4 FAQs about 2019 Medicare rates

Some high-income enrollees of Medicare Part B may experience premium increases of 7.4 percent. According to Medicare managers, Medicare Part B premium increases will be held to about 1.1 percent for most enrollees in 2019. Read on to learn more.

Medicare managers announced last week that they will hold increases in Medicare Part B premiums to about 1.1 percent for most enrollees in 2019. For some high-income enrollees, however, premiums will rise 7.4 percent.

Medicare Part B is the component of the traditional Medicare program that covers physician services and hospital outpatient care.

Here’s a look at how the monthly Part B premiums will change, by annual income level:

  • Individuals earning less than $85,000, and couples earning less than $170,000:$135.50 in 2019, from $134 this year.
  • Individuals earnings $160,000 to $500,000, and couples earning $320,000 to $750,000: $433.40 in 2019, from $428.60 this year.
  • Individuals earning $500,000 or more, and couples earning $750,000 or more: $460.50 in 2019, from $428.60 this year.

The annual Medicare Part B deductible will increase by 1.1 percent, to $185.

Another component of the traditional Medicare program, Medicare Part A, covers inpatient hospital bills.

Medicare managers use payroll taxes to cover most of the cost of running the Medicare Part A program. Few Medicare Part A enrollees pay premiums for that coverage. But, for the enrollees who do have to pay premiums for Medicare Part A coverage, the full premium will increase 3.6 percent, to $437 per month.

The Medicare Part A deductible for inpatient hospital care will increase 1.8 percent, to $1,340.

Why are high earners paying so much more for Medicare Part B?

Congress has been increasing the share of Medicare costs that high earners pay in recent years.

For 2018, the top annual income category for Medicare Part B rate-setting purposes was for $160,000 and over for individuals, and for $320,000 and over for couples. Premiums from those Medicare Part B enrollees are supposed to cover 80 percent of their Part B claims.

In the Balanced Budget Act of 2018, Congress added a new annual income category: for individuals earning $500,000 or more and couples earning $750,000 or more. Premiums from Part B enrollees in that income category are supposed to cover 85 percent of those enrollees’ Part B claims.

Who do these rate increases actually affect?

Medicare now has about 60 million enrollees of all kinds, according to the CMS Medicare Enrollment Dashboard.

About 21 million are in Medicare Advantage plans and other plans with separate premium-setting processes.

About 38 million are in the traditional Medicare Part A, the Medicare Part B program, or both the Medicare Part A and the Medicare Part B programs. CMS refers to the traditional Medicare Part A-Medicare Part B program as Original Medicare. The rate increases have a direct effect on the Original Medicare enrollees’ costs.

How do the Medicare increases compare with the Social Security cost-of-living adjustment (COLA)?

The Social Security Administration recently announced that the 2019 Social Security COLA will be 2.8 percent.

That means the size of the COLA will be greater than the increase in Medicare premiums for all Medicare enrollees other than the highest-income Medicare Part B enrollees and the enrollees who pay the full cost of the Medicare Part A premiums.

Why should financial professionals care about Original Medicare premiums?

For consumers who already have traditional Medicare coverage, the Part A and Part B premiums may affect how much they have to spend on other insurance products and related products, such as Medicare supplement insurance coverage.

For retirement income planning clients, Medicare costs are something to factor into income needs calculations.

Because access to Medicare coverage is critical to all but the very wealthiest retirees, knowledge about how to get and keep eligibility for Medicare coverage on the most favorable possible terms is of keen interest to many consumers ages 50 and older. Some consumers may like to get information about that topic from their insurance agents, financial planners and other advisors.


Officials at the Centers for Medicare and Medicaid Services, the agency that runs Medicare, are preparing to publish the official 2019 Medicare rate notices in the Federal Register on Wednesday. A preview copy of the Part A notice is available here, and a preview copy of the Part B notice is available here.

SOURCE: Bell, A. (16 October 2018) "4 FAQs about 2019 Medicare rates" (Web Blog Post). Retrieved from https://www.benefitspro.com/2018/10/16/medicare-posts-2019-rates-pinches-high-earners-412/

Are you ready for self-funding? Three tools to help you decide

Are you ready for a self-funded health plan? Self-funding and other alternative funding options may seem risky to many HR professionals. Continue reading for three tools to help you decide if you’re ready to switch.

When your health plan is fully insured, it’s easy for your finance department to budget for the cost — you just pass on the health insurer’s annual renewal premium amount to them and that becomes the annual budget number. But you and your broker may have come to suspect that you are leaving money on the table by continuing on a fully insured basis, and you may want to test the self-funded waters.

By now, you may already know there are significant benefits to self-funding, but actually making the switch is a scary prospect for HR directors.

Before you can transition to a self-funded plan, you need to be financially stable and willing to take a bit of a risk. As a safeguard, you also need to familiarize yourself with the two forms of stop-loss insurance. One caps the impact on any one covered member’s claims (individual or specific stop loss), and the other caps your total annual claim liability (aggregate stop loss). Your broker can guide you on which stop loss levels and which stop-loss coverage periods are right for your population when transitioning from fully insured to self-funding.

