What’s the Deal With 529 Plans?

It’s never too early to invest. A 529 Savings Plan, prudent financial direction, and steady contributions are paramount to a successful college fund. Due to the intricacies of the financial instrument, an advisor is recommended to guide contributors throughout the process. In this installment of CenterStage, Cyrus Dhatigara – an investment advisor representative – has presented new contributors with his advice on 529 Savings Plans and how they can be beneficial for costly tuition fees.

How are they beneficial?

The 529 Savings Plan is a great way to save money for college. First, there are comparatively high limits on the amounts that parents or grandparents can contribute. Second, these plans are tax free: unlike with a tax-deferred 401(k), funds are exempt from taxation once they are eventually withdrawn. Third, mutual fund companies that are affiliated with state Tuition Trust Authorities are able to offer professional management leveraging a diverse array of funds. Fourth, 529 Savings Plans allow contributors to change the focus of their investments, typically starting with an aggressive strategy during a child’s younger years and moving towards a more conservative approach when he or she gets older.

How much to start?

Parents would naturally like to know how they can foster such an investment. Most have the basic idea of what a 529 Savings Plan is, but not much more. Seeking sound financial advice should fill any gaps in proficiency. Also, there’s no excuse to wait – it takes a mere $25 per month to initiate a plan. Further, 529s can make use of automated checking account withdrawals to enable healthy growth. This is a flexible product, though annual contributions will likely need to increase on that basis. The maximum limit per child is around $300,000; parents can contribute whatever they want and supplement the fund via one-off investments from grandparents.

What do they cover?

Anything that’s necessary for class is covered: books, tuition, fees, and computers or iPads, among other things. In fact, a 529 Savings Plan even covers grad school. Since the investments are earmarked for higher education, money is transferred directly from the mutual fund to the university without any contributor intervention. As a result, parents shouldn’t be concerned about quarterly or semester requirements, and there isn’t room for IRS violations since their only further interaction is taking a receipt.

How can Saxon help?

Cyrus crafts strategic savings plans around children to help fund college tuition, while providing the tools for protection and investment. His largest passion project is an extension of the daily work he does. He revels in contributing financial education to all ages. Saxon’s goal is simple, to mold this program to fit contributors’ individual needs, right from the beginning. We know college savings plans are not one-size-fits-all. Whether you are looking to save for tuition, room and board fees, books, supplies or required computer equipment and technology, Saxon can help.

Please contact Cyrus Dhatigara with any questions you may have on 529 Savings Plans. You can reach him at 513.236.9334 or send him an email at cdhatigara@gosaxon.com.

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Fresh Brew With Tabitha McIntosh

Welcome to our brand new segment, Fresh Brew, where we will be exploring the delicious coffees, teas, and snacks of some of our employees! You can look forward to our Fresh Brew blog post on the first Friday of every month.

“Each client is different!”

Tabitha enjoys helping customers and prides herself on the understanding of their needs and the discovery of knowledge along the way. She especially enjoys following through with the customer and learning new things that will help her excel in her career and better service future clients.

Favorite Brew

Pumpkin Spice Latte

“I love grabbing this from either Starbucks or Royce Cafe in Lebanon!”

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Favorite Snack

…Nothing!

“I like my coffee on it’s own. There are plenty of calories in each cup!”

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LIMRA aims to shape benefits data exchange standard

How will LIMRA shape the benefits data exchange standard? Find out in this article from Benefits Pro.

LIMRA wants to help develop electronic data transmission standards for the employee benefits market.

The life and health market research group, has formed an alliance with the Object Management Group (OMG), a nonprofit technology standards group based in Needham, Massachusetts.

LIMRA has been working on the benefits market data standards issue for more than a year.

To help benefits market players develop standards, OMG has set up a Workplace Benefits Domain Task Force. The chairs of the new task force are Edie Bice of Unum; InAh Chambers of LIMRA; and Aaron Roby of Texas Life.

The task force organizers hope to develop data exchange standards for non-medical, non-retirement benefits.
The standards could apply both to group benefits and to individual benefits products sold at the worksite.

Organizers say the new task force will be open to benefits brokers, independent benefit plan administrators, benefits administration technology vendors, and insurers that offer non-medical, non-retirement employee benefits products.

The task force will start its first face-to-face meeting June 18, in Boston.

Source:
Bell A. (4 May 2018). "LIMRA aims to shape benefits data exchange standard" [web blog post]. Retrieved from address http://bit.ly/2wfIZey


These 3 industries are leading the way in HDHP adoption

Interested in knowing which industries are leadig the way in HDHP adoption? Check out this blog article.

Employers in the education, health care, manufacturing and retail sectors are using a variety of tactics to drive selection of HDHPs, with varying levels of adoption from employees, so says the report, based on anonymous employee benefit election data on the Benefitfocus Platform from more than 540 large employers in those sectors.

In the education sector, HDHPs are becoming less the exception, more the rule.

“Back in 2016, traditional health plans like PPOs and HMOs represented an overwhelming majority of health plan offerings and elections among employers in the education industry,” the authors write. “But just two short years later, things look completely different. In an industry known historically for its generous health insurance benefits, the HDHP has made remarkable gains in popularity.”

The share of employers in the education sector offering at least one HDHP has more than doubled since 2016, from 23 to 50 percent, according to the report. Employers have done a lot to make HDHPs attractive — they now pay 87 percent of the total HDHP premium and have doubled their contribution to employees’ HSAs since 2016. Their efforts have worked — 34 percent of employees selected an HDHP when given the choice for 2018, up from 20 percent two years ago.

In the health care sector, employers are encouraging consumer-driven plans with moderate success, according to the report.

“Over the past two years, employers in the health care industry have taken steps to shift more health insurance costs onto employees, while providing ways to help them manage the additional burden,” the authors write. “But there remains a long runway of opportunity for these organizations to boost adoption of the consumer-driven health care model.”

The number of employers offering HDHPs has nearly doubled in two years, with 73 percent offering at least one in 2018, up from 41 percent in 2016. However, despite there efforts, only 27 percent of employees selected an HDHP for 2018. Health care employers are likely trying to raise the adoption rate by transferring more PPO plan costs onto workers — the average employee premium contribution for a single-coverage PPO is up 24 percent from 2016.

In the manufacturing sector, despite boom in HDHP offerings among those employers, more of their workers are still opting for PPOs. “Manufacturing employers have displayed a particularly strong and growing enthusiasm for HDHPs in recent years,” the authors write. “But cost-sharing dynamics appear to be driving employees away from these plans and back into traditional health plans. Meanwhile, voluntary benefits maintain above-average popularity among both employers and employees.” The majority (88 percent) of employers in manufacturing now offer an HDHP, up from 54 percent in 2016. However, the percentage of employees electing an HDHP continues to decrease, while PPO participation grew from 36 percent in 2016, to 57 percent for 2018.

The report also found that voluntary benefits have become increasingly prevalent among manufacturers, with nearly 60 percent of employers offering at least one for 2018, up from 34 percent in 2016.

In the retail sector, employees shoulder more health plan costs, while more employers offer voluntary benefits to supplement coverage, according to the report.

“As employers in the retail industry look to keep benefit costs under control, health care is getting more expensive for their employees,” the authors write. “And while voluntary benefits offer additional financial protection for the majority of these workers, there remains a long runway of opportunity for health spending accounts to help them manage their out-of-pocket liabilities.”

