If it's On-site, It's Alright

Source: United Benefit Advisors, LLC

During this period of health care reform, most employers are looking at ways to control health care costs while still maintaining a healthy workforce and providing excellent medical services to their employees. One of the ways to accomplish this goal is by having an on-site clinic or one that’s nearby. A survey conducted by the National Association of Worksite Health Centers (NAWHC) revealed that 95% of the companies surveyed said they met their goals -- at least partially -- of increasing employee satisfaction and productivity with an on-site clinic. When you consider such a high percentage was achieved, it makes having an on-site clinic a no-brainer; right? Especially when that same survey also found that more than 80% reported that access to care was improved by their clinic and increased participation in worksite health programs was increased by 75%. Even more amazing is that nearly 70% said the clinic improved their health and 64% said reduced medical costs were achieved.
How can such huge percentages be possible with such a seemingly easy solution? The answer is in the way employees use the clinic. In an article on Employee Benefit News titled What’s the Value of Onsite Clinics?, researchers at the NAWHC discovered that, rather than going to the emergency room (which can be expensive) for something that’s not an emergency, employees went to their employer’s on-site clinic. This was also a great time saver for employees in that they didn’t have to take as much time off work for a minor, unscheduled medical issue. Furthermore, it appears that on-site clinics are a better way to get employees to use and benefit from preventive health care and management programs for certain health conditions. As such, the clinic can be a terrific central focal point for where work-related health programs are hosted.

Most on-site clinics provide basic services such as minor care, preventive screenings, and wellness programs. A few also provide behavioral health services and more than 30% can even handle primary care. According to the NAWHC, the latter service is expected to grow. Another statistic that’s predicted to increase is the number of employers that have on-site or nearby clinics.

That’s because these clinics are being examined by employers of all sizes. It’s not just large employers who can benefit from them. In fact, the NAWHC survey found that the number of employers that manage the clinic themselves is more than 35% and they utilize nurse practitioners and physician assistants to provide medical services.

Health care reform has caused employers to take a second look at having an on-site clinic and it appears that these employers like what they’re finding. Clinics can be an invaluable resource that provides great ROI in curtailing health care costs, reducing employee absenteeism, and creating heightened satisfaction among employees


Deadline Looms to Obtain Group Health Plan Identifiers

Originally posted October 17, 2014 by Stephen Miller on www.shrm.org.

updated 9/19/2014

Self-insured employers should take note of approaching deadlines under a Department of Health and Human Services (HHS) final rule that requires large health plans to obtain health plan identifiers (HPIDs) by Nov. 5, 2014; for small plans, the deadline is Nov. 5, 2015.

An HPID is intended to serves as a unique identifier for health plans involved in transactions subject to the Health Insurance Portability and Accountability Act (HIPAA). HIPAA defines a small health plan as one with annual receipts of $5 million or less.

Employers “are really struggling with the requirements for health plan identifiers,” said Gretchen Young, senior vice president for health policy at the ERISA Industry Committee (ERIC), in a news release. “Regulations issued by HHS were clearly not written with self-insured group health plans in mind.”

Clarification Sought

ERIC recently polled its members, who are large employers that sponsor benefit plans for their workers, and found that the vast majority of these companies had not tried to obtain an HPID as of September 2014. The poll indicated that nearly half of the respondents (45 percent) were still waiting, with hopes that HHS would publish relevant guidance.

For those members who have attempted to obtain an HPID, 100 percent found the process to be “very difficult” or “difficult,” Young said. Common problems included the lack of guidance from HHS regarding the manner in which self-insured plans should calculate the number of plans that need an HPID.

“Many plan sponsors use a single document that includes a variety of different benefit programs and they treat all of the benefit programs as a single plan for reporting purposes under ERISA. It is unclear whether companies would need to treat each type of benefit as a separate [controlling health plan] that needs its own HPID, even if they use a single document and their benefits are treated as a single plan for ERISA purposes,” explained Young.

“It is critical that HHS act quickly to address the deficiencies in the current guidance...given the lack of guidance and difficulties using their system,” she said.