Beyond these stop-loss safeguards, size will dictate how you pay. If you have fewer than 100 covered employees, you may be able to pay the same amount monthly, just as you do with your fully insured premium. This monthly payment equals projected claims plus an aggregate margin, a monthly administration fee and the stop loss charge. This eliminates unpredictable monthly payments for a small self-funded group.

However, for larger groups of over 100 employees, moving to self-funding will mean paying claims as they are processed (which means uneven claim payments), plus stop loss and administration.

To help you determine if you’re ready for self-funding, you may want to analyze your plan in a few different ways.

1. Look back: A look back analysis is just what it sounds like — a view of how your plan would have performed over the last couple years had you been self-funded, compared to how it did perform under a fully insured model. This should be an easy enough task for your broker to take on, especially if they have sought out self-funded quotes from claim administrators and stop-loss carriers on your behalf. In addition, they should know what your actual claims costs were. The result is that you’ll know whether you would have saved money or not.

2. Look forward: You may already know what your upcoming fully insured renewal looks like. But even if you don’t have hard numbers yet, you can work with your broker to determine a strong estimate of what your proposed premiums will be. Then, your broker should get a self-funded quote, which includes the expected and maximum claims, plus the administrative fees and stop-loss premiums. This is your expected self-funded costs for the upcoming policy period. Compare that estimate to your fully insured renewal costs. (Make sure the self-funded costs are on the same “incurred claims with runout” basis that the fully insured costs would be, for a fair apples-to-apples comparison.)
3. Probability. While the “look forward” analysis compares your fully insured costs to your expected self-funded costs, it is based on “expected” claims. The risky part of self-funding is that your actual claims will not ultimately materialize exactly as expected. There are some more sophisticated tools that combine group-specific data (such as your claims history, demographics and the proposed fixed costs) with a fairly large actuarial database to come up with thousands of possible outcomes.

By charting all of these outcomes, you can produce likelihood percentages of where your actual claims will come in at — versus the “expected” level, and versus the fully insured renewal rate. Not all brokers have this tool on hand, and as a result, there may be a cost associated with producing one. The output from this tool may appeal to your colleagues in the finance department.

Other considerations

During your analysis, you may want to set your self-funded policy year liability based on incurred claims (plus fixed costs), even though your actual paid claims within that policy year may be less due to the lag between when provider services occur and when you actually fund them. The lag is a cash-flow advantage but it does not represent a reduced claim liability.

Finally, don’t lose sight of the cost of high claimants, an important part of planning if you choose the self-funding route. Will your past high claimants continue into your renewal period? Are you aware of new high claimants on the horizon? Stop-loss carriers generally insure only “unknown risks,” not “known risks.” If a plan member has an expensive chronic condition, such as kidney failure, a stop loss carrier may “laser” that individual and set a higher individual stop-loss threshold. It’s important that you know what’s excluded and factor in any uncovered catastrophic claimants into your analysis.

In the end, it may turn out that self-funding is not a good fit, or possibly that this year is just not the year for it. But whether it is, or it isn’t, it is comforting to know that you’ve done your due diligence and have documentation supporting the decision you’ve reached.

SOURCE: DePaola, Raymond (5 October 2018) "Are you ready for self-funding? Three tools to help you decide" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/ready-for-self-funding-three-tools-to-help-you-decide

Identity theft protection benefits and the business case for employers

Employees are turning to their employers for identity theft protection benefits with the rise in identity theft news. Continue reading to learn more.

With identity theft in the news constantly, many employees are turning to their employers to ask for an identity protection benefit.

Let us focus on productivity and wellness. Identity theft can wreak havoc on an employee’s personal and work life. According to SANS Institute, it takes an average of six months and up to 200 hours of personal time to resolve issues related to the theft. This includes hours calling banks, credit card companies, filing police reports, notifying the Social Security Administration, and alerting credit bureaus. Most of these calls and follow up activity must be made during business hours. According to ITRC’s latest study, 22% of respondents took time off of work when dealing with issues of identity theft.

Identity theft also impacts wellness and mental health. According to the ITRC study, 75% of respondents reported that they were severely distressed by the misuse of their information, and many sought professional help to manage their identity theft experience — either by going to a doctor for their physical symptoms or seeking mental health counseling.

These findings make it clear that identity theft directly impacts productivity and wellness. That is why comprehensive and compassionate restoration services should be a key element of any ID Protection plan offered by the employer.

Restoration services are the fixers in a comprehensive identity protection plan. For victims of identity theft, the restoration specialist will do the required work to restore the victim’s identity. Specialists make the calls during business hours, complete the necessary paperwork, and manage the process. They free up the employee to focus on their job, and alleviate the stress of dealing with the challenges of identity restoration.

There are a range of features to look for when evaluating restoration services across plans. Some plans only offer advice and information kits to guide members on what steps they need to take. Those services typically do not do the work for the member.

