 2017, she concedes that given the current political climate “a lot is up in the air.” Most employers were hesitant to make substantive changes to their plans due to the election, she says. We may see the same thing this year as changes are made to the ACA and the Cadillac Tax, she adds.

“What I was interested in were the incremental changes and some of the creativity being applied to longstanding issues of getting costs under control,” she says.

See the original article Here.

Source:

Albinus P. (2017 March 05). Employers embrace new strategies to cut healthcare costs [Web blog post]. Retrieved from address http://www.employeebenefitadviser.com/news/employers-embrace-new-strategies-to-cut-healthcare-costs?brief=00000152-1443-d1cc-a5fa-7cfba3c60000


SBC Template, and Required Addendums for Covered Entities under ACA Section 1557

Make sure to stay updated with all the recent rules and regulation regarding the ACA, thanks to our partners at United Benefits Advisor (UBA).

A Summary of Benefits and Coverage (SBC) is four page (double-sided) communication required by the federal government. It must contain specific information, in a specific order, and with a minimum size type, about a group health benefit’s coverage and limitations. If an employer providing an SBC is a covered entity under the ACA’s Section 1557, additional requirements apply.

On April 6, 2016, the Centers for Medicare and Medicaid Services (CMS), the Department of Labor (DOL), and the Department of the Treasury issued the final 2017 summary of benefits and coverage (SBC) template, group and individual market SBC instructions, uniform glossary of coverage and medical terms, a coverage example calculator, and calculator instructions.

The SBC is to be used by all health plans, including individual, small group, and large group; insured and self-insured; grandfathered, transitional, and ACA compliant. The new SBC must be used for plan years with open enrollment periods beginning after April 1, 2017. It will not be used for marketplace plans for the 2017 coverage year.

For fully insured plans, the insurer is responsible for providing the SBC to the plan administrator (usually this is the employer). The plan administrator and the insurer are both responsible for providing the SBC to participants, although only one of them actually has to do this.

For self-funded plans, the plan administrator is responsible for providing the SBC to participants. Assistance may be available from the plan administrator’s TPA, advisor, etc., but the plan administrator is ultimately responsible. (The plan administrator is generally the employer, not the claims administrator.)

Changes

The template includes a new “important question” that asks “Are there services covered before you meet your deductible?” and requires family plans to disclose whether or not the plan has embedded deductibles or out-of-pocket limits. This is reported in the “Why This Matters” column in relation to the question “what is the overall deductible?” and plans must list “If you have other family members on the policy, they have to meet their own individual deductible until the overall family deductible has been met” or alternatively, “If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.”

Tiered networks must be disclosed and the question “Will you pay less if you use a network provider?” is now included. The SBC also includes language that warns participants that they could receive out-ofnetwork providers while they are in an in-network facility. The SBC also indicates that a consumer could receive a “balance bill” from an out-of-network provider.

The “explanatory coverage page” was dropped from the template.

The coverage examples provided clarify the “having a baby” example and the “managing type 2 diabetes” example, in addition to providing a third example of “dealing with a simple fracture.” The coverage example must be calculated assuming that a participant does not earn wellness credits or participate in an employer’s wellness program. If the employer has a wellness program that could reduce the employee’s costs, the employer must include the following language: “These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: [insert].”

The column for “Limitations, Exceptions, & Other Important Information” must contain core limitations, which include:

  • When a service category or a substantial portion of a service category is excluded from coverage (that is, the column should indicate “brand name drugs excluded” in health benefit plans that only cover generic drugs);
  • When cost sharing for covered in-network services does not count toward the out-of-pocket limit;
  • Limits on the number of visits or on specific dollar amounts payable under the health benefit plan; and  When prior authorization is required for services.
  • When prior authorization is required for services.

The template and instructions indicate that qualified health plans (those certified and sold on the Marketplace) that cover excepted abortions (such as those in cases of rape or incest, or when a mother’s life is at stake) and plans that cover non-excepted abortion services must list “abortion” in the covered services box. Plans that exclude abortion must list it in the “excluded services” box, and plans that cover only excepted abortions must list in the “excluded services” box as “abortion (except in cases of rape, incest, or when the life of the mother is endangered).” Health plans that are not qualified health plans are not required to disclose abortion coverage, but they may do so if they wish

Impact of Section 1557 of the ACA – Addendum Required for Covered Entities

On May 13, 2016, the Department of Health and Human Services (HHS) issued a final rule implementing Section 1557 of the Patient Protection and Affordable Care Act (ACA), which took effect on July 18, 2016. Under these regulations, covered entities must provide notices stating they do not discriminate on certain grounds in “significant public-facing publications.” HHS has gone on to confirm that an SBC is a significant public-facing publication.

