Most health insurers plan to continue offering free preventative care services despite a federal judge having imposed a nationwide injunction on an Affordable Care Act requirement that these services are covered with no out-of-pocket costs on the part of patients, according to a letter by industry trade groups.
With concern growing that this important part of the ACA would suddenly be revoked, some of the nation’s largest insurers and industry trade associations penned a letter to lawmakers, stating that: “The overwhelming majority do not anticipate making changes to no-cost-share preventive services and do not expect disruptions in coverage of preventive care while the case proceeds through the courts.
“Our associations have long supported preventive care and continue to do so. By responding together, we wish to make clear our strong support for continued access to preventive health care for millions of Americans who rely on it. ”
Signatories to the letter include the Blue Cross Blue Shield Association, the American Benefits Council and America’s Health Insurance Plans.
The letter was written in response to Democrats on health committees in the U.S. Senate and House or Representatives asking for information from 12 of the nation’s largest health insurers on how they plan to respond to the decision by the U.S. District Court for the Northern District of Texas in Braidwood Management Inc. vs. Becerra.
That decision struck down the ACA requirement that most health plans and issuers cover without cost-sharing the more than 100 preventative services recommended by the U.S. Preventive Services Task Force (USPSTF).
The judge in the case reasoned that the ACA requirement to cover with no cost-sharing medications for HIV prevention violates the rights of the plaintiffs who have religious objections to these medicines. The order immediately blocked the requirement nationwide to cover not only the HIV-prevention medicines, but all preventative services recommended by the USPSTF.
The U.S. Department of Health and Human Services has appealed the decision to the U.S. Fifth District Circuit Court and the Justice Department has asked that the decision be paused as the appeal process plays out.
The lawmakers also asked if the insurance carriers would honor the ACA’s rules until all appeals are exhausted, including all the way to the U.S. Supreme Court.
Fallout from the ruling
The federal court’s decision has caused panic and concern among patients’ rights advocates that insurers would immediately stop covering these services, which have become an essential part of health care in the last decade.
If the ruling stands and survives appeals, insurers could impose deductibles and copays for potentially lifesaving screening tests.
The lawmakers on April 13 wrote in their letter to the insurance industry: “We are very concerned that the decision will unnecessarily cause confusion, force consumers to pay out-of-pocket, and result in patients foregoing preventive services screenings and treatment altogether. There is evidence that even modest cost-sharing deters patients from accessing care and exposure to cost-sharing reduces the use of preventive care.”
The trade associations that responded to the lawmakers’ request to continue honoring the ACA rules said that preventative care is popular and effective, and that the decision from the federal judge likely is just the start of a lengthy legal process.
If the decision were to stand, there are still some preventative screenings that are not covered by the ACA, and it would not affect all states. There are 15 states with laws requiring insurers to cover with no patient cost-sharing the same preventative services that the federal law requires.
A recent article has highlighted the breadth of Big Pharma’s control of information regarding their medications, even reaching as far as drug research papers that are published in major medical journals.
The article “America’s Broken Health Care: Diagnosis and Prescription” in the Imprimis publication of Hillsdale College, cites studies finding that 74% of pharmaceutical research is conducted by for-profit research companies and only 26% by universities, which calls into question how much the results can be relied upon.
Even more surprising, 50% of contracts that drug companies have with academic institutions allow drug makers to ghostwrite articles and allow the named authors to only suggest revisions, but not make corrections or edit the articles. After seizing control of these “research” papers, the pharmaceutical companies will often use the published papers to market their expensive drugs and send their sales reps to doctor’s offices to convince practitioners to prescribe their medications … but at whose expense?
Many of these new drugs are extremely expensive and they may have a host of side-effects that plan sponsors and patients would want to avoid. Particularly since there are often alternative proven therapies on the market that are effective and significantly less expensive.
With that in mind, how can plan sponsors ensure their members are getting the best medications for their specific conditions and that they aren’t being steered towards expensive alternatives that may not be any better than established alternatives?
That’s where US-Rx Care can help by ensuring Better Outcomes and Lower Costs.
Through our fiduciary pharmacy risk management services, our clinicians work in your and your members’ best interest. They evaluate prescriptions written by your employees’ doctors with the goal of helping you and your members access the best therapies and where possible save money with less expensive pharmaceuticals. To ensure both the effectiveness and the health of your members, US-Rx Care relies on a combination of resources, including National Organizations’ guidelines, such as the American College of Rheumatology, American Academy of Dermatology, our practicing physicians that participate on our P&T Committee, in addition to academic research.
US-Rx Care’s programs are proven to deliver Better Outcomes and Lower Cost, the holy grail in care management.
A new report has found that small businesses that purchase their group health insurance online or through payroll vendors saw the largest premium hikes in 2022, significantly higher than those that went through brokers.
Overall rates for employers with 10 or fewer employees saw their family plan health insurance premiums jump 12% from 2021, compared to just 5.4% for all small to mid-sized businesses with up to 250 employees, according to the report by HR and benefits software company Ease.