Other Self-Funded Arrangements

“While it is the insurer that is responsible to obtain an HPID on behalf of fully insured health plans, plan sponsors of fully insured health plans should be aware that an HPID may be required for other self-funded arrangements,” cautioned Tripp Vander Wal, an attorney with law firm Miller Johnson, in an online article.

Examples of these self-funded arrangements include health reimbursement arrangements (HRAs) or medical flexible spending accounts (FSAs). “The good news is that HRAs and FSAs are likely to qualify as small health plans and have an additional year to obtain an HPID,” he noted.

Update: 

In a subsequently issued set of FAQs, the Centers for Medicaid and Medicare Eligibility stated that neither health FSAs nor HSAs are required to obtain an HPID because they are “individual accounts directed by the consumer to pay health care costs.” In addition, CMS stated that whether an HRA needs an HPID depends on what it reimburses. HRAs that cover only deductibles or out-of-pocket costs do not require HPIDs; however, HRAs that pay for other costs (e.g., health insurance premiums) still need HPIDs.

Commented law firm Alston & Bird LLP in an Advisory Update, “We note that, while this guidance may appear to be welcome news for employers with only fully insured plans and health FSAs or HRAs (whose only potential HPID enumeration responsibility would be because of the health FSA or HRA), it is not consistent with HIPAA’s definition of health plan, under which both health FSAs and HRAs are health plans, as CMS has previously recognized. Employers should be able to rely on CMS’s clear statement in this guidance that FSAs and certain HRAs do not require HPIDs, but we advise caution. Given the inconsistency with previous guidance on FSAs and HRAs and the manner in which CMS has phrased the FAQ, the guidance may not create as broad an exception as it first appears.”


IRS Expands Midyear Election Change Rules for Section 125 Plans

Originally posted October 1, 2014 on https://blog.thinkhr.com.

On September 18, 2014, the Internal Revenue Service (IRS) issued Notice 2014-55, Additional Permitted Election Changes for Health Coverage under § 125 Cafeteria Plan, which allows employers to make specific changes to their plans. These changes will make it easier for employees to change their group plan elections and take advantage of individual health plans available to them through the Marketplace exchanges created by the Affordable Care Act (ACA).

Section 125 cafeteria plans generally require participants to make binding elections for an entire plan year, with employers being able to allow employees to make changes only in limited cases (e.g., marriage, birth, or adoption of child). With the issuance of Notice 2014-55, the list of possible exceptions expands somewhat, making it possible for the employer to amend its plan design to allow an employee to drop employer-sponsored group coverage in order to enroll in a state or federally-facilitated Health Insurance Marketplace.

This guidance applies only to health coverage offered through a cafeteria plan that is minimum essential coverage. Thus, it does not apply to stand-alone dental and/or vision coverage or to health flexible spending accounts (FSAs). Further, an employer’s choice to amend its plan to adopt any of these exceptions is voluntary.

Reduction in Hours

Under the new exceptions, if an employee experiences a reduction in work hours to less than 30 hours per week, the employee may revoke coverage in the cafeteria plan if he or she plans to enroll in coverage through the Marketplace or another health plan.

This new opportunity for exemption could allow an employee who is changing to part-time status to benefit from subsidies available through the Marketplace. This is likely to be the case if an employee expects to experience lower household income after a change in status.

Previously, participant elections were irrevocable during the plan year unless the employee experienced certain family status changes, or unless the plan sponsor made significant changes to coverage or cost. For instance, under the ACA’s employer shared responsibility (play or pay) rules, a variable-hours employee may be covered for an entire “stability period” although the employee’s work schedule and earnings may change dramatically. The existing cafeteria plan rules would not allow the employee to revoke coverage in that case. The new exceptions, however, permit the employer to amend the cafeteria plan so an employee in that circumstance would be able to drop the coverage before the end of the stability period.

If a plan intends to adopt this exception, the following requirements must be met:

An employee must have been expected to average at least 30 hours per week prior to an actual change in the employee’s status that results in the expectation that the employee will average less than 30 hours per week. It does not matter if the employee will actually lose health plan eligibility due to hours — the expectation of averaging 30 hours per week is the test.
The change must correspond to the employee — including dependents experiencing a resulting change in coverage — intending to enroll in another plan providing minimum essential coverage.
The new coverage must be effective by the first day of the second month following the month in which the original coverage is revoked.