Retail employers offering at least one HDHP increased from 55 percent in 2016 to 76 percent. Nearly half (40 percent) of their employees elected HDHPs, but premiums for these plans are rising, with the average annual employee contribution for a single-coverage HDHP up nearly 20 percent since 2016.

Despite HDHP prevalence, retail employers contributed 40 percent less to HSAs than the average for all employers, and employees contributed 20 percent less than peers in other industries. To supplement coverage, 56 percent of employers offered at least one voluntary benefit, up from 43 percent in 2016.

“Everywhere you turn there’s a story about rising health care costs,” says Ray August. “What employers in every industry have in common is the struggle to economically provide the best plans and care for their employees.”

Source:
Kuehner-Hebert K. (7 May 2018). "These 3 industries are leading the way in HDHP adoption" [web blog post]. Retrieved from address http://bit.ly/2FUf4Ii


4 actions HR departments should take to prepare for GDPR

In this article from Benefits Pro, we are going to take a look at the top four actions HR departments should take to prepare for GDPR. Continue reading:

A few years ago, Mark Cuban famously advised that data is the new gold. However, things have changed since the Cambridge Analytica and Facebook scandal as the public has become increasingly concerned with how companies are using their personal information.

As businesses prepare for the arrival of the General Data Protection Regulation (GDPR), leaders could be forgiven for thinking that data can become more of a liability than an asset – depending on its handling.

GDPR is a much-needed update to data protection that aims to strengthen and unify security for everyone in Europe. The legislation goes live on May 25, 2018 and will enforce all businesses to secure and manage the personal data of all individuals living within the European Union.

After years of gathering data, we are now entering a new era where trust and transparency are the new global currency. GDPR will affect all businesses that store any aspect of personally identifiable information of all individuals, both customer and employee, living in the EU, whether or not that business has an office there.

The scope of GDPR includes employee data, so it directly affects HR departments. As a result, companies need to update processes around the lifecycle of basic employee personal data such as health information and family details.There are many resources surrounding the topic; some on which include free, user-friendly materials published by the EU governments in addition to those that act as “scaremongers” seeking to try to trick companies into paying for compliance help. What makes it most difficult for HR professionals is interpreting the rule, which was written broadly to address any type of personal data and applying it to employee data and HR practices, specifically. Compliance cannot be achieved overnight or ready for the big “go live” in May either. An entirely new way of working to understand where every aspect of data is obtained, how it is used, and where it is stored needs to be put in place. In short, this is not a job for the IT department alone, but rather requires a highly collaborative effort across the company. Silos will need to be broken down to efficiently unify all departments such as sales, marketing, finance, IT, and legal to understand the scale of how much data businesses are actively storing. But what do HR professionals need to know?

1. Create new or updated privacy policies
New privacy policies likely need to be created and implemented to reflect the new rights of employees. Equally, all existing policies should to be reviewed to determine which ones require updating to fall in line with GDPR’s transparency and accountability requirements.

In addition, a key difference between the current EU data rules and the GDPR is the emphasis on individual rights. Employees can now request that their data be completely erased at any time or request a copy of their data thats on file. HR teams need to be prepared to uphold these demands.

2. Revisit outdated processes
Reviewing HR processes, like onboarding a new employee, will help reveal what data you’re collecting that you don’t necessarily have a need for. Minimization is key to successful GDPR compliance; less is more. Implementing minimization will likely require you to update protocols and rethink processes that include the requesting of personal data from employees. For example, the onboarding and transfer of employees will need to be revisited to ensure that data collection practices meet GDPR requirements. You may also need to revisit your record retention policies and processes for ex-employees.

Ask your partners and vendors for their GDPR and compliance plan as risk is shared when they handle employee data on your behalf…

3. Allow data access only to those who really need it
The rise of shadow IT and sensitive data being increasingly stored in the public cloud combined with malware in cloud SaaS applications are the more significant concerns. CIOs and IT leaders now have the power to implement stronger cybersecurity and secure data-management policies that will protect personal data now and in the future. Security elements of the legislation demand that appropriate technical and organizational measures are taken to ensure all employee data is kept safe. HR’s responsibility is to ensure that only those who need access to personal data to do their job have access to it. Making sure that the right people have the appropriate access levels within a digital HR platform – or keys to the file cabinet – is the secret to successful compliance.

4. Centralize your employee file management
Learning about and documenting every element of employee data, where it is stored, and who has access is a process made much easier with centralized digital files. Going forward, a digital system makes it possible for HR to implement and internally audit procedures that will ultimately provide them with the visibility into compliance as well as potential vulnerabilities. GDPR and employee expectations means companies need to shift from a reactive to a proactive approach. A digital system is necessary to enable HR with visibility across their data, securely manage access to the data and implement at scale and policy changes.. With GDPR, the stakes are increasing yet again for companies; HR now must think about collecting the least amount of data they need to get the job done and being completely transparent around its usage, rather than burying this information in complicated terms and conditions. Sure, this will dramatically change the way companies globally deal with EU citizens’ data, but it’s something to be embraced rather than feared. By showcasing implementation of these new data protection practices, a brand can actually build its reputation. While board members might fear the ramifications of the GDPR, we all know that the breach of company data is something far worse. For these reasons alone, GDPR should be seen as an opportunity for every employee to focus on protecting their personal data or at least understanding their responsibilities. And for employers, take this opportunity to become more open to a review of outdated practices and investing in and building technology that can complement this forward thinking approach. Data protection compliance is now an on-going priority and its beneficial for all to take seriously.

Source:
Gouchan A. (4 May 2018). "4 actions HR departments should take to prepare for GDPR" [web blog post]. Retrieved from address http://bit.ly/2wl6ZwU


10 states with the most Social Security recipients

Which state economies will face a greater impact when cutting social security payments? Find out in this article for BenefitsPro.

More than 51 million American retirees or their survivors collected Social Security benefits last year, according to the Social Security Administration.

Those payments function as the foundation for their economic security during retirement, providing 90% or more of the income of almost one-third of those beneficiaries and the majority of the cash income for about 60% of them, according to a new report from the Democratic staff of the Joint Economic Committee (JEC).

The report, “Social Security: A Promise to American Workers and Families,” focuses not only the benefits to recipients who depend on those payments but also the broader economic costs of reducing them, which has been a priority for the Republican leadership in Congress.

Democratic members of Congress expect Republicans will continue to push for those cuts especially because the U.S. deficit is expected to grow by more than $1 trillion over the next 10 years as a result of the recent tax cut legislation.

“Slashing Social Security would not only have a negative impact on beneficiaries and their families, but have a devastating impact on the economy as a whole,” said Sen. Martin Heinrich, D-N.M., ranking member of the JEC, in a statement accompanying the release of the report.
According to the report, Social Security supports about $1.4 trillion in goods and services in the U.S. economy, accounting for more than 9 million jobs nationwide. Reducing benefits by 25% across the board would cost $349 billion in economic output, 2.3 million jobs and about $83 billion in employee compensation, the report notes, adding that such cuts would also put pressure on the families of beneficiaries to make up the difference.

In the gallery above are the 10 states with the most Social Security recipients and their average monthly benefit.