ACA Section 1557 provides that individuals shall not be excluded from participation, denied the benefits of, or be subjected to discrimination under any health program or activity which receives federal financial assistance from HHS on the basis of race, color, national origin, sex, age, or disability. The rule applies to any program administered by HHS or any health program or activity administered by an entity established under Title I of the ACA. These applicable entities are “covered entities” and include a broad array of providers, employers, and facilities. State-based Marketplaces are also covered entities, as are FederallyFacilitated Marketplaces.

The final regulations are aimed primarily at preventing discrimination by health care providers and insurers, as well as employee benefits programs of an employer that is principally or primarily engaged in providing or administering health services or health insurance coverage, or employers who receive federal financial assistance to fund their employee health benefit program or health services. Employee benefits programs include fully insured and self-funded plans, employer-provided or sponsored wellness programs, employer provided health clinics, and longer-term care coverage provided or administered by an employer, group health plan, third party administrator, or health insurer

Practically speaking, employers with fully insured group health plans will be subject to the regulations (because the carrier is a covered entity and is prohibited from selling discriminatory plans), and many self funded employers will be considered a covered entity based on their business model or financial details. Furthermore, most third party administrators (TPAs) will be considered a covered entity. The Office of Civil Rights (OCR) will investigate a TPA when there is alleged discrimination in the administration of the plan. However, if the alleged discrimination is in benefit plan design (that is, the choice of the employer), the OCR will process the complaint against the employer or plan sponsor. If the OCR lacks jurisdiction over the employer, it will refer the matter to the Equal Employment Opportunity Commission (EEOC). This means that employers who are not covered entities, but have a self-funded group health plan that utilizes a TPA that is a covered entity, could become the subject of an EEOC investigation for discriminatory business practices.

Employers with self-funded group health plans should seek legal counsel to determine if they are a covered entity, and to obtain legal advice on the applicability of these regulations to their individual situation.

Covered entities must take steps to notify beneficiaries, enrollees, applicants, or members of the public of their nondiscrimination obligations with respect to their health programs and activities. Covered entities are required to post notices stating that they do not discriminate on the grounds prohibited by Section 1557, and that they will provide free (and timely) aids and services to individuals with limited English proficiency and disabilities. These notices must be posted in conspicuous physical locations where the entity interacts with the public, in its significant public-facing publications, and on its website home page. In addition, covered entities that employ 15 or more persons must designate a responsible employee to coordinate the entity’s compliance with the rule and adopt a grievance procedure. Employers who are covered entities should seek advice of counsel on the ways these requirements apply to them and their group health plan, and employers who are not covered entities but have a fully insured group health plan should discuss how the insurance carrier will meet these requirements.

The OCR has provided a model notice and model statement of nondiscrimination, and taglines for employers to use. The OCR has also created an FAQ and table relating to the top 15 languages spoken in each state.

HHS has stated that an SBC is a publication that is “significant” under the Section 1557 regulations. As a result, CMS requires the use of an addendum to the SBC to accommodate applicable language access standards. Accordingly, covered entities required to provide an SBC must include the nondiscrimination notice and taglines in its addendum along with other applicable language access standards. This addendum must contain only the Section 1557 nondiscrimination notice and taglines and other applicable language access information.

To download the full compliance alert click Here.


Health Law’s 10 Essential Benefits: A Look At What’s At Risk In GOP Overhaul

Great article from Kaiser Health News about all the changes that could be coming with the ACA overhaul by Michelle Andrews

As Republicans look at ways to replace or repair the health law, many suggest shrinking the list of services insurers are required to offer in individual and small group plans would reduce costs and increase flexibility. That option came to the forefront last week when Seema Verma, who is slated to run the Centers for Medicare & Medicaid Services in the Trump administration, noted at her confirmation hearing that coverage for maternity services should be optional in those health plans.

Maternity coverage is a popular target and one often mentioned by health law critics, but other items also could be watered down or eliminated.

There are some big hurdles, however. The health law requires that insurers who sell policies for individuals and small businesses cover at a minimum 10 “essential health benefits,” including hospitalization, prescription drugs and emergency care, in addition to maternity services. The law also requires that the scope of the services offered be equal to those typically provided in employer coverage.

“It has to look like a typical employer plan, and those are still pretty generous,” said Timothy Jost, an emeritus professor at Washington and Lee University Law School in Virginia who is an expert on the health law.

Since the 10 required benefits are spelled out in the Affordable Care Act, it would require a change in the law to eliminate entire categories or to water them down to such an extent that they’re less generous than typical employer coverage. And since Republicans likely cannot garner 60 votes in the Senate, they will be limited in changes that they can make to the ACA. Still, policy experts say there’s room to “skinny up” the requirements in some areas by changing the regulations that federal officials wrote to implement the law.

