In response to a 2019 study showing that millions of patients fail to receive required medical care due to a lack of transportation, ride-sharing company Lyft is partnering with sponsoring
healthcare organizations to let patients request rides for non-emer- gency medical appointments, vaccinations or prescription pickups. While the company tried this previ- ously with employers covering the cost for employees, these “Lyft Passes,” similar to those used to provide rides to and from Covid-19 vaccinations, would be sponsored by health plans including Medicare and Medicaid.
New guidelines issued by CMS earlier this Spring state that all files uploaded by health plans and insurance carriers must be in formats the public can use. Before issuing this guidance, some files included coding that kept Google and other search engines from indexing names and prices listed by hospitals on their websites, making it very hard for consumers to access the data.
The American Hospital Association lost a suit to block the rule on the basis that HHS lacks the authority to oversee its regulation and such rates are not useful to consumers. According to CMS, hospitals are expected to comply with these requirements to provide pricing information that is searchable and accessible without barriers.
While former President Trump signed the No Surprises Act into law as part of the Consolidated Appropriations Act of 2021, CMS is still working on regulations that will become effective for insured and self-funded health plan years that begin on or after Jan. 1, 2022. Implementing this law will be interesting, experts say. While many of its provisions were designed to protect people from getting unexpected bills for care from out-of-network providers at in-network hospitals and surprise bills from out-of-network emergency care providers including air ambulance services, many types of bills that “surprise” consumers may indeed be outside the scope of the Act.
There are other concerns as well. One of these is a part of the law that requires health plans and out-of-network providers who disagree about charges to seek arbitration. Another is a provision that lets some providers offer care on an out-of-network basis if they advise the patient about potential billing and get a consent form signed. Even though there will be challenges to work through once the law is implemented, policymakers are confident that the No Surprises Act will be a great help to consumers.
In an effort to revive an important promise made to the American people prior to his election in 2016, President Trump recently signed 3 executive orders aimed at bringing the cost of prescription drugs more in line with what consumers in other countries pay. One order, directed at Medicare Part D plans, would require that PBMs pass discounts or manufacturer’s rebates directly to consumers rather than to their health plans.
A second order would permit individuals to import lower cost drugs from other countries, including Canada, and re-import insulin. The third order is intended to provide uninsured or underinsured individuals with life-saving medications such as insulin and epinephrine. It is doubtful that these executive orders will yield any immediate relief to consumers since legislative bodies and federal agencies will need to follow government protocols in order to put the orders into practice.
Inflation-adjusted limits for contributions to health savings accounts and high deductible health plans for the coming year were just announced. According to the announcement, eligible individuals with self-only HDHP coverage will be able to contribute $3,600 to their HSA in 2021, an increase of $50 from 2020. Those with family coverage will be able to contribute $7,200 in 2021 and those who are 55 years of age or older will be able to make an additional “catch-up” contribution of $1,000 to their HSA.
While minimum deductibles for HDHPs will remain the same for 2021 plan years at $1,400 for self-only coverage and $2,800 for family coverage, the maximum limits for out-of-pocket expenses will increase to $7,000 for individual coverage and $14,000 for family coverage.
America’s Health Insurance Plans, a national trade association whose member companies provide insurance coverage and health-related services to consumers and businesses, has released a study revealing the breakdown of today’s healthcare premium dollar, as follows:
23.3 cents of every premium dollar is used for prescription drugs
22.2 cents cover the cost of physician services
20.2 cents are used to pay for office and clinic visits
16.1 cents are used to cover hospital stays
13.5 cents are applied to care management, administrative expenses, business expenses, provider management and other fees
4.7 cents of every dollar go to taxes, and…
AHIP reports that on average, 2.3 cents of every premium dollar make it to the bottom line as net profit.
As reported by The Phia Group on March 29, 2019, a federal judge in Washington, D.C. ruled that the new Department of Labor rules expanding the marketing of Association Health Plans (AHPs) violate existing law. TPAs, brokers and employers see this as a significant blow to AHPs, especially new self-funded AHPs that have been preparing to launch on April 1, 2019.
Federal Judge John Bates sided with several states that took issue with the DOL’s final rules several months ago, arguing that a broad availability of AHPs is not within the scope of ERISA, which defines an employer as having at least two or more employees. The final rules were going to allow small employers, including working business owners (employers of one), to join with others based on either common geography or industry affiliation to form an AHP. It appears that the Judge’s ruling means that both criteria, geography and industry affiliation, must be met and that qualifying employers must have a minimum of two employees.
Thus far, we are not aware of any response filed by the DOL. We will continue to monitor reactions to the ruling and other developments regarding Association Health Plans.
There is a lot of misinformation surrounding medical cannabis, which can make it difficult to establish a plan document that accurately outlines its use. One particular obstacle is the lack of verified and sourced research regarding the medicinal use of cannabis, creating confusion around what the drug can and should be used for.
To address this confusion, benefit plans should limit coverage to areas where existing evidence supports the use. Create a benefit description that reflects approved applications determined by your state, while also limiting the care option to those members whose previous treatment options have failed. Experts agree that plan documents should clearly indicate that medical cannabis will not be authorized as a first line therapy.
Other parameters can be set, such as financial limitations within a certain time period, eligible products and dosages and even eligible suppliers. When addressing cost considerations, it’s important to know that medical cannabis should not be viewed as an alternative to prescription painkillers and opioids, but rather an add-on which does not eliminate those other costs.
In October, a bipartisan group of senators introduced a bill that would ease the ACA reporting mandates for employer-sponsored health plans. The bill would roll back the reporting requirements of Section 6056 and replace them with a voluntary reporting system. The bill would also allow payers to transmit employee notices electronically rather than having to send paper statements by mail.
While self-funded health plans must now comply with Sections 6055 and 6056, it is not yet clear how the bill would affect Section 6055 requirements. Senators Rob Portman of Ohio and Mark Warner of Virginia, sponsors of the bill, say their proposal would give the government a more effective way of applying premium tax credits to consumers who purchase insurance through an Exchange, something the administration has been trying to accomplish.
The gradual transition to high deductible health plans is having a significant impact on out-of-pocket costs, according to a study released by the Kaiser Family Foundation/Health Research & Educational Trust. In 2016, for the first time, just over half of all workers (51%) with single coverage faced a deductible of at least $1,000. The study also showed that 29% of workers were in high-deductible plans compared to just 20% two years earlier.