Source:
Napach B. (7 May 2018). "10 states with the most Social Security recipients" [web blog post]. Retrieved from address http://bit.ly/2HWmHnt


Student loan benefits more popular with workers than employers

"While a student loan benefit is the most-requested financial benefit, it’s only third on the priority list for HR professionals." Find out more in this article.

If you ask them, 78 percent of employees laboring under a load of student debt will tell you that they want their bosses to provide a student loan benefit that will help them dig out.

Bosses, not so much. While a student loan benefit is the most-requested financial benefit, according to an HRDive report, it’s only third on the priority list for HR professionals.

Related: The problem with student-loan repayment benefits

It’s not just younger workers who want it, either. The 78 percent of employees who wish their jobs came with a student loan benefit includes 65 percent of workers over age 55 who have problems with current or future loan debt.

The report points to a CommonBond study that finds student loan benefits not only help to keep employees on the payroll and even better their job performance, but they also help in recruiting new talent. The study finds that 75 percent of all workers have paid for their own education via student loans, and 21 percent plan to take out student loans for a child or another family member in the next five years.

Oh, and another disconnect between boss and worker: while 75 percent of HR executives think their benefits offerings are innovative, only 50 percent of workers agree.

Money, of course, is a big worry for workers—and it’s not all about salary, with 44 million Americans weighed down by some $1.4 trillion in student debt. Worrying about lingering student loans also cuts productivity at work, in addition to subjecting workers to increasing stress, so it’s really an employer’s problem too.
Not only do students owe an average of more than $25,000 by graduation, figures from The Student Loan Report indicate that the loan default rate and delinquency rates are more than 10 percent and 5 percent, respectively—not exactly conducive to either peace of mind or high productivity at work. So employers are increasingly getting involved, considering tuition payment programs for employees who want to pursue a degree or add new skills.

And that can help both groups as employers become increasingly desperate for a more skilled employee base. It also helps employers as employee stress falls, potentially cutting health care costs as well and making workers more productive.

Source:
Satter M. (7 May 2018). "Student loan benefits more popular with workers than employers" [web blog post]. Retrieved from address http://bit.ly/2wi9yA0


Fresh Brew With Kevin Hagerty

Welcome to our brand new segment, Fresh Brew, where we will be exploring the delicious coffees, teas, and snacks of some of our employees! You can look forward to our Fresh Brew blog post on the first Friday of every month.

“Try to save what you can. You’ll be glad you did later.”

Kevin has been a Financial Advisor for 18 years specializing in financial planning solutions.

He and his wife Lori enjoy spending their free time involved in various school and sporting events with their two sons. They also enjoy spending time visiting family on the shores of Northern Michigan’s Lakes and working on various projects around the house like landscaping.

Favorite Brew

Flavored Coffee

“I just like it! Highly recommend Carabello Coffee for your flavored coffee needs!”

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Favorite Snack

Breakfast Casserole

“A little breakfast casserole goes a long way!”

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Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA

Data provided through two, large government surveys, The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), Kaiser Family Foundation addresses the risk factors involved in repealing and repealing ACA.


Before private insurance market rules in the Affordable Care Act (ACA) took effect in 2014, health insurance sold in the individual market in most states was medically underwritten.1  That means insurers evaluated the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. To what extent people with pre-existing health conditions are protected is likely to be a central issue in the debate over repealing and replacing the ACA. This brief reviews medical underwriting practices by private insurers in the individual health insurance market prior to 2014, and estimates how many American adults could face difficulty obtaining private individual market insurance if the ACA were repealed or amended and such practices resumed.  We examine data from two large government surveys: The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), both of which can be used to estimate rates of various health conditions (NHIS at the national level and BRFSS at the state level). We consulted field underwriting manuals used in the individual market prior to passage of the ACA as a reference for commonly declinable conditions.

Estimates of the Share of Adults with Pre-Existing Conditions

We estimate that 27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C).  Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation poll, most people (53%) report that they or someone in their household has a pre-existing condition. A larger share of nonelderly women (30%) than men (24%) have declinable preexisting conditions. We estimate that 22.8 million nonelderly men have a preexisting condition that would have left them uninsurable in the individual market pre-ACA, compared to 29.4 million women. Pregnancy explains part, but not all of the difference. The rates of declinable pre-existing conditions vary from state to state. On the low end, in Colorado and Minnesota, at least 22% of non-elderly adults have conditions that would likely be declinable if they were to seek coverage in the individual market under pre-ACA underwriting practices.  Rates are higher in other states – particularly in the South – such as Tennessee (32%), Arkansas (32%), Alabama (33%), Kentucky (33%), Mississippi (34%), and West Virginia (36%), where at least a third of the non-elderly population would have declinable conditions.

Table 1: Estimated Number and Percent of Non-Elderly People with Declinable Pre-existing Conditions Under Pre-ACA Practices, 2015
State Percent of Non-Elderly Population  Number of Non-Elderly Adults
Alabama 33%                   942,000
Alaska 23%                   107,000
Arizona 26%                1,043,000
Arkansas 32%                   556,000
California 24%                5,865,000
Colorado 22%                   753,000
Connecticut 24%                   522,000
Delaware 29%                   163,000
District of Columbia 23%                   106,000
Florida 26%                3,116,000
Georgia 29%                1,791,000
Hawaii 24%                   209,000
Idaho 25%                   238,000
Illinois 26%                2,038,000
Indiana 30%                1,175,000
Iowa 24%                   448,000
Kansas 30%                   504,000
Kentucky 33%                   881,000
Louisiana 30%                   849,000
Maine 29%                   229,000
Maryland 26%                   975,000
Massachusetts 24%                   999,000
Michigan 28%                1,687,000
Minnesota 22%                   744,000
Mississippi 34%                   595,000
Missouri 30%                1,090,000
Montana 25%                   152,000
Nebraska 25%                   275,000
Nevada 25%                   439,000
New Hampshire 24%                   201,000
New Jersey 23%                1,234,000
New Mexico 27%                   332,000
New York 25%                3,031,000
North Carolina 27%                1,658,000
North Dakota 24%                   111,000
Ohio 28%                1,919,000
Oklahoma 31%                   706,000
Oregon 27%                   654,000
Pennsylvania 27%                2,045,000
Rhode Island 25%                   164,000
South Carolina 28%                   822,000
South Dakota 25%                   126,000
Tennessee 32%                1,265,000
Texas 27%                4,536,000
Utah 23%                   391,000
Vermont 25%                     96,000
Virginia 26%                1,344,000
Washington 25%                1,095,000
West Virginia 36%                   392,000
Wisconsin 25%                   852,000
Wyoming 27%                     94,000
US 27%              52,240,000
SOURCE: Kaiser Family Foundation analysis of data from National Health Interview Survey and the Behavioral Risk Factor Surveillance System. NOTE: Five states (MA, ME, NJ, NY, VT) had broadly applicable guaranteed access to insurance before the ACA. What protections might exist in these or other states under a repeal and replace scenario is unclear.