Habilitative Services

The law requires that plans cover “rehabilitative and habilitative services and devices.” Many employer plans don’t include habilitative services, which help people with developmental disabilities such as cerebral palsy or autism maintain, learn or improve their functional skills. Federal officials issued a regulation that defined habilitative services and directed plans to set separate limits for the number of covered visits for rehabilitative and habilitative services.

Those rules could be changed. “There is real room for weakening the requirements” for habilitative services, said Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms who has reviewed the essential health benefits coverage requirements.

Oral And Vision Care For Kids

Pediatric oral and vision care requirements, another essential health benefit that’s not particularly common in employer plans, could also be weakened, said Caroline Pearson, a senior vice president at Avalere Health, a consulting firm.

Mental Health And Substance Use Disorder Services

The health law requires all individual and small group plans cover mental health and substance use disorder services. In the regulations the administration said that means those services have to be provided at “parity” with medical and surgical services, meaning plans can’t be more restrictive with one type of coverage than the other regarding cost sharing, treatment and care management.

“They could back off of parity,” Palanker said.

Prescription Drugs

Prescription drug coverage could be tinkered with as well. The rules currently require that plans cover at least one drug in every drug class, a standard that isn’t particularly robust to start with, said Katie Keith, a health policy consultant and adjunct professor at Georgetown Law School. That standard could be relaxed further, she said, and the list of required covered drugs could shrink.

Preventive And Wellness Services And Chronic Disease Management

Republicans have discussed trimming or eliminating some of the preventive services that are required to be offered without cost sharing. Among those requirements is providing birth control without charging women anything out of pocket. But, Palanker said, “if they just wanted to omit them, I expect that would end up in court.”

Pregnancy, Maternity And Newborn Care

Before the health law passed, just 12 percent of health policies available to a 30-year-old woman on the individual market offered maternity benefits, according to research by the National Women’s Law Center. Those that did often charged extra for the coverage and required a waiting period of a year or more. The essential health benefits package plugged that hole very cleanly, said Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research and advocacy organization.

“Having it in the law makes it more difficult to either exclude it entirely or charge an arm and a leg for it,” Sonfield said.

Maternity coverage is often offered as an example of a benefit that should be optional, as Verma advocated. If you’re a man or too old to get pregnant, why should you have to pay for that coverage?

That a la carte approach is not the way insurance should work, some experts argue. Women don’t need prostate cancer screening, they counter, but they pay for the coverage anyway.

“We buy insurance for uncertainty, and to spread the costs of care across a broad population so that when something comes up that person has adequate coverage to meet their needs,” said Linda Blumberg, a senior fellow at the Health Policy Center at the Urban Institute.

See the original article Here.

Source:

Andrews M. (2017 February 21). Health law's 10 essential benefits: a look at what's at risk in GOP overhaul [Web blog post]. Retrieved from address http://khn.org/news/health-laws-10-essential-benefits-a-look-at-whats-at-risk-in-gop-overhaul/


Employees desperately need more information on health plans, study says

Did you know that a lot of your employees may be unaware of the health care options your company offers? Take a peek at this great article from HR Morning on how to improve your employees knowledge of their healthcare options by Jared Bilski

As an increasing number of employees are being asked to make smarter healthcare spending decisions, communication is more important than ever. Unfortunately, it looks like many firms have a lot of room for improvement.  

That’s one of the alarming takeaways from healthcare administrator Alegeus’ recent “State of Denial” study.

A number of the stats from the study point to a major employee healthcare problem that’s only getting worse. That problem: While employees’ health options are becoming increasingly complex, most workers don’t have the knowledge and/or accountability to make wise decisions involving those options.

Unaware and overwhelmed

Here are some of the most alarming stats from the study:

  • 63% of employees said they don’t know the benefit of an HSA
  • 50% don’t know how to predict current or future out-of-pocket healthcare expenditures and can’t select the best savings vehicle or rate
  • 26% of HSA accountholders don’t know they can use HSA funds beyond the immediate plan year, and
  • 41% of HSA accountholders were unaware they could invest HSA funds.

The study also highlighted some of the contradictions between what employees said they wanted or needed, and how they acted.

For example, although 70% of employees said they’d like to take a more active role in their healthcare decisions, just 50% intend to conduct more due diligence when purchasing healthcare in 2017.

The importance of one on one

One of the most effective ways to improve employees’ benefits understanding is through one-on-one communications.

To help ensure this is effective, here are three things HR pros should keep in mind, according to Winston Benefits, a voluntary benefits plan provider:

1. Prepare the right materials

When you’re doing a large-scale benefits presentation, you generally just hand out the materials, and employees look through and use those materials as they see fit.

But with individual sessions, benefits pros have to be prepared to explain those materials in any way an employee requests.

Example: Walking a worker through a tool or calculator in a step-by-step manner.