For plans that provide a full restoration process, consider if the plan provides victims with a dedicated restoration specialist as a single point of contact. Since the restoration process can take months or years, it’s best if a victim has a consistent person to speak with who knows the case and can provide periodic updates. Restoration services should be available 24/7 so victims can initiate the process immediately to lessen the damage. Plans should also provide multilingual specialists to best serve all members and handle all types of identity theft.

Although monitoring may alert individuals that are a victim of identity theft, the even greater value is in fixing the situation. Be sure to fully evaluate the restoration features of an identity protection plan as part of the selection process.

SOURCE: Hazan, J (31 August 2018) "Identity theft protection benefits and the business case for employers" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/identity-theft-protection-benefits-and-the-business-case-for-employers

7 wellness program ideas you may want to steal

Need more energy and excitement in your office? Keep your employees healthy and motivated with these fun wellness program ideas.

Building your own workplace wellness program takes work–and time–but it’s worth it.

“It’s an investment we need to make,” Jennifer Bartlett, HR director at Griffin Communication, told a group of benefits managers during a session at the Human Resource Executive Health and Benefits Leadership Conference. “We want [employees] to be healthy and happy, and if they’re healthy and happy they’ll be more productive.”

Bartlett shared her experiences building, and (continually) tweaking, a wellness program at her company–a multimedia company running TV outlets across Oklahoma –over the last seven years. “If there was a contest or challenge we’ve done it,” she said, noting there have been some failed ventures.

“We got into wellness because we wanted to reduce health costs, but that’s not why we do it today,” she said. “We do it today because employees like it and it increases morale and engagement.”

Though Griffin Communication's wellness program is extensive and covers more than this list, here are some components of it that's working out well that your company might want to steal:

  1. Fitbit challenge.Yes, fit bits can make a difference, Bartlett said. The way she implemented a program was to have a handful of goals and different levels as not everyone is at the same pace-some might walk 20,000 steps in a day, while someone else might strive for 5,000. There are also competition and rewards attached. At Griffin Communications, the company purchased a number of Fitbits, then sold them to its employees for half the cost.
  2. Race entry.Griffin tries to get its employees moving by being supportive of their fitness goals. If an employee wants to participate in a race-whether walking or running a 5k or even a marathon, it will reimburse them up to $50 one time.
  3. Wellness pantry.This idea, Bartlett said, was "more popular than I ever could have imagined." Bartlett stocks up the fridge and pantry in the company's kitchen with healthy food options. Employees then pay whole sale the price of the food, so it's a cheap option for them to instead of hitting the vending machine. "Employees can pay 25 cents for a bottled water or $1.50 for a soda from the machine."
  4. Gym membership."We don't have an onsite workout facility, but we offer 50 percent reimbursement of (employees') gym membership cost up to a max of 200 per year," she said. The company also reimburses employees for fitness classes, such as yoga.
  5. Biggest Loser contest.Though this contest isn't always popular among companies, a Biggest Loser-type competition- in which employees compete to lose the most weight-worked out well at Griffin. Plus, Bartlett said, "this doesn't cost us anything because the employee buys in $10 to do it." She also insisted the company is sensitive to employees. For example, they only share percentages of weight loss instead of sharing how much each worker weights.
  6. "Project Zero" contest.This is a program pretty much everyone can use: Its aim is to avoid gaining the dreaded holiday wights. The contest runs from early to mid- November through the first of the year. "Participants will weigh in the first and last day of the contest," Bartlett said. "The goal is to not gain weight during the holidays-we're not trying to get people to lose weight but we're just to not get them to not eat that third piece of pie."
  7. Corporate challenges.Nothing both builds camaraderie and encourages fitness like a team sports or company field day. Bartlett said that employees have basically taken this idea and run with it themselves- coming up with fun ideas throughout the year.

Mayer K (14 June 2018) "7 wellness program ideas you may want to steal" [Web Blog Post]. Retrieved from https://www.benefitspro.com/2015/10/10/7-wellness-program-ideas-you-may-want-to-steal/

How to Meet Growing Demands for Bigger, Better Voluntary Plans

Has there been an increase in demand from your employees to offer more voluntary benefits? Check out this great article by Whitney Ehret from Employee Benefits Adviser on what you can do to meet your employees' demand for more voluntary benefits.

Over the years, voluntary benefits or worksite products have unfortunately earned a negative reputation in the marketplace. This is largely due to overzealous carriers with aggressive sales tactics and brokers purely seeking higher commissions.

With the introduction of the Affordable Care Act in 2010, employers began to shift more of the benefits cost to employees via high-deductible health plans, increased coinsurance costs and copays. The majority of today’s workforce is comprised of millennials, coupled with Generation Z quickly entering the workforce. There’s no question: traditional employer benefit offerings are about to undergo some major changes.

With a new administration in place and increasing generational challenges, employers are becoming more open to creative ideas to improve their total benefits offering. Today’s voluntary benefits market isn’t shy of options, which in turn makes things quite confusing. Companies will need to shift focus from traditional offerings and begin to get more resourceful — not only with the products they offer, but also with their entire strategy. Communications, enrollment and marketing will all become especially critical in retaining and attracting top talent in the coming months and years.