At any given time, the vast majority of these approximately 52 million people with declinable pre-existing conditions have coverage through an employer or through public programs like Medicaid. The individual market is where people seek health insurance during times in their lives when they lack eligibility for job-based coverage or for public programs such as Medicare and Medicaid.  In 2015, about 8% of the non-elderly population had individual market insurance.  Over a several-year period, however, a much larger share may seek individual market coverage.2  This market is characterized by churn, as new enrollees join and others leave (often for other forms of coverage). For many people, the need for individual market coverage is intermittent, for example, following a 26th birthday, job loss, or divorce that ends eligibility for group plan coverage, until they again become eligible for group or public coverage.  For others – the self-employed, early retirees, and lower-wage workers in jobs that typically don’t come with health benefits – the need for individual market coverage is ongoing.  (Figure 1 shows the distribution of employment status among current individual market enrollees.) Prior to the ACA’s coverage expansions, we estimated that 18% of individual market applications were denied. This is an underestimate of the impact of medical underwriting because many people with health conditions did not apply because they knew or were informed by an agent that they would not be accepted.  Denial rates ranged from 0% in a handful of states with guaranteed issue to 33% in Kentucky, North Carolina, and Ohio. According to 2008 data from America’s Health Insurance Plans, denial rates ranged from about 5% for children to 29% for adults age 60-64 (again, not accounting for those who did not apply).

Figure 1: Employment Status of Non-Group Enrollees, 2016

Figure 1: Employment Status of Non-Group Enrollees, 2016

Medical Underwriting in the Individual Market Pre-ACA

Prior to 2014 medical underwriting was permitted in the individual insurance market in 45 states and DC.  Applications for individual market policies typically included lengthy questionnaires about the health and risk status of the applicant and all family members to be covered.  Typically, applicants were asked to disclose whether they were pregnant or contemplating pregnancy or adoption, and information about all physician visits, prescription medications, lab results, and other medical care received in the past year.  In addition, applications asked about personal history of a series of health conditions, ranging from HIV, cancer, and heart disease to hemorrhoids, ear infections and tonsillitis.  Finally, all applications included authorization for the insurer to obtain and review all medical records, pharmacy database information, and related information. Once the completed application was submitted, the medical underwriting process varied somewhat across insurers, but usually involved identification of declinable medical conditions and evaluation of other conditions or risk factors that warranted other adverse underwriting actions. Once enrolled, a person’s health and risk status was sometimes reconsidered in a process called post-claims underwriting. Although our analysis focuses on declinable medication conditions, each of these other actions is described in more detail below.

Declinable Medical Conditions

Before the ACA, individual market insurers in all but five states maintained lists of so-called declinable medical conditions.  People with a current or past diagnosis of one or more listed conditions were automatically denied.  Insurer lists varied somewhat from company to company, though with substantial overlap.  Some of the commonly listed conditions are shown in Table 2.

Table 2: Examples of Declinable Conditions In the Medically Underwritten Individual Market, Before the Affordable Care Act
Condition Condition
AIDS/HIV Lupus
Alcohol abuse/ Drug abuse with recent treatment Mental disorders (severe, e.g. bipolar, eating disorder)
Alzheimer’s/dementia Multiple sclerosis
Arthritis (rheumatoid), fibromyalgia, other inflammatory joint disease Muscular dystrophy
Cancer within some period of time (e.g. 10 years, often other than basal skin cancer) Obesity, severe
Cerebral palsy Organ transplant
Congestive heart failure Paraplegia
Coronary artery/heart disease, bypass surgery Paralysis
Crohn’s disease/ ulcerative colitis Parkinson’s disease
Chronic obstructive pulmonary disease (COPD)/emphysema Pending surgery or hospitalization
Diabetes mellitus Pneumocystic pneumonia
Epilepsy Pregnancy or expectant parent
Hemophilia Sleep apnea
Hepatitis (Hep C) Stroke
Kidney disease, renal failure Transsexualism
SOURCE: Kaiser Family Foundation review of field underwriting guidelines from Aetna (GA, PA, and TX), Anthem BCBS (IN, KY, and OH), Assurant, CIGNA, Coventry, Dean Health, Golden Rule, Health Care Services Corporation (BCBS in IL, TX) HealthNet, Humana, United HealthCare, Wisconsin Physician Service.  Conditions in this table appeared on declinable conditions list in half or more of guides reviewed.  NOTE: Many additional, less-common disorders also appearing on most of the declinable conditions lists were omitted from this table.

Our analysis of rates of pre-existing conditions in this brief focuses on those conditions that would likely be declinable, based on our review of pre-ACA underwriting documents. Our analysis is limited – and our results are conservative – because NHIS and BRFSS questionnaires do not address some of the conditions that were declinable, and in some cases the questions that do relate to declinable conditions were too broad for inclusion. See the methodology section for a list of conditions included in the analysis. In addition to declinable conditions, many insurers also maintained a list of declinable medications.  Current use of any of these medications by an applicant would warrant denial of coverage.  Table 3 provides an example of medications that were declinable in one insurer prior to the ACA. Our analysis does not attempt to account for use of declinable medications.

Table 3: Declinable Medications
 Anti-Arthritic Medications

  • Adalimumab/Humira
  • Cyclosporine/Sandimmune
  •  Methotrexate/Trexall
  • Ustekinumab/Stelara
  • others
 Anti-Diabetic Medications

  • Avandia/Rosiglitazone
  • Glucagon
  • Humalog/Insulin products
  • Metformin HCL
  • others
Medications for HIV/AIDS or Hepatitis

  • Abacavir/Ziagen
  • Efavirenz/Atripla
  • Interferon
  • Lamivudine/Epivir
  • Ribavirin
  • Zidovudine/Retrovir
  • others

 

Anti-Cancer Medications

  • Anastrozole/Arimidex
  • Nolvadex/Tamoxifen
  • Femara
  • others
Anti-Psychotics, Autism, Other Central Nervous System Medications

  • Abilify/Ariprazole
  • Aricept/Donepezil
  • Clozapine/Clozaril
  • Haldol/Haldoperidol
  • Lithium
  • Requip/Ropinerole
  • Risperdal/Risperidone
  • Zyprexa
  •  others
Anti-Coagulant/Anti-Thrombotic Medications

  • Clopidogrel/Plavix
  • Coumadin/Warfarin
  • Heparin
  • others
Miscellaneous Medications

  • Anginine (angina)
  • Clomid (fertility)
  • Epoetin/Epogen (anemia)
  • Genotropin (growth hormone)
  • Remicade (arthritis, ulcerative colitis)
  • Xyrem (narcolepsy)
  • others
SOURCE:  Blue Cross Blue Shield of Illinois, Product Guide for Agents

Some individual market insurers also developed lists of ineligible occupations.  These were jobs considered sufficiently high risk that people so employed would be automatically denied.  In addition, some would automatically deny applicants who engaged in certain leisure activities and sports.  Table 4 provides an example of declinable occupations from one insurer prior to the ACA.  Our analysis does not attempt to account for declinable occupations.

