Is Your Health Plan Delivering Value?

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The American Benefits Council reports that employer-sponsored healthcare plans deliver a healthy return on investment for U.S. taxpayers. In fact, the Bureau of Economic Analysis and Joint Committee on Taxation say in 2019, every dollar U.S. companies saved due to tax exemptions resulted in $5.34 spent on employee healthcare.

For plan sponsors, there is no question that their plan members receive value. Virtually all health plans provide much stronger benefits than members could afford on their own. What about your plan? Are there steps you can take to achieve greater value for your organization and your people?

Time for Examination

While COVID is still concerning, this is a good time for close examination. One strategy yielding cost savings and quality outcomes for many self-funded plans is the use of Centers of Excellence (COE). These programs, often focused on specialized care such as joint replacement surgeries, cardiovascular procedures and maternity care, may prove very valuable as people pursue screenings and treatments that were delayed during the pandemic. You don’t have to be a Fortune 500 company to pursue a COE program. Knowledge of the local provider land- scape and value-based claims expertise enable your TPA to pursue these and other opportunities on your behalf.

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Quality Health Benefits Can Be Affordable

health-benefitsLast Fall, COVID-19 was weighing so heavily on our minds that simply keeping health benefits available during the Pandemic was the top priority. Today, with many people needing medical care they may have postponed and pressure to maintain sufficient staffing, keeping your health plan both effective and affordable is a must.

The fact is that after a year unlike any other, your organization needs to huddle with its broker/advisor and TPA to do all it can to fight back against rising healthcare costs. Remember that your organization transitioned to self-funding to take control of rising costs and gain the flexibility needed to compete successfully in a rapidly changing world. So, with 2022 right around the corner, let’s revisit a few steps that could keep your organization on the path to high quality, affordable healthcare.

Question Everything – For self-funded employer groups, there are no off the shelf plan designs. When a plan year was successful, we want our clients to know what made the difference. If claims were higher than expected, we help you understand where your healthcare dollars went and what your plan can do to bend the curve.

Be a Disruptor – Annual rate increases of 5 to 7 percent should never be accepted as being par for the course. Solutions to rising costs are in your claims data and the right advisors can help you explore new options. Carve-outs for Specialty Pharmacy and Referenced Based Pricing are just two of the ways we’re helping health plans achieve significant savings.

Blocking & Tackling – Monitoring claims and utilization data day in and day out takes industry-leading technology and skilled claims analysts. Digging deeper into claims will help your plan uncover billing errors and find hidden revenue in your health plan.

Communicate, Educate, Advocate – Because managing the cost and quality of employee healthcare is a year-round responsibility, we do our best to keep employers, plan members and broker advisors informed and supported throughout the year. This is especially critical given the costs associated with chronic healthcare conditions and the rising frequency of high-dollar claims.

These measures may not be new, but when implemented consistently, they will produce significant savings, not only for your health plan but also for the members your business depends on.

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What the Pandemic Has Taught Us

pandemicWhether you’re a TPA, broker, employer, plan member or healthcare provider, the past year has been unlike any other. While adapting has often been difficult, some of the lessons learned can have a positive impact on employee healthcare in the future. Here are a few to consider as you begin your planning for the coming year.

Open Enrollment

According to the IFEBP, 1 in 5 companies handled open enrollment differently in 2020, with many using virtual benefit events. Virtual benefits meetings can be viewed by members from any location at any time. In addition, members can easily share their benefits information with a spouse or family member, something that cannot be done with traditional in-person events. Many used short video introductions and important details were typically made available on secure online employee portals following the virtual event. Offering a dedicated email address, phone line or online chat option can make it easy for members to ask questions.

Telemedicine

Think for a moment that Cleveland Clinic delivered 1.2 million virtual physician visits in 2020, compared to just 37,000 in 2019. Even after resuming in-person appointments, 30% to 40% of all visits at Stanford Health Care are virtual and while physicians and patients say there is certainly room for improvement, nearly 3 of 4 patients say they are likely to choose a video consult over in-person in the future. While many physicians say they would prefer to use telehealth visits to manage chronic diseases, many cite low or no reimbursement and technology challenges on the part of their patients as the biggest obstacles to its continued use.