For the most part, the majority of brokers and employers are somewhat familiar with the top voluntary products in the market: dental, vision, accident, critical illness, cancer, hospital indemnity, disability and life insurance. Those are traditionally the products that spark initial voluntary benefit conversations, although there are many more — including legal, identity theft, auto/home, pet, employee purchasing programs, unemployment gap, tuition and loan assistance programs.

For the remainder of 2017, the conversation is predicted to still involve the top voluntary products, but shift to a new focus. Nearly two thirds of employers are looking to voluntary benefits to reduce overall financial stress on employees, the 2016 Xerox HR Services Financial Wellbeing & Voluntary Benefits Survey found. Integrating voluntary benefits with core benefits may reduce financial stress that ultimately leads to health issues and higher overall benefit costs.

The main goal of these products is to provide employees with cash resources, paid directly to the insured, should they experience an unexpected life event. Insureds can use these payments for anything they choose: mortgage, rent, groceries, deductibles, coinsurance payments, copays and more. Compared to state disability programs, these payments are generally made more quickly and offer a simpler claim filing process. If an employee is faced with a difficult situation, these conveniences can greatly reduce stress during a highly sensitive and vulnerable time.

Financial wellbeing is the focus
A recent Employee Benefit News article found 89% of millennials are interested in receiving financial advice, yet only 58% have been offered this type of assistance. With the majority of the workforce now comprised of millennials, employers will need to offer more diverse benefit options that are tailored to this population.

Millennials aren’t the only ones who are concerned about their financial wellbeing. The MetLife’s U.S. Employee Benefit Trends Study found 49% of employees are concerned, anxious, or fearful about their current financial situation, 72% said that a customized benefits package increases loyalty and only 27% are satisfied with their progress toward paying down student loans. These statistics demonstrate the immediate need for a comprehensive voluntary benefit offering.

Student loan debt is an issue for all generations in the workforce. Whether the individual is a millennial trying to get established and create wealth, a Gen X employee who is struggling with existing student loan debt family debt and saving for retirement, or a baby boomer who is trying to help support the family’s educational needs — namely children and grandchildren — everyone, at some level, has a need for student loan assistance.

Additionally, most voluntary products offer wellness benefits, which is a direct payment to the individual for completing an annual wellness exam. With amounts ranging between $50-$200 (employer selected), this is pure profit to the individual, since ACA requires preventative exams to be covered 100% by insurance carriers.

In addition, this benefit helps to subsidize the actual cost of the product annually. There are carriers in the market that will pay this benefit multiple times in a single year for a single insured.

Increasingly, companies are getting involved with wellness specific initiatives and incentives for their employees to hopefully drive healthy habits that will, in turn, lower healthcare costs and increase workplace satisfaction. To promote these wellness programs, employers offer reduced pricing on their medical plans or make contributions into a medical savings account if employees complete their annual exams or participate in various wellness activities. Offering voluntary products with a wellness benefit is another way to enhance a company’s total health portfolio at no cost to the employer.

Carrier selection Is key
Like many other industries, this business is all about relationships. Brokers and employers need to be able to trust and rely on their voluntary benefits carriers. As HR staffing has shrunk and brokers are required to provide more services with the same resources, it’s imperative that the appropriate carrier is selected for each unique case.

Voluntary benefits, as “cookie-cutter” as we may perceive them to be, are just not that. Since their onset, voluntary benefits have come with administrative obstacles that have historically taken up too much of HR’s time.

Unfortunately, while these products do provide a valuable benefit to employees, they are not the priority for most employers. Employers don’t often care about how many products they are offering as long as the plans aren’t administrative-heavy, the 2016 Employee Benefit News annual survey found. Carriers recognize this issue, and have steadily made improvements to these processes over recent years.

There are carriers in the marketplace today that allow clients to self-bill and self-pay, which is essentially what employers are already used to doing on their basic and supplemental group life and AD&D plans. For claims issues, they have also made this process easier by making it electronic and not requiring extensive information from the employees in the claims-filing process.

Core carriers (traditional medical carriers) are also beginning to get into the worksite market and are further simplifying the claims process by linking their medical system with their voluntary system. This allows the carrier to proactively initiate claims and file complete claims for the insured since the majority of the claims information is already within the single carrier system.

The other benefit to offering voluntary plans with the core medical carrier is that often some products may provide additional benefits if employees have a certain medical condition. For example, voluntary dental plans will provide more cleaning exams per year if an insured is pregnant. Most insureds would not realize they have this benefit, but by linking these systems with a core carrier, the insured makes sure to get the most out of their plan.

Communication style and strategy are imperative 
Not only is it important to consider the products and carriers that are offered, but also how they are enrolled and communicated. From the voluntary benefits perspective, these products have typically been enrolled face to face with employees. While this may be the best way to fully educate employees on their benefit options, that is no longer the future of employee benefits enrollment.