The cost for individual group health plans increased 6.7% for the smallest SMBs, compared to just 4.3% overall between 2021 and 2022. As stated, the numbers for smaller companies were the most pronounced for those who buy their coverage online or via payroll vendors.
Meanwhile, employees’ share of premiums increased at a slower rate overall of 4.15% between 2021 and 2022, meaning that employers were not passing on the full increases in group health plan premiums to their staff.
Since 2018, individual premiums have increased by 21% while family premiums have increased by 18%. To put it into dollar signs, that’s an extra $104 for individuals and $231 for families each month for medical insurance.
The Ease report notes that those higher premiums are likely hurting those small employers more than larger SMBs with between 51 and 250 workers. The latter have seen an increase in health plan enrollment among their employees between 2018 and 2022, while those with one to 50 employees saw overall decreases. Overall, more than half of SMB employees opt out of their employer-sponsored coverage.
The HDHP effect
The report found that health maintenance organizations and preferred provider organizations continue to dominate the landscape in group health benefits for SMBs. While high-deductible health plan (HDHP) enrollment grew at an astounding 68% between 2021 and 2022, they only accounted for 6% of group health plan enrollment.
Some employers have gravitated towards HDHPs to reduce their and their employees’ overall premium spend, but these plans come at a cost: more out-of-pocket costs for workers.
In those cases, Ease CEO and co-founder David Reid recommends pairing an HDHP plan with other voluntary benefit plans that can “insure” gaps in coverage, such as short-term disability plans and group supplemental health insurance plans called Gap plans. They are similar to the Medigap supplemental insurance plans millions of seniors purchase each year to fill in holes in Medicare parts A&B.
Gap plans can help by providing coverage when employees have not met their health care deductible. These plans may cover most inpatient and outpatient services that are covered by the underlying primary health care plan and applied to the deductible or coinsurance provision.
Plans differ and employers may choose a variety of coverage options, including varied inpatient and outpatient benefits. Deductibles can be added to the plan to manage premium costs.
Coverage can often be configured to be compatible with HDHPs using health savings accounts.
Importance of your broker
Reid said that the report’s findings illustrate the importance of employers working with brokers and consultants to purchase their employee benefits.
“[SMBs] getting good advice are using more innovative solutions that allow them to make their dollars go as far as a large corporation’s dollar-spend on benefits,” he told the trade publication BenefitsPro. “Those who are bypassing a consultant and purchasing benefits through, say, their payroll vendor are generally seeing fully insured, off-the-shelf plans that increase in cost more quickly.”
As your broker, we have access to plans from different carriers and can work with you to put together offerings that will best accommodate your employees.
Both employers and employees have much to gain from a solid voluntary benefits program.
For employees, being able to enroll in an insurance product through a workplace voluntary benefits program offers them the advantage of group pricing, the convenience of paying through payroll deduction, and perhaps access to insurance that would be difficult to get on an individual basis.
For employers, offering a range of voluntary insurance products can help increase employee satisfaction – along with loyalty and morale – and make the business more competitive in attracting and retaining the best talent.
These advantages alone, however, do not ensure that a voluntary benefits program will be a success. Careful planning, including the selection of benefits to offer, choice of vendors and well-crafted communications, are keys to program success. Consider the following:
Get the right mix – Bring in the kinds of benefits that employees want and will enroll in. Survey employees as to what types of additional benefits they would participate in if given the opportunity. Depending on your employee demographics, these could include additional life insurance options, long-term care – or even pet insurance.
Voluntary benefits enable employees to self-customize an individual benefits package that is uniquely appropriate to them.
Look for gaps – Look for gaps in your company’s current benefits coverage, and consider how voluntary benefits plans can be used to fill them.
For companies that have had to scale back on their regular benefits package, voluntary benefits can be particularly helpful. If your benefits budget is tight and, for example, needs to be dedicated to helping fund medical benefits, offering dental and vision on a voluntary basis gives employees easy and affordable access to these benefits.
Get the word out – While we can often supply some communications materials, your internal communications concerning the program will help to incorporate it into your overall benefits program in the eyes of employees, making it more likely they will enroll.
Consider announcing new voluntary benefits offerings in a communication from top management, which will demonstrate the company’s commitment to the program.
Make voluntary benefits enrollment a part of your annual enrollment process, and incorporate descriptions and information on voluntary benefits offerings into the communications materials for your core plans.
Work closely with us – We are here to help you make a selection that best fits your company’s needs, and to help you communicate with your employees and enhance enrollment.
This will be particularly important if any of the voluntary benefits have minimum participation requirements. We can come in for presentations, individual meetings or enrollment sessions, all of which can be very effective in increasing participation in these programs.
The takeaway
Voluntary benefits can be a great add-on to any company’s benefits program. Careful planning and consideration of the various issues that can affect participation can increase the chances of program success.