Health Benefit Value

One challenge that remains even as the threat of Covid-19 lessens is the rising costs facing employer-sponsored health plans. Research from the Kaiser Family Foundation and The Hartford show a decline in the perceived value of health benefits by plan sponsors and members. These trends can only change as personal service improves and the barriers standing in the way of healthcare cost transparency are overcome.

As an independent TPA, we place the needs of your health plan and members first by providing personalized service and striving to eliminate costly conflicts of interest that have plagued our healthcare system.

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Unemployed to Get Help with COBRA

cobraIn the American Rescue Plan Act (ARPA), which was signed into law by President Biden on March 11, 2021, there are several provisions for healthcare plans, including a 100% subsidy of coverage premiums for eligible COBRA enrollees. The subsidies, which will run from April 1, 2021 through September 30, 2021, will be paid to employers by the federal government as payroll tax credits.

The subsidy will last for six months at most, ending on the earlier of the individual’s maximum period of COBRA coverage (generally 18 months) or September 30, 2021. Subsidies will also end early for individuals who become eligible for coverage under another group health plan or Medicare. Those employees who terminate employment voluntarily are not eligible for the subsidy.

Notices are Required

Employers should talk with their TPA about notice requirements and to determine who may be eligible for the subsidy. As a result of the eligibility period running through April, 2021, a list must be compiled including individuals who terminated employment as far back as November of 2019. A Notice of Assistance must be provided to individuals who become eligible to elect COBRA coverage between April 1 and September 30, 2021. Eligible workers who haven’t elected COBRA by April 1 and those who elected COBRA but then discontinued it must also be notified, since former employees have an extended election period running for 60 days after April 1, 2021.

Finally, a Notice of Expiration must be provided between 45 and 15 days prior to the subsidy expiring, unless the subsidy is expiring because the individual has become eligible for coverage by another group health plan or Medicare. The DOL is expected to issue new model COBRA forms within 30 days of the March 11, 2021 enactment date. In addition, individuals are required to notify the group health plan if they forfeit eligibility because they have become eligible for another group health plan or Medicare.

To learn more about the American Rescue Plan notice requirements, visit https://www.congress.gov/117/bills/hr1319/BILLS-117hr1319enr.pdf or contact us at your convenience.

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Self-Funding: The Greatest Benefit is Compassion

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Ask an independent TPA what sets their business apart and you’ll likely hear something about customer service and a promise to always put their client’s health plan and its members first. Seldom have these qualities been more meaningful than during the uncertainty of the past few months.

Fortunately, self-funding provides the flexibility employers have needed throughout this crisis. By collaborating with broker partners and other colleagues, TPAs have worked to make plan design changes that lower costs while exploring ways to keep coverage in force for as many employees as possible. Unfortunately, most have been involved in the difficult decisions employers have had to make in order to sustain quarantines, stay-at-home orders and extended closures. Their team members have worked tirelessly to help members access non-emergency medical care while avoiding the risks related to the coronavirus.

Overcoming Challenges

In addition to addressing health benefit concerns, TPAs have demonstrated great empathy in encounters with employers, members and providers. While the majority of self-funded health plans offer a telehealth benefit, some groups have been slow to engage with this service. With many organizations working remotely during the pandemic, however, the number of virtual visits has increased significantly.

TPAs have helped many patients avoid visits to the ER by directing them to alternative care settings. Some in need of treatment for chronic illnesses have been directed to high-quality, lower-cost providers rather than traditional facilities and, in some cases, treatment has been administered in the home. Searching for solutions takes a tremendous amount of time and coordination but being an advocate for members is nothing new for TPAs.

Health benefits are complicated for everyone. In times of disruption, plan sponsors and members need every possible tool at their disposal. Self-funding offers manyvaluable tools. When backed by expert administration and open communication, these tools can help health plans build trust and take great care of employees.

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Is Direct Primary Care the Future?

A fee-based model that gives individuals unlimited access to a primary care physician without their insurance being billed is being heralded as the right prescription for healthcare. Most patient needs, such as consulting, tests, drugs and treatment are included, and no insurance billing is involved.

Sources estimate there are about 1,000 direct primary care practices in the continental United States. While most patients pay for the service out-of-pocket, more and more employers are choosing to offer this as a benefit and sharing in the cost.