ACA has also helped enrollment move to the electronic platform because of the requirements made on employers for reporting. Millennials are the technology generation, making them naturally comfortable using technology to enroll and learn about benefits and even be treated by a virtual doctor.

Employers are trending toward a more self-service enrollment environment, which brings its own challenges. Most of these systems are built with decision tools that allow for the enrollment experience to be customized to the employee. These tools will make plan recommendations for the employees based on the answers to health and financial questions. Often, videos within the enrollment site are used to further enhance the educational experience.

Some of the main problems with electronic enrollments include keeping employees engaged, offering voluntary benefit products and carriers that work with the system, keeping costs low or free for the employer and ensuring data accuracy and security.

A company’s overall benefits package is becoming increasingly important in the decision-making process for prospective employees, as well as to retain top industry talent. Employers, rightfully so, are concerned about cost and maintaining this delicate balance while still attempting to manage the complex administration of these plans.

More and more, employers are looking for voluntary benefits to solve this need by offering “free” technology and enrollment solutions to their groups. There is no doubt that if employers want to retain and attract top talent, they are going to have to adapt with the market and offer their employees a wide array of benefit options and new technology that is tailored to their employee needs.

See the original article Here.


Ehret W. (2017 July 24). How to meet growing demands for bigger, better voluntary plans [Web blog post]. Retrieved from address https://www.employeebenefitadviser.com/opinion/how-to-meet-growing-demands-for-bigger-better-voluntary-plans

Employer health plans could suffer in ACA repeal

From BenefitsPro by Marlene Satter

Although Congress may feel as if it has the bit in its teeth on repealing the Affordable Care Act, some experts are warning that it might not be all that easy—or even beneficial—particularly for employer-sponsored health plans.

In a Bloomberg report, Greta E. Cowart, a shareholder at Dallas-based Winstead PC, warned that an ACA repeal or major overhaul might put employers in the crosshairs; they could end up having to return money they previously received from the federal government for some initiatives, such as the early retiree reinsurance program, which provided financial assistance to employer-sponsored health plans.

In addition, Cowart said in the report that many of the mandates on what should be included in employer-sponsored health plans that were neither exempted nor grandfathered in will be hard to take out of employers’ plans, because employees would see that as a benefit reduction. And that, of course, would not make the employer look good.

In its report on the matter, HRDive.com warned employers to “keep an eye on” HHS secretary nominee Tom Price, a determined opponent of the ACA. His “empowering patients first” plan calls for complete repeal of the ACA—and that could lead to just such problems for businesses’ health plans.

Employers who have been calling for the repeal of the ACA might want to rethink their strategy, particularly since it could not only cost them money in the form of give-backs but also cost them employee loyalty if they take away health plan features once they’re no longer mandated by the ACA.

HRDive suggested that “employers should be prepared for all outcomes,” and perhaps consider offering their employees high-deductible health plans or health savings plans as cost-saving measures.

In addition, tracking prescription drug prices could help them keep an eye on costs.

See the original article Here.


Satter M. (2016 December 1). Employer health plans could suffer in ACA repeal[Web blog post]. Retrieved from address http://www.benefitspro.com/2016/12/01/employer-health-plans-could-suffer-in-aca-repeal?ref=mostpopula

The Next Innovation In Controlling Healthcare Costs

As healthcare costs continually increase, understanding where the cost come from and how to manage them is critical. Bruce Barr gives a great editorial on why new trends are essential in controlling costs.

Original post from EmployeeBenefitAdviser.com on August 1, 2016.

Four decades ago, PPOs were hailed as the “silver bullet” to control healthcare costs. Participating providers were contractually obligated to accept discounted fees, which seemed like an obvious solution to out-of-control increases in healthcare costs. Self-funded plan sponsors readily adopted this approach to gain access to network discounts and lower their healthcare costs. In fact, some self-funded plan sponsors still periodically conduct a re-pricing analysis or another method of comparing which PPO yields the best discounts for their specific group.

However, as provider contacts expired, they were renegotiated at higher rates for providers and higher costs for plan sponsors. In addition, hospital charge-masters have increased at an exorbitant pace and have largely gone unregulated and uncontrolled. As a result, the significant discounts once achieved by PPOs no longer deliver the true savings that were seen in the 1980s and 1990s.

For example, a 60% discount on a $1,000 “oral cleansing device” (more commonly referred to as a toothbrush) clearly does not deliver value for the plan sponsor or member and is indicative of some of the billing practices that go undetected. The same could be said of a $150,000 knee replacement. Using a PPO for its discounted fees is somewhat analogous to buying a car by negotiating a discount off the list or sticker price.

As employers gain a better understanding of the questionable value of PPO discounts and pricing optics, reference based pricing (RBP) and reference based reimbursement (RBR) provide possible solutions by addressing the demand for:

· Price transparency,
· Benchmarking the cost of claims,
· Eliminating inappropriate charges, and
· A fiduciary or co-fiduciary serving on behalf of the plan sponsor.

