by US Rx Care | Apr 6, 2022 | Uncategorized
The Department of Health and Human Services has issued some new “frequently asked questions” for its Affordable Care Act pages, and new guidelines that require group health plans to expand what they are required to cover with no cost-sharing.
The new FAQ section expands the age group for which insurers must cover colonoscopies and adds some women’s services that must also be covered with no out-of-pocket costs on the part of the insured patient.
Additionally, the HHS updated its rules on women’s breastfeeding supplies, coverage for obesity treatment in some women, as well as adding screening for suicide risk for some age groups.
The new FAQs and rules by the HHS will require health plan sponsors to ensure that their health plans have made the necessary policy changes to comply with the new guidance.
It’s also important that employers inform their employees about these rule changes, so they know of the added services and treatments that are available without out-of-pocket costs on their part.
Here’s a rundown of the new rules:
Colonoscopy rules
Under current Affordable Care Act rules, non-grandfathered health plans are required to cover without cost-sharing regular colorectoral screening starting at the age of 50 and through the age of 75. That includes:
- Required specialist consultant prior to the screening procedure;
- Bowel preparation medications prescribed for the screening procedure;
- Anesthesia services performed in connection with a preventive colonoscopy;
- Polyp removal performed during the screening procedure; and
- Any pathology exam on a polyp biopsy performed as part of the screening procedure.
The new rules extend that coverage to people between the ages of 45 and 49 if they get abnormal results from a stool-based test.
These new rules take effect on health plan years that start on or after May 31, 2022. That means most people won’t see the changes until Jan. 1, 2023 since most plans run on calendar years.
Coverage of contraceptives
The ACA requires non-grandfathered health plans to cover FDA-approved contraceptives with no cost-sharing. More importantly, if a patient’s doctor recommends a particular service or specific FDA-approved based on their determination that is of medical necessity, the plan must cover that service with no patient out-of-pocket costs.
However, the HHS says it’s been receiving complaints about health plans sometimes denying some of these FDA-approved services despite the patients’ doctors determining it to be of medical necessity. In some cases, the insurer is requiring patients to try other services first or fail in their use of other services before approving use of the FDA-approved contraceptive method.
The HHS is reminding plans and insurers of their obligation to cover these contraceptives, regardless of if they are in the current FDA Birth Control Guide or not, as it does not include every FDA-approved method.
Other changes
HHS guidelines allow for certain breastfeeding services and supplies to be covered with no cost-sharing. There are a number of services and supplies already covered, but the new guidelines add coverage for double breast pumps.
The HHS also approved a new guideline aiming to prevent and reduce obesity in midlife women (ages 40 to 60) through counseling with no cost-sharing required.
The HHS has also issued new guidelines requiring universal screening for suicide risk to the current Depression Screening category for individuals ages 12 to 21, and new guidance for behavioral, social and emotional screening. There are also new guidelines for assessing risks for cardiac arrest or death for individuals ages 11 to 21 and assessing risks for hepatitis B virus infection in newborns to 21-year-olds.
These too are services that would have to be covered with no out-of-pocket costs to the insured patient.
Employer responsibility
You should check with your plan sponsor that their plans will add the new guidelines to their coverages.
If your plan does not run on a calendar year, you’ll have to do this earlier. Additionally, during the next Open Enrollment, make sure to cover these changes when you hold your Open Enrollment meeting for your staff.
by US Rx Care | Mar 23, 2022 | Uncategorized
It’s no secret that most employees do not fully understand all of their health insurance benefits, which can lead to worse health outcomes and them spending more money than they need to for some medical procedures.
A recent survey of 226 executives by Harvard Business Review Analytic Services concluded that employees and employers could enjoy better outcomes if it were easier for employees to find, understand and use the benefits available to them.
One of the biggest roadblocks to making that possible, the survey indicates, is the difficulty workers have in navigating their benefits programs.
Fortunately, a number of health technology companies have come to the fore to help employees see better health outcomes, shop around for medical services, educate themselves about their health and disease management, and choose the health plan that is best for them.
These tools can help employees make informed health care decisions, while their employer can save money. The tools can help them choose proper care that meets their needs and is within their budget. Some of the new tools on the market include:
Quizzify — This tool gamifies learning about health care through humorous, trivia-style quizzes, reviewed by doctors at Harvard Medical School. The system can help employees build knowledge about diagnostics, medical procedures, dental care, how to shop around for health services, and more.
The creators of Quizzify said they want to address the problem of Americans making far too few primary care visits, while they also receive too much health care that is unnecessary. All of that costs employees because:
- Missing regular doctor’s appointments and preventative services can result in health emergencies later, and
- Overtreatment and unnecessary treatments can lead to worse health outcomes and higher out-of-pocket costs.