Table 4: Ineligible Occupations, Activities
Active military personnel Iron workers Professional athletes
Air traffic controller Law enforcement/detectives Sawmill operators
Aviation and air transportation Loggers Scuba divers
Blasters or explosive handlers Meat packers/processors Security guards
Bodyguards Mining Steel metal workers
Crop dusters Nuclear industry workers Steeplejacks
Firefighters/EMTs Offshore drillers/workers Strong man competitors
Hang gliding Oil and gas exploration and drilling Taxi cab drivers
Hazardous material handlers Pilots Window washers
SOURCE: Preferred One Insurance Company Individual and Family Insurance Application Form

Other Adverse Underwriting Actions

Beyond the declinable conditions, medications and occupations, underwriters also examined individual applications and medical records for other conditions that could generate significant “losses” (claims expenses.)  Among such conditions were acne, allergies, anxiety, asthma, basal cell skin cancer, depression, ear infections, fractures, high cholesterol, hypertension, incontinence, joint injuries, kidney stones, menstrual irregularities, migraine headaches, overweight, restless leg syndrome, tonsillitis, urinary tract infections, varicose veins, and vertigo. One or more adverse medical underwriting actions could result for applicants with such conditions, including:

  • Rate-up – The applicant might be offered a policy with a surcharged premium (e.g. 150 percent of the standard rate premium that would be offered to someone in perfect health)
  • Exclusion rider – Coverage for treatment of the specified condition might be excluded under the policy; alternatively, the body part or system affected by the specified condition could be excluded under the policy. Exclusion riders might be temporary (for a period of years) or permanent
  • Increased deductible – The applicant might be offered a policy with a higher deductible than the one originally sought; the higher deductible might apply to all covered benefits or a condition-specific deductible might be applied
  • Modified benefits – The applicant might be offered a policy with certain benefits limited or excluded, for example, a policy that does not include prescription drug coverage.

In some cases, individuals with these conditions might also be declined depending on their health history and the insurer’s general underwriting approach.  For example, field underwriting guides indicated different underwriting approaches for an applicant whose child had chronic ear infections:

  • One large, national insurer would issue standard coverage if the child had fewer than five infections in the past year or ear tubes, but apply a 50% rate up if there had been more than 4 infections in the prior year;
  • Another insurer, which used a 12-tier rate system, would issue coverage at the second most favorable rate tier if the child had just one infection in the prior year or ear tubes, at the fifth rate tier if there had been 2-3 infections during the prior year, and at the seventh tier if there had been 4 or more infections; for some conditions, this company’s rating might depend on the plan deductible – applicants with history of ear infections would be offered the second rating tier for policies with a deductible of $5,000 or higher;
  • Another insurer would issue standard coverage if the child had just one infection in the prior year or if ear tubes had been inserted more than one-year prior, apply a rate up if there were two infections in the prior year, and decline the application if there were three or more infections;
  • Another insurer would issue standard coverage if the child had fewer than 3 infections in the past year, but issue coverage with a condition specific deductible of $5,000 if there had been 3 or more infections or if ear tubes had been inserted.

In a 2000 Kaiser Family Foundation study of medical underwriting practices, insurers were asked to underwrite hypothetical applicants with varying health conditions, from seasonal allergies to situational depression to HIV.  Results varied significantly for less serious conditions. For example, the applicant with seasonal allergies who made 60 applications for coverage was offered standard coverage 3 times, declined 5 times, offered policies with exclusion riders or other benefit limits 46 times (including 3 offers that excluded coverage for her upper respiratory system), and policies with premium rate ups (averaging 25%) 6 times.

Pre-existing Condition Exclusion Provisions

In addition to medical screening of applicants before coverage was issued, most individual market policies also included more general pre-existing condition exclusion provisions which limited the policy’s liability for claims (typically within the first year) related to medical conditions that could be determined to exist prior to the coverage taking effect.3

Example of pre-existing condition exclusion Jean, an Arizona teacher whose employer provided group health benefits but did not contribute to the cost for family members, gave birth to her daughter, Alex, in 2004 and soon after applied for an individual policy to cover the baby.  Due to time involved in the medical underwriting process, the baby was uninsured for about 2 weeks. A few months later, Jean noticed swelling around the baby’s face and eyes.  A specialist diagnosed Alex with a rare congenital disorder that prematurely fused the bones of her skull.  Surgery was needed immediately to avoid permanent brain damage.   When Jean sought prior-authorization for the $90,000 procedure, the insurer said it would not be covered.  Under Arizona law, any condition, including congenital conditions, that existed prior to the coverage effective date, could be considered a pre-existing condition under individual market policies.  Alex’s policy excluded coverage for pre-existing conditions for one year.  Jean appealed to the state insurance regulator who upheld the insurer’s exclusion as consistent with state law. Source:  Wall Street Journal, May 31, 2005

The nature of pre-existing condition exclusion clauses varied depending on state law.  In 19 states, a health condition could only be considered pre-existing if the individual had actually received treatment or medical advice for the condition during a “lookback” period prior to the coverage effective date (from 6 months to 5 years).  In most states, a pre-existing condition could also include one that had not been diagnosed but that produced signs or symptoms that would prompt an “ordinarily prudent person” to seek medical advice, diagnosis or treatment.  In 8 states and DC, conditions that existed prior to the coverage effective date – including those that were undiagnosed and asymptomatic – could be considered pre-existing and so excluded from coverage under an individual market policy.  For example, a congenital condition in a newborn could be considered pre-existing to the coverage effective date (the baby’s birth date) and excluded from coverage.  About half of the states required individual market insurers to reduce pre-existing condition exclusion periods by the number of months of an enrollee’s prior coverage.

Example of policy rescission Jennifer, a Colorado preschool teacher, was seriously injured in 2005 when her car was hit by a drug dealer fleeing the police. She required months of inpatient hospitalization and rehab, and her bills reached $185,000.   Jennifer was covered by a non-group policy which she had purchased five months prior to the accident.   Shortly after her claims were submitted, the insurer re-reviewed Jennifer’s application and medical history.  Following its investigation, the insurer notified Jennifer they found records of medical care she had not disclosed in her application, including medical advice sought for discomfort from a prolapsed uterus and an ER visit for shortness of breath.  The insurer rescinded the policy citing Jennifer’s failure to disclose this history. Jennifer sued the insurer for bad faith; four years later a jury ordered the insurer to reinstate the policy and pay $37 million in damages. Source:  Westword, February 11, 2010.

Unlike exclusion riders that limited coverage for a specified condition of a specific enrollee, pre-existing condition clauses were general in nature and could affect coverage for any applicable condition of any enrollee.  Pre-existing condition exclusions were typically invoked following a process called post-claims underwriting.  If a policyholder would submit a claim for an expensive service or condition during the first year of coverage, the individual market insurer would conduct an investigation to determine whether the condition could be classified as pre-existing. In some cases, post-claims underwriting might also result in coverage being cancelled.  The investigations would also examine patient records for evidence that a pre-existing condition was known to the patient and should have been disclosed on the application.  In such cases, instead of invoking the pre-existing condition clause, an issuer might act to rescind the policy, arguing it would have not issued coverage in the first place had the pre-existing condition been disclosed.

Discussion

The Affordable Care Act guarantees access to health insurance in the individual market and ends other underwriting practices that left many people with pre-existing conditions uninsured or with limited coverage before the law. As discussions get underway to repeal and replace the ACA, this analysis quantifies the number of adults who would be at risk of being denied if they were to seek coverage in the individual market under pre-ACA rules. What types of protections are preserved for people with pre-existing conditions will be a key element in the debate over repealing and replacing the ACA. We estimate that at least 52 million non-elderly adult Americans (27% of those under the age of 65) have a health condition that would leave them uninsurable under medical underwriting practices used in the vast majority of state individual markets prior to the ACA. Results vary from state-to-state, with rates ranging around 22 – 23% in some Northern and Western states to 33% or more in some southern states. Our estimates are conservative and do not account for a number of conditions that were often declinable (but for which data are not available), nor do our estimates account for declinable medications, declinable occupations, and conditions that could lead to other adverse underwriting practices (such as higher premiums or exclusions). While most people with pre-existing conditions have employer or public coverage at any given time, many people seek individual market coverage at some point in their lives, such as when they are between jobs, retired, or self-employed. There is bipartisan desire to protect people with pre-existing conditions, but the details of replacement plans have yet to be ironed out, and those details will shape how accessible insurance is for people when they have health conditions.