With RBP, the plan specifies the amount that will be allowed for certain common procedures such as MRIs or knee replacements based on prevailing charges. Covered members have access to a list of participating providers who have agreed to accept these payments. Should the member choose a higher-priced provider, he or she may be responsible for the balance of the payment.

RBR uses a common “pricing reference” — often tied to the Medicare allowance and the actual cost for a specific service – and then reimburses the hospital or facility an additional 20-80%, allowing for the provider to make a “fair and reasonable” profit. For context, many PPO discounts result in net payments equal 250% or more of the Medicare allowance.

There are different ways this strategy can be implemented. Some employers begin using RBR exclusively for out-of-network claims. In other cases, RBR is used for all facility claims in conjunction with a PPO network for physician claims or an accountable care organization.

While used successfully by many employers, RBR can be disruptive for some employees when a provider attempts to “balance bill” patients for the difference between the set plan allowance and the provider’s billed charges. In the overwhelming majority of cases, however, these issues are quickly and easily resolved in favor of the plan sponsor and member. Rarely does a discrepancy like this lead to legal action.

Employers who decide to implement a RBR strategy need to carefully select a partner with expertise in communicating and educating employees about how these arrangements work and what to do should they receive a balance bill. The RBR partner should also have expertise in negotiating pricing discrepancies with providers, providing employee advocacy, indemnifying the plan and its members, and modifying the language in the plan document.

Many early adopters of this approach were often those who were subject to extreme increases in healthcare costs and who saw RBP and RBR as a last ditch effort that would enable them to continue to provide medical benefits for their employees. We’re now beginning to see more employers adopt this approach as a way to more effectively determine and control the cost of healthcare.

See Original Post Here.


Barr, B.F., (2016, August 1). The next innovation in controlling healthcare costs [Web log post]. Retrieved from http://www.employeebenefitadviser.com/opinion/the-next-innovation-in-controlling-healthcare-costs

Top 10 catastrophic claims for self-funded employers

Great read on what may impact your self-funded plan by Jack Craver. See results from the study below.

Original Post from BenefitsPro.com on July 13, 2016

There are a range of illnesses that can prompt a self-funded employer to make a claim on their stop-loss insurance policy, but a new study by Sun Life Financial Inc. finds that a majority (53 percent) of the $5.3 billion in such claims paid by insurers from 2012 to 2015 came from 10 ailments.

The study shows the incredible impact of cancer. All types of cancer account for more than a quarter of all stop-loss claims, with breast cancer alone accounting for 13 percent of the total reimbursements.

Claims that exceeded $1 million continue to be rare — only 319 during the four-year period — but they account for nearly a fifth of the total reimbursements.

This voluntary benefit is on the rise, driven by employers offering it to workers.

They have also steadily increased every year, from 60 in 2012 to 107 in 2015. The number of claims exceeding $2 million, however, has not risen steadily, jumping from two to 20 in 2013 but then dropping again in the subsequent two years.

"By highlighting the conditions that create catastrophic claims and providing insights into trends influencing high costs, we can help employers anticipate what they'll see when self-funding and raise awareness about the importance of cost-containment resources and stop-loss insurance,” says Brad Nieland, vice president of Sun Life Financial’s stop-loss division, in a press release.

Here are the top 10 ailments associated with self-funded employer claims:

10. Septicemia

A condition that arises when the body reacts violently to an infection, damaging critical organs in the process and in the most severe cases leading to septic shock, septicemia resulted in $54.7 million in reimbursements between 2012 and 2015, or 2.4 percent of the total.

9. Respiratory failure

Pulmonary collapse or respiratory failure was the ninth leading claim for self-funded employers, resulting in $55 million in reimbursements from stop-loss insurance policies. Risk factors for the condition include binge-drinking, smoking, and working in an environment that leads to inhalation of chemicals that irritate the lungs, all issues that employers can have a hand in improving.

8. Cerebrovascular disease

Most commonly manifested through a stroke, cerebrovascular disease or blood brain vessels prompted $57.4 million in reimbursements between 2012 and 2015, for 2.4 percent of the total. Although strokes are the fifth leading cause of death for Americans, but two-thirds of stroke patients are over the age of 65, suggesting the burden of caring for stroke patients falls mostly on Medicare, rather than employers.

7. Congestive heart failure

The condition that afflicts roughly 2 percent of the adult population and 5 percent of those age 60-69 resulted in $57.8 million in reimbursements from catastrophic insurance policies in 2012-15, accounting for 2.5 percent of the total.

6. Transplants

Transplants are becoming more common than ever, but the good news is that the operations are not as likely to force catastrophic coverage. While transplants increased 65 percent between 2012 and 2015, the total amount of stop-loss reimbursements paid because of transplants only ticked up 0.7 percent compared to 2011-14, to $62.2 million.

5. Premature births/low birth weight

Babies that are born prematurely and have to undergo long hospital stays in incubators or other treatment can prompt astronomical costs for patients and their employers. From 2012 to 2015, employers received $75 million in reimbursements related to such costs incurred by employees, or 3.2 percent of the total.