“Intending to enroll” in other coverage is determined by the statement of the employee experiencing a change in status. The employer may rely on such an employee’s reasonable representation of intentions. This reasonable representation applies to the employee and any related individuals impacted by the change.

Changes in Connection with Marketplace Enrollment

The IRS Notice also provides for another exception so employees can make midyear election changes. This new exception may be beneficial to employees who are covered by non-calendar year cafeteria plans, or who are finding Marketplace plans more attractive after a change in family status, to resolve the gap between an employer’s cafeteria plan year and the Marketplace open enrollment January 1st effective date. The current cafeteria plan rules do not allow employees to drop coverage at work midyear in order to enroll in a Marketplace plan. The Marketplace offers open enrollment for new policies starting January 1; however, many employer plans do not operate on a calendar-year basis.

Employers are now able to adopt provisions allowing an employee to revoke an enrollment election in order to obtain coverage through the Marketplace. The following conditions must be met for this exception to be allowed:

The employee must be seeking to enroll in the Marketplace during annual open enrollment or during a special enrollment period.
Enrollment in the Marketplace plan must be effective immediately following loss of coverage from the employer-sponsored plan.
Any related individuals who were dependent on the employee’s previous enrollment must also be enrolled in the new plan.

In this case, the employer is not required to prove that other coverage is actually elected. Rather, the employer is allowed to rely on the reasonable representation of an employee that he or she is intending to enroll in Marketplace coverage immediately after the change to enrollment in the employer’s plan is effective. Thus, there should be no gap in coverage if an employee is allowed to exercise this option.

Adopting the New Optional Provisions

Employers may adopt one or both of the new exceptions for midyear election changes by amending the cafeteria plan. For convenience, the IRS is allowing employers to amend their plans for the 2014 plan year by adopting the amendment at any time on or before the last day of the plan year that begins in 2015. Although the employer has extra time to adopt the formal amendment, the employer must take the following steps before allowing the exceptions:

Operate the cafeteria plan in accordance with the guidance outlined in IRS Notice 20144-55; and Notify all plan participants of the changes.

For complete details, read IRS Notice 2014-55.


Millennials under insured compared to other age groups

Originally posted August 27, 2014 by Chris McMahon on https://ebn.benefitnews.com.
Nearly a quarter of millennials, Americans between the ages of 18 and 29, lack health insurance according to a report from insuranceQuotes.com; and 16 percent of all adults do not have health insurance despite the Affordable Care Act’s mandate that all Americans have health insurance.

“A lot has been made of the so-called ‘young invincibles’ who are choosing to forgo health insurance,” said Laura Adams, senior analyst, insuranceQuotes.com. “This could be a costly mistake, especially because this group has easy access to health insurance. Young people typically pay much lower prices to obtain coverage via the health insurance exchanges and can receive subsidies depending on their income. Plus, they can stay on their parents’ health insurance policies until age 26.”

 

Millennials also are less likely than other age groups to own health, auto, life, homeowner’s, renter’s and disability insurance, according to the report. Some of the disparity can be attributed to living with their parents or having fewer assets to protect, insuranceQuotes.com said, but millennials appear to be under insured across all insurance lines.

 

“Fewer Gen Yers are buying houses and more are living at home with their parents,” said Kile Lewis, co-CEO and co-founder of oXYGen Financial, a financial planning firm serving generations X and Y. “But only 12 percent of 18- to 29-year-olds have renters insurance despite the fact that almost four out of five adults under 25 live on their own, and two-thirds of adults ages 25 to 29, rent their homes, according to a report from the Joint Center for Housing Studies of Harvard University.”

Highlights from the report:

  • 95 percent of millennials said their overall financial security is very or somewhat important, almost the same number as consumers aged 30 to 64.
  • 12 percent of millennials have renter’s insurance.
  • 64 percent of millennials lack life insurance. The most common objection is that it costs too much.
  • 36 percent of millennials do not have auto insurance, which could be attributed to declining numbers of young adult drivers.
  • 10 percent of millennials have homeowners insurance, compared to half of consumers ages 30 to 49, and 75 percent of those 65 and older.
  • 13 percent of millennials have disability insurance, compared with 37 percent of those 30 to 49.