The Centers for Medicare and Medicaid Services has proposed new rules aimed at streamlining the prior approval process for most health plans in the U.S. Under the proposal, starting in 2026, insurers would be required to render a decision within seven days for a non-urgent service or item (compared to the current 14 days), and 72 hours if it is urgent. It would also require most group and individual health plans, Medicare Advantage, Medicaid managed care and state Medicaid agencies to implement electronic prior authorization systems by 2026 and streamline their processes for approving care. The rule is aimed at tackling one of the biggest headaches for patients and practitioners alike. Prior authorization can sometimes take time to receive, often delaying much-needed care. Waiting for approval can have serious consequences, with studies finding:
It often leads to delays in care for serious conditions like cancer.
It often leads to more people being hospitalized as their condition worsens as they wait for care or medicine to be approved.
Prior authorization rules can also be confusing, time-consuming and frustrating for both patients and doctors, with the latter often feeling as if the insurer is questioning their expertise.
Insurers use prior authorization as a cost-containment tool that requires providers to seek approval from them before referring a patient for certain services and prescribing some medications. Studies have found that the number of prior authorization requests has exploded in the last few years, straining the system and delaying care. The proposed rule The goal of the rule is to reduce the bureaucracy around prior authorizations and cut wait times for responses that some providers say sometimes take weeks to get approved. The proposed rule — a revised version of a similar one floated by the Trump administration that was withdrawn due to cost concerns — applies to all Affordable Care Act-qualified health plans, Medicare Advantage plans and state Medicaid programs. As mentioned above, the time insurers have to approve a prior authorization request would be reduced to seven days, and 72 hours if it is urgent. Additionally, if the insurer denies the request, it would be required to include a specific reason for doing so. Under the proposed rule, insurers will be required to build and maintain a system for electronically approving prior authorizations, known as a fast healthcare interoperability resources application programming interface (FHIR API).
The FHIR API must be able to ascertain whether a prior authorization request is required and “facilitate the exchange of prior authorization requests and decisions” from the provider’s electronic health records or practice management system. Some doctor’s groups have said the new rule doesn’t go far enough and that seven days is still too long.
While drugmakers have been assailed for years for increasing their prices and driving the cost of medications higher and higher, there is another player in the health care space that is receiving increased scrutiny: pharmacy benefit managers.
PBMs are intermediaries, acting as go-betweens for insurance companies, self-insured employers, drug manufacturers and pharmacies.
They can handle prescription claims administration for insurers and employers, facilitate mail-order drug delivery, market drugs to pharmacies, and manage formularies (lists of drugs for which health plans will reimburse patients.)
Express Scripts, which provides network-pharmacy claims processing, drug utilization review, and formulary management, among other services, is the best-known PBM. CVS Caremark and UnitedHealth Group’s OptumRx are other major players.
PBMs typically contract with both insurers (or self-insured employers) and pharmacies. They charge health plans fees for administering their prescription drug claims and create formularies that spell out the prices pharmacies receive for each drug on the list.
Commonly, the price the plan pays for a drug is more than the pharmacy receives for it. The PBM collects the difference between the two prices.
It can do this because the health plan does not know what the PBM’s arrangement is with the pharmacy, and vice versa. Also, the plan doesn’t know the details of the PBM’s arrangements with its competitors.
A PBM could charge one plan $200 for a month’s supply of an antidepressant, charge another plan $190 for the same drug, and sell it to a pharmacy for $170. None of the three parties knows what the other parties are paying or receiving.
Additionally, PBMs have been accused of pocketing the rebates that drug manufacturers offer, instead of passing them on to the end users: the patients who are prescribed the medications. Those rebates can be significant.
In the crosshairs
In theory, the PBMs should pass these rebates back to the individuals who are prescribed the medication so that they can reduce their out-of-pocket costs. However, if most of those costs are born by the insurer, those rebates would conceivably be transferred to the insurer that is paying for the drugs and the insurer could pass some of those savings on to enrollees.
But, because these arrangements are also confidential, the extent to which these savings are passed back to health plans is unknown.
As pressure on PBMs has grown, federal and state lawmakers, attorneys general in various states and state regulators have been taking action.
In 2022, 12 states enacted 19 measures that included a variety of restrictions and requirements for PBMs, according to the National Academy for State Health Policy.
A number of state attorneys general have filed lawsuits against some of the country’s largest PBMs. Ohio Attorney General David Yost has managed to wring more than $100 million in settlements with PBMs in the last three years, after filing lawsuits accusing them of violating state antitrust laws and overcharging state agencies like the Ohio Bureau of Workers’ Compensation and the Ohio Department of Medicaid.
And in Washington D.C., a bipartisan bill introduced in the U.S. Senate would require PBMs to file an annual report with the Federal Trade Commission about fees charged to pharmacies and reimbursements sought from drug companies.
The bill also authorizes state attorneys general “to conduct investigations, to administer oaths or affirmations, or to compel the attendance of witnesses or the production of documentary or other evidence.”