4. Congenital anomalies

The top claim that specifically relates to a condition at birth, congenital anomalies prompted $96.3 million in reimbursements from 2012 to 2015, holding relatively steady from the 2011 to 2014 period. That accounts for 4.1 percent of total reimbursements.

3. Chronic renal disease

Employers received $156 million from claims related to severe disease of the kidneys, accounting for 6.7 percent of the total. That is a 1 percent decrease from the 2011 to 2014 period. While the costs of treating the condition have decreased 21 percent in the past four years, the disease remains common and costly nonetheless. According to some estimates, chronic renal failure as much as 10 percent of the population, but it is the later stages of the condition that are the most severe and the most costly, often resulting in kidney transplants.

2. Leukemia/lymphoma/multiple myeloma

The second family of cancers is the No. 2 claim for catastrophic insurance. Its financial impact is great, but much smaller. Employers received $188 million between 2012 to 2015 from stop-loss reimbursements related to these conditions, accounting for 8.1 percent of total claims nationally. The value of such claims has remained steady in recent years.

1. Malignant neoplasm

The leading type of cancer is by far the leading reason that employers make claims on their stop-loss policies. These types of cancer accounted for 18.5 percent of all stop-loss claim reimbursements from 2012 to 2015, the study found, totaling a whopping $429 million. That represents a 0.9 percent increase over the 2011 to 2014 period.

See Original Article Here.


Craver, J. (2016, July 13). Top 10 catastrophic claims for self-funded employers [Web log post]. Retrieved from http://www.benefitspro.com/2016/07/13/top-10-catastrophic-claims-for-self-funded-employe?ref=hp-in-depth&page_all=1&slreturn=1468939510

3 Key Takeaways of Designing Employee Benefits Programs

Original Post from BenefitsPro.com

By: Nate Randall

Throughout my career, I’ve had the good fortune to work for a variety of industry leading organizations from stratospheric startup Tesla Motors to Fortune 100s Safeway and Washington Mutual.

I planted myself knee deep in managing, analyzing, and creating everything related to employee benefits and have learned more than a few finer points along the way.

The common thread across these three companies was a genuine desire and drive to apply innovative, forward-thinking approaches to change and improve the way employee benefits are delivered.

I’ve reflected on my experiences to give you three takeaways that helped these companies make the biggest impact possible with their benefits and employee experience programs.

Innovation isn’t easy

Much has been written about long work hours. Stories abound of people sleeping in their cars or under their desks and subsisting on Top Ramen and frozen vegetables. That might exist for you at some point along the path, but that’s not the type of innovative environment that I’m talking about here. I am talking about an atmosphere that applies a conscious drive for change which can lead to meaningful acceptance of new ideas.

Whether you’re rethinking the value of the way health insurance is delivered to families or trying to disrupt a 100-year-old automotive industry, mindfully striving for innovation isn’t a cakewalk.

That’s because humans are programmed not to like change, and for many, working through innovation doesn’t come naturally. It takes a laser-focused and cognizant decision to examine the way things are traditionally or typically done. To do that, you’ll need to gather data, build a team, prove a case, influence, iterate, fail, and to achieve success, you’ll need to do all of these things quickly with minimal errors and missteps.

In my experience, it all comes down to the team that you surround yourself with. When hiring or building your team, I always advise to think creatively about your problems and look for passion in those you recruit. More important than having “done it before” is an intense drive to solve problems and an underlying interest in the core subject.

Early in my career at Tesla, an HR manager said to me, “there are three reasons people come to Tesla. Either they are passionate about cars, passionate about the environment, or passionate about their chosen profession. And Tesla is the best place in the world to be for all three of those things.” Notice there is nothing about money, benefits, or perks. That brings me to the second lesson I’ve learned..

Top talent doesn’t care about perks (until you take them away)

Rarely do candidates and their families make the decision to change their lives — in some cases moving across the country or world — because of the benefits and perks you offer.

Attracting top talent is about storytelling. It’s about having a mission and purpose that a person (and his or her family) can identify with through hard work. I have literally witnessed thousands of people join a common mission early on with little more than unlimited cereal and coffee being offered as the perk. And this was in the geographic backyard of arguably the most intense company perk culture on the planet in Silicon Valley. At the end of the day, people want to feel like they are contributing to something bigger than themselves.

Don’t get me wrong, I don’t mean to imply employees don’t care about the benefits offered to them. They must be satisfied knowing that the basics — health, disability, life insurance, and retirement — are covered. But in my experience, top talent doesn’t make the decision to join a company because of free lunches and massages on Wednesdays.

Keeping that in mind, it is extremely important to construct benefits and perks with care and thought. Once implemented, any experienced HR manager will tell you his or her sad tale of trying to take something away that people are accustomed to.

It’s also imperative to align benefits with perks. Trust me, employees notice if either appears alien to the company culture and mission. I learned this lesson at Safeway during a program that linked the amount of premium a person paid for health insurance to their biometric measures like blood pressure and cholesterol. Employees scratched their heads wondering why the company cafeteria featured cheap burgers and sodas in comparison to the healthy (but pricey) salad bar if poor eating habits could potentially equate to higher health insurance premiums. To promote the healthy lunch options, we had to align its costs with the culture we were trying to foster.