“Despite all of this evidence that millennials do not have a lot of insurance, most millennials are confident they are prepared for the financial consequences of car accidents, having their belongings stolen, incurring substantial medical bills or becoming disabled,” InsuranceQuotes said. “Sixty percent of 18-29 year-olds are either very or somewhat confident that they are prepared for those risks; older adults are equally confident in their own preparations.”

The survey was conducted by Princeton Survey Research Associates International, and findings are based on responses from 1,003 adults in the continental United States. Statistical results were weighted to correct known demographic discrepancies; the margin of sampling error for the complete set of weighted data is plus or minus 3.5 percentage points,

 


Are pharmacy discount cards still relevant?

Originally posted August 15, 2014 by Michael Giardina on https://ebn.benefitnews.com

Providers of prescription drug discount cards are increasing their efforts to reach out to employers, even as the Affordable Care Act is expected to decrease the ranks of those most likely to use the cards – those without health insurance.

The FamilyWize Community Service Partnership, which seeks to reduce the cost of prescription medicine for children, families and individuals by $1 billion by the end of 2015, is one provider looking to educate more employers about its discount card program.

“One of the areas we have really focused is with employers with lower waged workers because many of them do not work full-time, or they may not opt for the plan the company is providing because of costs,” says Lori Overstreet, vice president of marketing for FamilyWize. “Obviously, if they were part-time, then the company wouldn’t need to cover them, but this would give them a benefit, or if they opt out of the company plan this will also give them a benefit because the card is free to the consumer and free to the company.”

FamilyWize works with Envision Pharmaceutical Services, a pharmacy benefit management company, to negotiate prices at more than 60,000 brand name pharmacies such as Walmart, Kmart, CVS and Target. These negotiated prices are realized when FamilyWize discount drug card are used by consumers.

“The price depends obviously on the chain, the prescription itself, and even where they are,” says Steve Tremitiere, vice president of strategic partnerships at FamilyWize. He adds that most of the discounts appear with generics, but some can be for brand name drugs.

FamilyWize recently cemented 10-year national partnership with United Way Worldwide in an effort to address needs for the uninsured and underinsured. The average savings for FamilyWize discount card holders is 40% and can reach up to 75%, Tremitiere says.

Tremitiere, wants to be clear that all types of employees and employers can use the benefit, which easily be registered for online and printed out directly from a user’s home or work computer. “Employers are a good conduit because they are a trusted resource,” Tremitiere explains.

But not everyone agrees that these types of prescription drug discount cards still offer value in the post-ACA world.

“With the advent now of the Affordable Care Act and what’s involved, you probably have fewer and fewer people that would need it [prescription discount cards] because they can probably get the negotiated discount off their prescription drugs through their employers or exchanges,” says Michael J Staab, president and co-founder of Innovative Rx Strategies, a pharmacy consulting firm.

Gregory I. Madsen, a registered pharmacist and principal and co-CEO of Innovative Rx Strategies, adds that these discount cards are for “people who don’t have prescription drug coverage, which is very few people anymore.”

A virtual game changer of the prescription drug discount program was the introduction of Medicare Part D, also called the Medicare prescription drug benefit. The Medicare Prescription Drug Modernization Act was first signed into law by President George W. Bush in December 2003, and was seen as a safety net for seniors who were paying out-of-pocket for their prescription drugs.

“They were the cash-paying customer, they were the cash cows of the pharmacy world,” says Madsen. “They were paying cash for all their stuff and these cards were really targeting those people. And then Medicare Part-D came in and they got in under contracted rates and the cash-paying customer sort of went away, except for this small group of part-time employees that were employed.”

Even though the number of uninsured is shrinking because of the ACA, small employers may find value in discount prescription drug cards.

“If they [these employers] have less than 50 employees, they [employees] are part-time, this card will still be a better deal than them paying cash,” Madsen explains.