Gary Claxton, Cynthia Cox, Larry Levitt, and Karen Pollitz are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.

Methods

To calculate nationwide prevalence rates of declinable health conditions, we reviewed the survey responses of nonelderly adults for all question items shown in Methods Table 1 using the CDC’s 2015 National Health Interview Survey (NHIS).  Approximately 27% of 18-64 year olds, or 52 million nonelderly adults, reported having at least one of these declinable conditions in response to the 2015 survey.  The CDC’s National Center for Health Statistics (NCHS) relies on the medical condition modules of the annual NHIS for many of its core publications on the topic; therefore, we consider this survey to be the most accurate means to estimate both the nationwide rate and weighted population. Since the NHIS does not include state identifiers nor sufficient sample size for most state-based estimates, we constructed a regression model for the CDC’s 2015 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the prevalence of any of the declinable conditions shown in Methods Table 1 at the state level.  This model relied on three highly significant predictors: (a) respondent age; (b) self-reported fair or poor health status; (c) self-report of any of the overlapping variables shown in the left-hand column of Methods Table 1.  Across the two data sets, the prevalence rate calculated using the analogous questions (i.e. the left-hand column of Methods Table 1) lined up closely, with 20% of 18-64 year old survey respondents reporting at least one of those declinable conditions in the 2015 NHIS and 21% of 18-64 year olds in the 2015 BRFSS.  Applying this prediction model directly to the 2015 BRFSS microdata yielded a nationwide prevalence of any declinable condition of 28%, a near match to the NHIS nationwide estimate of 27%.

 

Methods Table 1: Declinable Medical Conditions Available in Survey Microdata
Declinable Condition Questions Available in both the 2015 National Health Interview Survey and also the 2015 Behavioral Risk Factor Surveillance System Declinable Condition Questions Available in only the 2015 National Health Interview Survey
Ever had CHD Melanoma Skin Cancer
Ever had Angina Any Other Heart Condition
Ever had Heart Attack Crohn’s Disease or Ulcerative Colitis
Ever had Stroke Epilepsy
Ever had COPD Difficulty Due to Mental Retardation
Ever had Emphysema Difficulty Due to Cerebral Palsy
Chronic Bronchitis in past 12 months Difficulty Due to Senility
Ever had Non-Skin Cancer Difficulty Due to Depression
Ever had Diabetes Difficulty Due to Endocrine Problem
Weak or Failing Kidneys Difficulty Due to Blood Forming Organ Problem
BMI > 40 Difficulty Due to Drug / Alcohol / Substance Abuse
Pregnant Difficulty Due to Schizophrenia, ADD, or Bipolar Disorder

In order to align BRFSS to NHIS overall statistics, we then applied a Generalized Regression Estimator (GREG) to scale down the BRFSS microdata’s prevalence rate and population estimate to the equivalent estimates from NHIS, 27% and 52 million.  Since the regression described in the previous paragraph already predicted the prevalence rate of declinable conditions in BRFSS by using survey variables shared across the two datasets, this secondary calibration solely served to produce a more conservative estimate of declinable conditions by calibrating BRFSS estimates to the NHIS.  After applying this calibration, we calculated state-specific prevalence rates and population estimates off of this post-stratified BRFSS sample. The programming code, written using the statistical computing package R v.3.3.2, is available upon request for people interested in replicating this approach for their own analysis.

This article was written by Gary Claxton, Cynthia Cox, Anthony Damico, Larry Levitt and Karen Pollitz on Kaiser Family Foundation. Published: Dec 12, 2016

Proposals for Insurance Options That Don’t Comply with ACA Rules: Trade-offs In Cost and Regulation

Now in the fifth year of implementation, the Affordable Care Act (ACA) standards for non-group health insurance require health plans to provide major medical coverage for essential health benefits (EHB) with limits on deductibles and other cost sharing.  In addition, ACA standards prohibit discrimination by non-group plans: pre-existing conditions cannot be excluded from coverage and eligibility and premiums cannot vary based on an individual’s health status.  The ACA also created income-based subsidies to reduce premiums (premium tax credits, or APTC) and cost-sharing for eligible individuals who purchase non-group plans, called qualified health plans (QHPs), through the Marketplace.  ACA-regulated non-group plans can also be offered outside of the Marketplace, but are not eligible for subsidies.

New: A look at the tradeoffs in costs and protections involved in four proposed health plan alternatives that would operate outside the ACA’s rules and regulations

Individual market premiums were relatively stable during the first three years of ACA implementation, then rose substantially in each of 2017 and 2018.  Last year, nearly 9 million subsidy-eligible consumers who purchased coverage through the Marketplace were shielded from these increases; but another nearly 7 million enrollees in ACA compliant plans, who do not receive subsidies, were not.  Bipartisan Congressional efforts to stabilize individual market premiums – via reinsurance and other measures – were debated in the fall of 2017 and the spring of 2018, but not adopted.  Meanwhile, opponents of the ACA at the federal and state level have proposed making alternative plan options available that would be cheaper, in terms of monthly premiums, for at least some people because plans would not be required to meet some or all standards for ACA-compliant plans. This brief explains state and federal proposals to create a market for more loosely-regulated health insurance plans outside of the ACA regulatory structure.

Background

When ACA Marketplaces first opened in 2014, on average, the cost of the benchmark silver QHP was lower than many had predicted.  Many insurers underpriced QHPs at the outset, either because they couldn’t accurately predict the cost of providing coverage to a new population under new ACA rules, or to aggressively compete for market share, or both.  As a result, insurers offering ACA-compliant policies generally lost money in 2014-2016.  In the fall of 2016, for the 2017 coverage year, most issuers implemented a substantial corrective premium increase for their benchmark QHP – on average, a 21% increase for a 40-year-old consumer.  This increase, along with growing experience with new market rules, allowed many insurers to regain profitability in 2017, and, going forward, stabilization of QHP rates might otherwise have been expected.

Instead, though, a new wave of uncertainty arose last year as Congress debated repeal of the ACA and as the Trump Administration threatened administrative actions with the stated intent of undermining the program, including by ending reimbursement to insurers for required cost-sharing reductions (CSRs) that, by law, they must offer low-income enrollees in silver QHPs.  The value of CSRs was estimated by CBO to be $9 billion for 2018.  To compensate for the lost reimbursement, most insurers significantly increased 2018 premiums for silver level QHPs, through which cost sharing subsidies are delivered.  Largely due to this so-called “silver load” pricing strategy, the average benchmark silver QHP premium for a 40-year-old rose another 33% for the 2018 coverage year. (Figure 1) Premiums for bronze and gold plans rose more slowly, but still substantially given uncertainty on a number of issues, including whether the ACA’s individual mandate would be enforced.