Silicon Valley has become legendary for perks and what many of my colleagues across the country consider frivolous and extravagant benefits. While I agree that many of the Valley’s largest and most iconic brands along with many wannabe cool kids are foolishly wasting time, resources, and money on programs that really do not serve any identifiable goal, I will argue that offering smartly aligned, personalized benefits and perks are the wave of the future. And that brings me to my third and final take-away...

Let the people choose

We have a lot of choice in our lives. We choose the items, price points, and brands to put into our carts when shopping at Safeway. Every Tesla purchase is made to order, built to the specific requirements of the buyer. Google organizes information to make it individualized and useful. Amazon provides a personalized online shopping experience. Uber and Airbnb tap into excess individual capacity in existing systems to create value. We all have different needs, priorities, family situations, and interests, so is it so difficult to offer benefits that can be personalized, too?

The traditional way of offering limited choice employee benefits and perks for everyone (i.e., group benefits) is outdated and bloated with waste. Upwards of 30 percent of compensation costs are funneled to these traditional benefits and American companies spend over a trillion and a half dollars on these inefficient benefits per year.

And that doesn’t even include any so-called perks. In my own research, most employers are paying anywhere from $7,000 to $25,000 per year for a single traditional benefits package. That’s a huge chunk of change and much of those benefits will never be used by the individual if it doesn’t apply to their situation or they find no personal value in it.

Instead of these antiquated and engorged traditional benefits, smart people are creating systems and methods whereby employees can build personalized benefits packages that meet individual needs and circumstances. Giving people the choice and ability to craft what they need can and will make a real difference in people’s daily lives.

Adoption by forward-leaning employers along with regulatory cooperation will finally result in a system for employee benefits and perks that is modern, flexible, and valued. A system that looks like the rest of our world: personalized.

Why Employers Should Boost Dental Benefits Enrollment

Original post benefitsnews.com

You might eat a balanced diet and squeeze in a mix of cardio and weight-lifting workouts every week to stay healthy. But to be truly healthy, you’ve got to focus on more than just working out and eating well. Believe it or not, you’ve also got to focus on oral health.

The link between oral health and cardiovascular health isn’t new; however, there is new evidence that more closely ties periodontitis, better known as gum disease, to heart attacks and stroke. One study showed that treating oral inflammation caused by gum disease with a topical remedy reduced vascular inflammation, which is a leading risk of hypertension, heart attack and stroke.

Heart disease is a serious problem in the United States — one in four people will die of the malady if it goes untreated. It’s also a major expense for Americans, including employees and employers who sponsor their health plans; heart disease costs nearly $1 billion a day in medical care and lost productivity.

Gum disease can affect more than just the heart. For pregnant women, it can also affect unborn babies. The bacteria caused by periodontitis can get into the blood stream and target the fetus, contributing to premature birth or low birth weight. Not only does prematurity and low birth weight put newborns at risk for issues in the beginning of life and learning, as well as developmental issues later on, it’s also costly for a family. In its first year, a preemie can cost around $49,000 in expenses, compared to just $4,551 for an infant who doesn’t experience complications. The March of Dimes reports that pre-term birth costs more than $12 billion in excess healthcare costs.

Diabetics also need to pay special attention to their oral health. In addition to monitoring their feet, eyes, kidneys and heart for complications, they are more prone to periodontitis. A higher risk of gum disease can make it more difficult to control blood glucose, and can also cause disease and infections in the bones that hold teeth in place, making it more difficult to chew. Gum disease may also lead to tooth loss. Diabetes costs the United States $322 billion in a combination of healthcare fees and lost productivity.

It’s important for employers and employees to understand how oral health plays a part in overall health, and that simple, inexpensive treatment can save businesses and plan participants thousands of dollars and countless hours of pain and suffering.

Analyzing claims data is one way to see how oral health might affect employees. The highest number of claims typically comes from cardiovascular, maternity, diabetes and musculoskeletal claims — all of which are exacerbated by periodontitis.

For years, dental health was given a back seat in health plans, wellness initiatives and employee education. Most initiatives focused on preventing heart disease through diet and exercise, and focused little, if at all, on dental care. Many health plans did not — and still do not — include dental coverage, which is a minimal expense compared to other program costs overall. Consequently, employees may simply write off dental care because they may not have a history of cavities. But dental coverage and consistent employee education and communication can help them understand the risks, develop good habits and begin to take their dental health into their own hands.

Employers can work closely with insurance brokers to understand medical and dental coverage, and what their costs and claims are for both. They’ll likely see that medical claims are far higher than dental claims. They can then work together with benefit consultants to create an affordable dental plan, or bridge the gap between dental and medical for those at higher risk for periodontitis issues so that employees can get the treatment they need.

Finally, employers need a long-term communication strategy to educate employees on the value of benefit offerings and the importance of good oral hygiene. They’ll be happy and healthier, and the employer’s medical costs will decrease.

Everybody wins.