Other examples of prescription drug discount cards or prescription discount programs, in general, are surviving the ACA’s implementation. For instance, the National Association of Counties, the only national organization that represents county governments on Capitol Hill, offers the NACo Prescription Discount Card Program. The free program, operated by CVS Caremark, has been in place since 2005.

Andrew Goldschmidt, NACo director of membership marketing, says that the program is one of the “oldest and most mature” offered by the association, which dates back to administration of President Franklin Delano Roosevelt.

“You have a lot of folks that have a lot of prescriptions that are off formulary, depending on what kind of plan they have, or if they even have a plan,” says Goldschmidt. The NACo prescription discount card program has saved $570 million on 45 million prescriptions for employees in over 1,400 counties.

“The prescription drug program [usage] has gone down a bit, and rightly so if people are getting coverage through the ACA that didn’t have it before,” explains Goldschmidt, while noting that now it can be used as a good complementary program for employers.

Jackie Chin, executive vice president of New York State Restaurant Services, a division that handles all insurance programs for the New York State Restaurant Association, says the ACA “should not slow down registration” for its WellCard program. In addition to its prescription discounts, its WellCard offers discounts on dental, medical and vision coverage for uncovered employees and their families.

“Since there is no cost to participate in this discount card program, an employee can still register with WellCard because with regular health insurance through ACA or public health exchanges, your co-pays for prescription may be more expensive,” Chin explains. The New York State Restaurant Association includes a diverse group of approximately 10,000 members that range from small mom-and-pop restaurant owners to large restaurant groups.

“It differs from other prescription drug discount card because there is no membership fee and there is no cost to the employee and the employee's family member to avail themselves of any savings they can receive by using this discount card,” Chin says.

 

90% will qualify for individual mandate exemption

Originally posted August 7, 2014 by Dan Cook on https://www.benefitspro.com

There are now so many exemptions to PPACA’s individual mandate that the CBO says the number who would face fines for lack of coverage has dropped from seven million to four million.

That means that almost 90 percent of the nation’s uninsured population would not have to pay a penalty under PPACA in 2016, according to a report from the Congressional Budget Office and the Joint Committee on Taxation.

Though it’s good news for those who decide not to seek health insurance coverage as required by the law, it’s bad news for the insurance industry, which was to receive revenue from the fines. Instead of collecting $7 billion, the CBO now estimates $4 billion will be assessed.

The new numbers are posted on the CBO website.

As PPACA has been tossed back and forth between the legal and the political arenas, the number of exemptions has grown rapidly. The CBO lists the following major categories:

  • Unauthorized immigrants, who are prohibited from receiving almost all Medicaid benefits and all subsidies through the insurance exchanges;
  • People with income low enough that they are not required to file an income tax return;
  • People who have income below 138 percent of the federal poverty guidelines (commonly referred to as the federal poverty level) and are ineligible for Medicaid because the state in which they reside has not expanded eligibility by 2016 under the option provided in PPACA;
  • People whose premium exceeds a specified share of their income (8 percent in 2014 and indexed over time);
  • People who are incarcerated or are members of Indian tribes. (CBO doesn’t explain why these two constitute a single bullet point).

According to the Wall Street Journal, the Obama administration in December 2013 expanded the number of exemptions to include 14 ways residents can file for an exemption based on hardships, including domestic violence or a recent death of a family member.

The upshot is that about nine in 10 of those who will choose not to purchase insurance won’t have to pay the fine, which is $95 for an adult or 1 percent of an individual’s taxable income, whichever is higher. Currently, penalties are set to increase to $325, or 2 percent, in 2015, and $695, or 2.5 percent, in 2016.

Based on these latest numbers, CBO said, “An estimated $4 billion will be collected from those who are uninsured in 2016, and, on average, an estimated $5 billion will be collected per year over the 2017–2024 period. Those estimates differ from projections … made in September 2012, when the agencies last published such estimates. About 2 million fewer people are now projected to pay the penalty for being uninsured in 2016, and collections are now expected to be about $3 billion less for that year.”