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Figure 1: Average marketplace benchmark premium for a 40-year-old has increased, but so have premium tax credits

For consumers who are eligible for APTC and who buy the benchmark silver plan (or a less expensive plan) through the Marketplace, subsidies absorb annual premium increases and the net cost of coverage has remained relatively unchanged from 2014 through today.  Roughly 85% of Marketplace participants in 2017 were eligible for APTC.  (Figure 2)  However, for the 15% of Marketplace participants who were not eligible for subsidies, and for another roughly 5 million individuals who bought ACA compliant plans outside of the Marketplace, these consecutive annual rate increases threatened to make coverage unaffordable. That threat was even greater in some areas, where 2018 QHP rate increases were much higher than the national average.

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Figure 2: Most in ACA-compliant plans are protected from rate increases by premium subsidies

Looking ahead, another round of significant premium increases is possible for the 2019 coverage year.  A new source of uncertainty arose when Congress voted to end the ACA’s individual mandate penalty, effective in 2019.  The Congressional Budget Office (CBO) estimated repeal of the mandate would fuel adverse selection – as some younger, healthier consumers might be more likely to forego coverage – and average premiums in the non-group market would increase by about 10 percent in most years of the decade, on top of increases due to other factors such as health care cost growth.

ACA opponents have argued QHP premium increases reflect a failure of the federal law.  As an alternative, some have proposed different kinds of health plan options to offer premium relief to consumers who need non-group coverage but who are not eligible for premium subsidies, primarily by relaxing rules governing required benefits, coverage of pre-existing conditions, and/or community rating. These include:

Short-Term, Limited Duration Health Insurance Policies

In 2018 the Trump Administration proposed a new draft regulation that would promote the sale of short-term, limited duration health insurance policies that offer less expensive coverage because they are not subject to ACA market rules.

Short-term limited-duration health insurance policies (STLD), sometimes referred to as limited-duration non-renewable policies, are designed to provide temporary health coverage for people who are uninsured or are losing their existing coverage but expect to become eligible for other, more permanent coverage in the near future.  Historically, people who have used these policies include graduating students losing coverage through their parents or their school, people with a short interval between jobs, or newly hired employee subject to a waiting period before they are eligible for coverage from their job. Because these policies are not intended to provide long-term protection (they generally cannot be renewed when their term ends), they are lightly regulated by states and are exempt from many of the standards generally applicable to individual health insurance policies. They also are specifically exempt under the ACA from federal standards for individual health insurance coverage, including the essential health benefits, guaranteed availability and prohibitions against pre-existing condition exclusions and health-status rating.  These differences can make them considerably less expensive (for those healthy enough to qualify to buy them) than ACA compliant plans.

STLDs are similar to major medical policies in that they typically cover both hospitalization and at least some outpatient medical services, but unlike ACA-compliant policies, they often have significant benefit and eligibility limitations.  STLD policies often either exclude are have significant limitations on benefits for mental health and substance abuse, do not have coverage for maternity services, and have limited or no coverage for prescription drugs.  Policies also generally have dollar limits on all benefits or specific benefits and may have deductibles and other cost sharing that is much higher than permitted in ACA-compliant plans.  Insurers of STLD policies typically use medically underwriting, which means that they can turn down applicants with health problems or charge them higher premiums.  Policies also exclude coverage for any benefits related to a preexisting health condition: a backstop for insurers in case a person with a health problem otherwise qualifies for coverage and seeks benefits. Because STLD policies are not renewable, people who become ill after their coverage begins are generally not able to qualify for a new policy when their coverage term ends.

Due to their lower premiums, some people have been purchasing STLD policies instead of ACA compliant plans. This has happened even though STLD policies are not considered minimum essential coverage, which means that people who purchase them do not satisfy the ACA mandate to have health insurance and may be subject to a tax penalty.  In 2016, CMS expressed concern about these policies being sold as a type of “primary health insurance” and issued regulations shortening the maximum coverage period under federal law for STLD policies from less than 12 months to less than three months and prescribing a disclosure that must be provided to new applicants.  The intent of the regulation was to limit sale of these policies to situations involving a short gap in coverage and to discourage their use a substitute for primary health insurance coverage. The rule took effect for policies issued to individuals on or after January 1, 2017. In February 2018, the Trump Administration issued a new proposed regulation to reinstate the “less than 12 months” maximum coverage term for STLD policies. The preamble to the proposed regulation specified that this would provide more affordable consumer choice for health coverage. For more information about STLD policies, see this issue brief.

Extending the coverage period for STLD policies back to just under a year is likely to make them a more attractive choice for healthier individuals concerned about the cost of ACA-compliant plans.  This is particularly true beginning in 2019 when the individual mandate penalty ends and purchasers will no longer need to pay a penalty in addition to the premiums for these policies.

Under the ACA framework, STLD plans may provide a lower-cost alternative source of health coverage for people in good health.  With ACA policies as a backup, people who purchase STLD policies and develop a health problem would not be able to renew their short-term policy at the end of its term, but would be able to elect an ACA-compliant plan during the next open enrollment.

It is possible, as one estimate concluded, that more healthy individual market participants may switch to short-term policies as a result.  Such “adverse selection” would raise the average cost of covering remaining individuals in ACA-compliant plans, leading to further premium increases in those policies.  For people with pre-existing conditions who do not qualify for subsidies, the rising cost of ACA-compliant coverage could challenge affordability, especially for people with pre-existing conditions who have incomes that make them ineligible for premium subsidies.

Association Health Plans

Another draft regulation proposed by the Trump Administration would permit small employers and self-employed individuals to buy a new type of association health plan coverage that does not have to meet all requirements applicable to other ACA-compliant small group and non-group health plans.  While many types of health insurance are marketed though associations, including STLDs, hospital indemnity plans and cancer or other dread disease policies, current policy discussions about AHPs tend to focus on arrangements formed by groups of employers (called multiple employer welfare arrangements, or MEWAs) which could also offer group health insurance coverage to self-employed people without any employees (“sole proprietors”).

The U.S. Department of Labor recently proposed regulations under the Employee Retirement Income Security Act (ERISA) to expand the types of MEWAs that could offer health plans that would not be subject to certain ACA requirements. Under the draft regulation, AHPs – a type of MEWA – could offer health coverage to sole proprietors and to small businesses, but would be subject to large group health plan standards.  Key ACA requirements for the non-group and small group market do not apply to large group health plans today, and so would not apply to AHP coverage sold to self-employed individuals or small employers.  In particular, AHPs would not be required to cover essential health benefits; it would be possible under the proposed regulation for AHPs to offer policies that do not cover prescription drugs, for example.

Under the draft regulation, AHPs would be subject to a nondiscrimination standard that would prohibit basing eligibility or premiums on an enrollee’s health status.  However, other ACA rating standards in the non-group and small group market would not apply; in particular, AHPs would be allowed to vary premiums by more than 3:1 for age and without limit based on gender, geography, and other factors such type of industry or occupation.

As a result, AHPs could provide self-employed individuals an alternative to individual health insurance that provides fewer benefits with more rating flexibility.   As nearly one-third (31%) of individual market enrollees are self-employed, the impact of AHPs could be significant.