TPAs and advisers supporting the trend caution that direct primary care is not a replacement for insurance, but rather a great supplement to an existing health plan. By removing the barrier of costly copays and deductibles, employees can forge a much closer relationship with their doctor, making them far less likely to choose a costly emergency room or urgent care clinic when the need for medical care arises. Direct primary care is an option that is growing and one we’d be happy to talk with you about at your convenience.

Federal Judge Derails New Association Health Plans

judgeAs 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.

Self-Funding: More Than a Means to an End

self-fundingIn an effort to take control of their healthcare spend, more employers continue to move to self-funding. But as those who have used this funding mechanism for some time have learned, designing a self-funded health benefit plan is just the beginning. When a health plan is self-funded, the entire healthcare supply chain is unbundled, giving everyone a clear, unobstructed view of the healthcare spend. An experienced Third Party Administrator will help you identify exactly where your healthcare dollars are going. Providers can be evaluated. Opportunities to achieve quality outcomes and lower costs can be explored. Best of all, unlike fully-insured health plans that are carrier-based, employers who self-fund their health benefits have the flexibility to act.

Target Cost Transparency

According to the Centers for Medicare and Medicaid Services, healthcare costs have increased by more than 260% since 1999. One of the biggest problems is costs for the same service can vary drastically from one provider to the next, even when the providers are located in the same marketplace. One way to attack this problem is with Reference Based Pricing, which typically allows qualified self-funded health plans to pay for medical services based on a percentage of Medicare, rather than by applying a percentage discount to a facility’s billed charges. Using an accepted index such as Medicare has enabled a growing number of health plans to bring cost transparency and consistency to hospital billing, since Medicare sets prices for every procedure.

Communicate with Purpose

From mobile cost transparency tools to telemedicine, employers are doing more than ever to help plan members utilize their benefits. Engagement rates, however, often tell a disappointing story as many employees are reluctant to use these new features. Experience tells us that whether we’re talking about a published provider directory or an online member portal, most people are confused by healthcare coverage.

Whether your company decides to place colorful posters in gathering spots, hold employee meetings or distribute email newsletters, emphasizing the steps you’re taking to make healthcare more accessible and affordable is critical. In this time of full employment and intense competition, health benefits can play an extremely important role in attracting and retaining valued employees. Don’t miss this opportunity to enhance your company culture and improve your employees’ quality of life.

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President Signs Right to Try Law

supreme-courtWith the recent passing of the Right to Try Act, which gives terminally ill patients access to experimental treatments that have not yet been approved by the FDA, it may be important to understand if and how this impacts the benefits you currently offer your employees. The first thing to know is that Right to Try does not mandate or require insurance coverage of experimental drugs, nor of their potential side effects. Another thing you may not know is that while experimental drugs were previously available under Right to Try legislation in 38 states, only one patient has taken advantage of the benefit.

According to the Self Insurance Institute of America, it is important for those with self-funded plans to review how the plan document treats access and payment of experimental drugs. It is also important to determine how your plan currently covers experimental drug treatments and side effects under the FDA Expanded Access program. Finally, we recommend having a conversation with your TPA to identify not only any potential compliance issues that may exist within your current plan, but how your company would like to treat Right to Try related expenses going forward.

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Are Costs Really Beyond Anyone’s Control?

In at least one big city, a major carrier is providing 100% coverage to public employees for MRIs, CT Scans and other imaging services only when free-standing, non-hospital based facilities are used. What do you know? Independent TPAs have been helping self-funded health plans do things like this for years.

Too many people have long considered rising health care costs to be a condition we simply must live with. Fact is there are alternatives, most of which can only be implemented when the plan’s best interests are first and foremost.

Detailed Reporting Needed

In contrast to a fully-insured plan or self-funding with a carrier-owned ASO, using an independent TPA enables the plan to make informed decisions based on detailed reporting – reporting that the plan owns.

There is no secret to controlling plan costs. It requires discipline and the tools to monitor individual parts of the plan, such as prescription drugs, imaging, chronic disease management and more. Analyzing expenditures such as these can yield huge savings over the course of a year, but only when your administrator is free of carrier or provider affiliations. Having checks and balances in place can make all the difference.

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