The fallout from these increasing exemptions will probably fall on those who actually have coverage. Carriers had based projected premium rates in part on the revenue from the fines assessed against those who shunned coverage. With that money dwindling, carriers have said they’ll have to raise premiums for those with coverage.


Play or Pay in 2015 — so many requirements, so little time

Originally posted August 6, 2014 by Dorothy Summers on https://ebn.benefitnews.com

2015 is getting close and the Employer Shared Responsibility Mandate (“Play or Pay”) under the Affordable Care Act (ACA) is almost here. So what does this mean for your organization? Play or Pay requires certain employers to offer affordable and adequate health insurance to full-time employees and their dependents, or they may be liable for a penalty for any month coverage is not offered.

Play or Pay goes into effect in the calendar year of 2015 for large employers only. However, mid-size employers aren’t entirely off the hook. They’ll have to report on insurance coverage even though they won’t be liable for penalties in 2015. By January 1, 2015, businesses with 100 or more full-time or full-time-equivalent employees must ensure they are offering health benefits to all of those working an average of 30 hours per week, or 130 hours per month. If an employer has a non-calendar year plan and can meet certain transitional rules, they can delay offering employee health benefits until the start date of their non-calendar year plan in 2015. Mid-sized employers will have to comply beginning in 2016.

Here are important questions that employers need to answer today:

  1. Do you know which category your business fits into?
  2. How do you classify who is a full-time employee?
  3. What do you need to do to comply with Play or Pay requirements?

Let’s take an in-depth look at each of these questions.

Which category do you fit into?

Whether you are a small, mid-sized, or large employer is determined by the number of full-time and full-time equivalent employees (FTEs). It sounds simple on the surface:

  • Small employers have 1-49 full-time or FTE employees
  • Mid-sized employers have 50-99 full-time or FTE employees
  • Large employers have 100+ full-time or FTE employees

However, it’s important to remember that these numbers can be affected by several factors, including whether the employer is a part of a control group, seasonal employees and variable-hour employees. That brings us to our next question:

Who is a full-time employee?

The law defines a “full-time employee” for penalty purposes as an employee who, for any month, works an average of at least 30 hours per week, or 130 hours. This includes any of the following paid hours: vacation, holiday, sick time, paid layoff, jury duty, military duty and paid leave of absence under the Family and Medical Leave Act.

Employees who aren’t considered full-time include non W-2 leased workers, sole proprietors, partners in partnerships, real estate agents, and direct sellers.

Variable-hour employees—those who don’t work a set amount of hours each week—fall into a gray area. That is, they don’t need to be counted as full-time employees until and unless it becomes an established practice for them to work more than 30 hours per week.

To assist employers in determining whether variable hour workers will meet the definition of full-time employees (and therefore need to be offered health insurance), employers may use various “look back” and “look forward” periods. Here is a summary of terms used for measuring variable-hour employees:

  • Measurement Period: A period from three to 12 months in which the employer would track hours to determine whether the employee worked an average of more than 30 hours per week.
  • Stability Period: A period from six to 12 consecutive months in which the employer must provide health insurance coverage to employees who worked more than 30 hours per week in the Measurement Period. Note: must be at least six months and cannot be shorter than the Measurement Period.
  • Administrative Period: A period not to exceed 90 days, which falls between the Measurement Period and Stability Period, and/or a short period after a new employee’s date of hire. Using this waiting period allows employers to analyze eligibility of full-time employees and provide enrollment information to enroll them in a plan before penalties could be assessed.

Does your plan meet the Play or Pay requirements?

To avoid penalties, you’ll need to make sure your plan meets certain requirements. First, coverage must be offered to full-time employees and their dependents. Under the ACA, dependents are defined as children under age 26. Spouses are not considered dependents.


Obamacare Challengers Eye Supreme Court Date

Source: https://insurancenewsnet.com - Originally posted by Kimberly Atkins of the Boston Herald.

Aug. 03--The legal battle over Obamacare federal subsidies could land before the nation's top court as soon as next year after challengers asked the U.S. Supreme Court to take up the case.

If the high court grants the request and ultimately rules that the Obama administration lacked authority under the law to authorize subsidies for individuals who purchase health care through the federal exchange rather than state-created exchanges, it would gut a crucial source of funding for the law and severely threaten its viability.