The draft regulation included other language related to state vs. federal regulatory authority over MEWAs, or AHPs.  Currently, MEWAs are subject to a somewhat complex mix of regulatory provisions at the federal and state levels; the applicable standards vary depending on a number of things, including whether the MEWA is self-funded or provides benefits through insurance, whether the arrangement itself is considered to be sponsoring an employee benefit plan as defined in ERISA, the sizes of the employers participating in the arrangement, and how the states in which the arrangements operate approach MEWA regulation.  The proposed rule generally leaves in place state authority over MEWAs/AHPs. However, the DOL requested comments on whether it should consider changes that would limit state regulation of self-funded AHPs to financial matters such as solvency and reserves, in effect, prohibiting states from regulating AHP rating and benefit design practices.

The degree of impact on individual health insurance markets will depend in part on the final rules, in particular whether the nondiscrimination provision is preserved and whether states retain current authority over AHPs.

Idaho Proposal for New State-Based Health Plans

In January 2018, pursuant to an executive order by Governor Otter, the Idaho Department of Insurance issued a bulletin outlining provisions of new individual health insurance products that insurance companies would be permitted to sell under state law. The new “State-Based Health Benefit Plans” would not have to comply with certain ACA requirements and, as a result, would likely be offered for premiums lower than those charged for ACA-compliant policies – at least for consumers who are younger and who don’t have pre-existing conditions.

State-Based Health Plans would be required to cover a package of health benefits and cost sharing that was less than that required for ACA-compliant plans.  For example, certain essential health benefit categories, such as habilitation services and pediatric dental and vision, appear not to be required.  In addition, ACA limits on cost sharing were not specified, and annual dollar limits on covered benefits could be applied.  If consumers reach the annual dollar limit on coverage under a state-based plan, the insurer would be required to transfer their enrollment into an ACA-compliant plan.

In addition, state-based plans would not be allowed to deny applicants based on health status and could be sold year round, outside of Open Enrollment.  However, State-Based plans could exclude coverage of pre-existing conditions for any individual who had experienced at least a 63-day break in coverage.  These plans would also be permitted to vary premiums by a factor of 3:1 based on health status (prohibited by the ACA), and by 5:1 based on age (higher than the 3:1 ratio permitted by the ACA). In order to offer a State-Based Health Plan, insurers would also be required to offer at least one QHP through the Idaho Marketplace.

The bulletin required that state-based plans and exchange-certified plans must comprise a single risk pool, with a single index rate for all plans that does not account for differences in the health status of individuals who enroll, or are expected to enroll in a particular type of plan.  However, the Academy of Actuaries noted that, because the two types of plans would not be competing under the same rules, “there would be, in effect, two risk pools – one for ACA coverage and one for state-based coverage.  Premiums for ACA coverage would increase, threatening sustainability of the ACA market and its pre-existing condition protections.”

The Idaho State-Based Health Plan proposal is similar in many respects to an amendment offered by Senator Ted Cruz during the ACA repeal debate in 2017.  The amendment, which was not enacted, would have allowed insurers that sell ACA-compliant marketplace plans to also offer other policies that could be medically underwritten and that would not have to meet other ACA standards.  Although CBO did not estimate how the amendment would impact premiums or coverage, representatives of the insurance industry predicted that, “As healthy people move to the less-regulated plans, those with significant medical needs will have no choice but to stay in the comprehensive plans, and premiums will skyrocket for people with preexisting conditions. This would especially impact middle-income families that that are not eligible for a tax credit.”

The Idaho proposal appears to be not moving forward at this time.  Recently, the director of the federal Center on Medicare and Medicaid Services (CMS) advised Idaho officials that these State-Based health plans would be in violation of federal law.  Under the ACA, states do not have flexibility to authorize the sale of individual health insurance policies that do not meet federal minimum standards.  In states that do not enforce federal minimum standards, the federal government is required to step in and enforce.

The CMS letter did generally express sympathy with Idaho’s approach, citing “damage caused by the [ACA],” and encouraged the state to pursue modified strategies to expand availability of more affordable plans that do not meet all ACA requirements.  The letter specifically urged Idaho to consider promoting short-term policies as a legal alternative to ACA-compliant health plans, and it invited the State to develop other alternative strategies using ACA state waiver authority.

Farm Bureau Health Plans Exempt from State Regulation

A new Iowa law enacted this month would permit the sale of health coverage by the state’s Farm Bureau.  The Farm Bureau is not a licensed health insurer.  Under the new law, Farm Bureau health plans would be deemed to not be insurance and explicitly would not be subject to state insurance regulation.  By extension, Farm Bureau plans also would not have to meet federal ACA standards for health insurance as these apply only to policies sold by state licensed health insurers.

The new Iowa law applies no other standards for Farm Bureau health plans – for example, it does not establish minimum benefit requirements, rating requirements, or rules prohibiting discrimination based on pre-existing health conditions. Appeal rights guaranteed to health insurance policyholders also would not apply to Farm Bureau enrollees, nor would state insurance solvency and other financial regulations.  The law does require the Farm Bureau to administer coverage through a state licensed third party administrator, or TPA (expected to be Wellmark, Iowa’s Blue Cross Blue Shield insurer.)  However, use of a TPA does not extend federal or state insurance law to the underlying Farm Bureau health plan.

The Iowa law closely resembles a Tennessee state law, enacted in 1993, which authorized the sale of health coverage by the Farm Bureau and deemed such coverage not to be health insurance subject to state regulation.  In Tennessee, it has been reported that roughly 25,000 residents purchase non-group Farm Bureau health plans that are medically underwritten.  (By comparison, more than 228,000 residents have ACA-compliant individual policies through the Marketplace this year.)  Farm Bureau plan premiums can be as much as two-thirds lower than for ACA-compliant plans because the underwritten policies can and do deny coverage to people with pre-existing conditions.  Adverse selection results, with sicker residents confined to the ACA-regulated market.  An analysis of risk scores for state insurance markets finds that Tennessee’s individual market has one of the highest risk scores in the nation.

Since 2014, Tennessee residents who buy underwritten Farm Bureau health coverage are not considered to have “minimum essential coverage” and so may owe a tax penalty under the ACA individual mandate.  However, this disincentive to purchase Farm Bureau plans in Tennessee and Iowa will end in 2019 when repeal of the mandate penalty takes effect.

Discussion

Each of these proposals follows a similar theme.  Creating parallel insurance markets with different, lesser consumer protections, allows insurers to offer lower premiums and less coverage to people while they are healthy, leaving the ACA-regulated market with a sicker pool and higher premiums.  Once repeal of the ACA individual mandate penalty takes effect in 2019, the net cost differential between regulated and less-regulated coverage will be even greater.

Premium subsidies in the ACA-regulated market will help to curb adverse selection, protecting people with lower incomes from the impact of higher premiums, and providing some continued stability in the reformed market.  However, middle-income people who are not eligible for subsidies, and who have pre-existing conditions, will not have any meaningful new coverage choices under these proposals.  Instead, the cost of health insurance that covers essential benefits and their pre-existing conditions will increase, potentially further pricing them out of affordable coverage altogether.

Source:
Pollitz K. (18 April 2018). "Proposals for Insurance Options That Don’t Comply with ACA Rules: Trade-offs In Cost and Regulation" [web blog post]. Retrieved from address https://kaiserf.am/2w89S3Z