2. Look to your broker

In many cases, benefits brokers are willing to go on site for one-on-one sessions, and companies should take advantage whenever possible.

Employees will be comfortable knowing there’s an in-house HR or benefits pro at the broker, and a broker’s expertise can really improve workers’ overall understanding.

3. Allot enough time

The point of these meetings is to give employees all the time they need to understand their options and make informed decisions.

Rushing workers through these meetings will ensure the one-on-one education falls flat.

See the original article Here.

Source:

Bilski J. (2017 February 17). Employees desperately need more information on health plans, study says [Web blog post]. Retrieved from address http://www.hrmorning.com/employees-desperately-need-more-information-on-health-plans-study-says/


Where exactly are we in the ACA repeal process?

Worried about the ACA repeal process? Check out this informative article from HR Morning about the status of the ACA's repeal by Christian Schappel,

President Trump, along with other Republican lawmakers, have promised to “repeal and replace” the Affordable Care Act (ACA). But it hasn’t happened yet. Here’s why, as well as a timeline for what’s to come. 

In his “Contract with the American Voter,” Donald Trump promised to repeal Obamacare within his first 100 days in office. But the reality is he can’t do it on his own. He needs votes to get it repealed outright — and he doesn’t have enough of them.

What’s the hold up?

Broad legislation that would repeal the ACA would require 60 votes in the Senate, and the GOP doesn’t control enough seats to make that a reality — or avoid a filibuster by the Democrats.

Still, that hasn’t stopped Trump from declaring war on the healthcare reform law. In one of his first acts as president, Trump issued an executive order that directs federal agencies to waive some of the requirements of the law that could impose a burden on individuals and certain businesses.

It was a clear sign from Trump that his administration plans to attack the ACA by any means necessary.

So what’s the plan now?

Congressional Republicans are now preparing to dismantle portions of the ACA using a process known as reconciliation. It will allow the GOP to vote on budgetary pieces of the health law, without giving the Democrats a chance to filibuster.

The problem for Republicans is reconciliation limits the extent to which they can reshape the law.

Parts of the law it appears they can roll back through reconciliation:

  • The individual mandate (which is imposed through a tax)
  • The employer mandate (which imposed through a tax), and
  • The subsidies to help individuals purchase coverage (which require government funding).

The Republicans believe that through reconciliation they can knock the legs out from under the ACA and begin to implement their own health reforms.

Some of the things members of the GOP have indicated they want to do:

  • Go to a more free-market approach, in which individuals would have greater ability to purchase health insurance across state lines
  • Expand health savings accounts
  • Allow individuals to deduct the cost of health insurance premiums from their income taxes, and
  • Let states manage Medicaid funds.

Two popular ACA provisions Republicans said they plan to keep in health plans:

  • The prohibition on denying coverage to those with pre-existing conditions, and
  • The ability for children to stay on their parents’ plans until age 26.

So when is it all going to happen?

When it comes to a timeline for when the GOP hopes to initiate reforms, things are a little murky. The problem is, due to the reconciliation process — and complaints from insurers about what the requirement to provide coverage to those with pre-existing conditions will do to risk pools and pricing — things aren’t as cut and dried as employers would like them to be.

But here’s what we know:

  • In late January, at its annual retreat, the GOP said it wants to bring a final reconciliation package to the floor of the House by late February or early March
  • In a pre-Super Bowl interview with Fox News’ Bill O’Reilly, President Trump said the repeal and replace process is “complicated” and could take until “sometime next year,” and
  • Just a few days after Trump’s statements to O’Reilly, House Speak Paul Ryan (R-WI) said the president’s remarks won’t alter the timeline for the House GOP to introduce significant repeal and replace legislation by the end of 2017. Still, Ryan did indicate that even if such legislation is passed, it could take some time for it to be fully implemented.

Bottom line: Employers are likely looking at a long legislative process, and an even longer implementation period.

Bills that could chip away at law

While Congress mulls larger-scale changes to the ACA, a few bills have been introduced for lawmakers to chew on.

The following could chip away at certain elements of reform:

  • The Middle Class Health Benefits Tax Repeal Act (H.R. 173) would kill the 40% deductible excise tax (a.k.a., “the Cadillac tax”) on high-cost employer health plans
  • The Health Savings Account Expansion Act (H.R. 247 and S. 28) would permit the reimbursement of health insurance premiums and increase the maximum allowable contribution, and
  • The Healthcare Tax Relief and Mandate Repeal Act (H.R. 285) would kill both the individual and the employer health insurance mandates.

See the original article Here.

Source:

Schappel C. (2017 February 10). Where exactly are we in the ACA repeal process? [Web blog post]. Retrieved from address http://www.hrmorning.com/where-are-we-aca-obamacare-repeal-trump/