The Supreme Court petition, filed late Thursday, comes just more than a week after federal appellate courts in Virginia and Washington, D.C., issued conflicting opinions as to whether the text of the law, which allows individuals to qualify for subsidies if they purchase insurance on exchanges "established by the state," applies to those in the 36 states that either refused to set up an exchange or for some other reason require residents to go to the federal exchange to enroll.

The Virginia plaintiffs, who claim that they would have qualified for the unaffordability exemption from the law requiring them to purchase health care but for the existence of the federal exchange subsidy, went directly to the Supreme Court instead of asking a full panel of the Virginia federal appellate court to rehear that case "because it's important to get a resolution as soon as possible," said Sam Kazman, general counsel at the Washington-based Competitive Enterprise Institute, which coordinated and funded the challenges to the federal subsidy.

Kazman said the case, one of several legal challenges to various provisions of the law that was largely upheld by the U.S. Supreme Court in 2012, was legal and not political.

"Once you get agencies going beyond the implementation of the law to actually rewriting it, one, it spells trouble and two, it's unconstitutional," Kazman said.

The Justice Department declined Friday to seek immediate Supreme Court review of the D.C. federal court that struck down the administration's interpretation of the law the same day the Virginia court upheld it. Instead, it asked a full panel of the D.C. Circuit to review the three-judge ruling.


What Americans think about health insurance & hiring practices

Originally posted July 25, 2014 by Lynette Gil on https://www.lifehealthpro.com

In a recent survey from Gallup, the majority (58 percent) of Americans said that they would justify charging higher health insurance rates to smokers. And about 39 percent said that they would justify raising health insurance rates to those significantly overweight.

Both percentages have gone down slightly since 2003, when Gallup asked these questions for the first time: from 65 percent for smokers having to pay higher rates and 43 percent for those significantly overweight.

The results are part of Gallup's July 7-10 2014 Consumption Habits survey, in which telephone interviews were conducted with a random sample of 1,013 adults, aged 18 and older, living in all 50 U.S. states and D.C.

The survey also asked participants if companies should be allowed to refuse to hire smokers or those significantly overweight. Most Americans agreed that there should not be discrimination against both. Only 12 percent said that companies should be allowed to refuse to hire people because they are significantly overweight (down from 16 percent in 2003); 14 percent said the same about smokers (up one percentage point from 13% in 2003).

Even though most Americans oppose “hiring policies that would allow companies to refuse to hire smokers or those who are significantly overweight,” it is unclear if those views are because they do not think smoking and obesity negatively affect workplace performance or they “simply reject discrimination of any kind in hiring,” the report says.

According to the report, smoking and being overweight are associated with higher health care costs, and even the Patient Protection and Affordable Care Act (PPACA) allows for higher insurance premiums for smokers. Some would argue that allowing companies to refuse to hire smokers and people who are overweight, or charging them higher health insurance rates, might help encourage healthier lifestyles.


Revisiting Medical Loss Ratio Rebates

Originally posted July 5, 2012 by Bob Marcantonio on https://www.shrm.org

The Patient Protection and Affordable Care Act (PPACA or ACA) requires insurers to report their Medical Loss Ratios (MLRs) to regulators and to meet certain MLR targets. If an insurer exceeds the minimum MLR, the insurer must issue a rebate to the policyholder. The first of these annual rebates is due in August 2012. How are rebates determined?

Rebates are determined according to the prior year’s MLR. Rebates issued in August 2012 will depend on 2011 performance and are not group or individual specific. They are calculated at the carrier and market segment (i.e., individual, small group and large group) level. In some instances the individual and small group markets may be merged.

The ACA defines a small employer as an employer having at least one but no more than 100 employees. However, it provides states the option of defining small employers as having at least one but not more than 50 employees in plan years beginning before Jan. 1, 2016.

 Generally, if you have fewer than 100 employees (using the definition for full-time equivalents) you will be purchasing coverage in the small group market.

The MLR is calculated by dividing the medical expenses of the carriers’ segment by the net earned premiums. Medical expenses include claims and activities to improve health care quality as defined in the rules. Net earned premiums include premiums paid by the policyholder minus taxes, licensing and regulatory fees. The MLR threshold for large groups (51+ benefits eligible) is 85 percent and the threshold for small groups (50 or fewer benefit eligible employees) is 80 percent. Certain states have received exemptions until 2014 that allow the MLR to be lower than those levels. In the case of states having more stringent MLR requirements, those requirements supersede the lower federal requirements.

Below are answers to common questions about MLR rebates.

My plan’s paid loss ratio is less than the target. Do I get a rebate?

Not necessarily. Rebates are not issued based on a single plan’s performance. Rebates depend on the insurer’s performance in a given market segment as outlined above.

How will insurers issue rebates?

For group health plans, insurers must issue the rebates to the plan. The plan must then pay out the rebates to the plan’s participants. If a group health plan terminates after the plan year but before the insurer issues rebates and the insurer cannot locate the plan, the insurer must attempt to issue the rebates directly to participants.

Who may receive a rebate?

Only fully insured policyholders are eligible. A policyholder can be an individual or an employer-sponsored group health plan. In the case of a group health plan receiving a rebate, Employee Retirement Income Security Act (ERISA) regulations regarding fiduciary duty apply. If the rebate is small—$20 or less for a group health plan—the insurer does not need to issue the rebate to the plan.

What should you do if your group receives a rebate?

The Department of Labor (DOL) issued Technical Release No. 2011-04 outlining the proper handling of rebates. The release states that:

"If the participants and the employer each paid a fixed percentage of the cost, a percentage of the rebate equal to the percentage of the cost paid by participants would be attributable to participant contributions. Decisions on how to apply or expend the plan’s portion of a rebate are subject to ERISA’s general standards of fiduciary conduct. Under section 404(a)(1) of ERISA, the responsible plan fiduciaries must act prudently, solely in the interest of the plan participants and beneficiaries, and in accordance with the terms of the plan to the extent consistent with the provisions of ERISA.

"With respect to these duties, the Department notes that a fiduciary also has a duty of impartiality to the plan’s participants. A selection of an allocation method that benefits the fiduciary, as a participant in the plan, at the expense of other participants in the plan, would be inconsistent with this duty. In deciding on an allocation method, the plan fiduciary may properly weigh the costs to the plan, the ultimate plan benefit, and the competing interests of participants or classes of participants provided such method is reasonable, fair and objective. For example, if a fiduciary finds that the cost of distributing shares of a rebate to former participants approximates the amount of the proceeds, the fiduciary may decide to allocate the proceeds to current participants based upon a reasonable, fair and objective allocation method.

"Similarly, if distributing payments to any participants is not cost-effective (e.g., payments to participants are of de minimis amounts, or would give rise to tax consequences to participants or the plan), the fiduciary may utilize the rebate for other permissible plan purposes including applying the rebate toward future participant premium payments or toward benefit enhancements."

When will insurers issue the rebates?

Under the regulations, the first rebates are due Aug. 1, 2012, although the precise dates of receipt may be before the deadline, depending on the insurer. Insurers will send written notices to subscribers informing them that a rebate has been issued. Plan administrators should be prepared to field questions from employees who receive such notices.

 

Additionally, insurers not issuing a rebate must send letters to subscribers explaining the MLR rule notifying their health insurer had a medical loss ratio that met or exceeded the requirements.

How much might the rebates be worth?

The not-for-profit Kaiser Family Foundation released statistics garnered from insurers’ filings to the National Association of Insurance Commissioners. In the large-group segment, total reported rebates are $541 million nationwide. Among the insurers, 125 reported they expect to issue rebates to large groups covering 7.5 million enrollees. Insurers in 14 states do not expect to issue rebates in 2012. The largest average per-enrollee rebates projected are in Vermont ($386), Nebraska ($248), Minnesota ($146), New York ($142) and North Carolina ($121).

Among large group enrollees, 19 percent are projected to receive rebates nationwide. Taken in total, the average annual rebate in the entire large group segment per year will be $14 per enrollee, according to rebate estimates based on insurer filings to the National Association of Insurance Commissioners (NAIC).