Employees who use the tool rave about it, particularly how it helps them negotiate medical costs and provides them with advance knowledge that can help them save thousands of dollars in health care expenses.
Jellyvision’s Alex platform — This tool gives employees advice about accessing their health benefits and using their health savings accounts (HSAs) more effectively. It’s mainly geared towards large companies, but there are similar products being developed for the small and mid-sized employer market.
Some of Alex’s features include:
- Personalized guidance during enrollment and ongoing engagement during the year, as it sends out reminders and tips about an employee’s health insurance and health maintenance.
- A focus on reducing the cost to employers of employee confusion.
- A built-in HSA that actively promotes investing in the account throughout the year.
- Chronic disease management tools.
- Benefits videos.
- Engagement tools that help employers and staff improve their health literacy and save money.
League — This online tool and app is designed to help your employees choose which health plans are best for them, and to identify health risks and help them access preventative care. The platform also includes a mobile-first communications channel for employers.
League provides employees with a personalized health profile, as well as a digital wallet that holds employee assistance program information and other programs that you may be providing, such as HSAs.
The main features for employees include:
- Digital wallet — This also holds HSA funds and allows your employees to pay for health and wellness services, review benefit coverage, and keep tabs on their HSA balance.
- Marketplace — League can help your staff book appointments with over 1,000 local, vetted health professionals and access discounts on services and products.
- Health concierge — They can talk to a registered nurse directly for instant advice.
- Claims reimbursement — They can submit claims digitally to get reimbursed for services.
- Tailored content — They can receive AI and data-driven recommendations and nudges regarding healthy behavior or recommendations for health screenings or procedures.
The takeaway
Online or digital tools alone won’t work for every worker. Some need a more human-centered approach to help them understand their benefits, how to get the most out of them and improve their health.
But tools like the above can go a long way towards educating them about their health and health benefits.
While many of your workers will easily adopt electronic price transparency tools, others will need time to get used to them. It’s important that you provide training for any benefit tool you roll out, and also leave the door open for employees to access one-on-one advice so they can make the right choices.
by US Rx Care | Mar 18, 2022 | Uncategorized
With more lawsuits proliferating against employers during the COVID-19 pandemic, businesses have to be more diligent than ever about their record-keeping.
Besides facing lawsuits alleging a business didn’t do enough to protect its employees or the public, employers are also contending with a tougher regulatory climate thanks to a number of new state and federal laws and regulations that have grown out of the pandemic.
Failing to keep adequate records can result in penalties and make it harder to defend against lawsuits that may arise.
Here are two of the main issues that employers should pay attention to:
OSHA COVID-19 rules
Work-related COVID-19 cases are recordable events and need to be logged in a company’s records of workplace injuries and illness. Guidelines from OSHA state that:
- If a worker comes down with a confirmed case of COVID-19, the employer next must investigate whether there was workplace exposure. If the employers finds the case was most likely contracted at work, the confirmed case will need to be recorded. If the investigation finds no workplace exposure, no record-keeping is required.
- If the case is work-related, the employer must investigate whether other employees were possibly exposed. If other workers had possibly been exposed, the employer will need to notify them of their possible exposure. Employees will need to keep records of those actions.
All work-related COVID-19 cases must also be recorded on the employer’s OSHA Forms 300 and 300A. OSHA requires all records to be kept for five years.
Records in case of litigation
Businesses are being sued by a number of parties as a result of the pandemic. They may be sued by a customer who blames lax safety standards at a store for them contracting COVID-19.
Lately, family members are suing employers when an employee contracts the coronavirus at work and spreads it at home.
Since most of these claims zero in on a business’s alleged missteps in COVID-19 safety protocols, it will be incumbent on those businesses to prove otherwise.
During this time of heightened litigation, companies need to keep records of their efforts to reduce the spread of COVID-19 among staff and customers, and to show they comply with OSHA workplace safety standards.
Records you may want to retain include:
- A list of all COVID-19 safety protocols, including when they were created or modified. Retain records of training and any documentation you circulated among your employees on the requirements they need to abide by. The documents should show what standards the business was relying on for guidance, such as OSHA, the Centers for Disease Control and the Equal Employment Opportunity Commission.
- Records showing that employees were following safety protocols.
- Records of workplace COVID-19 outbreaks and the steps you took to conduct contact tracing and contain the outbreak. Also, you should have documentation of any staff you ordered to isolate at home.
- Any other records your counsel may recommend.
If you are sued, do not destroy any records. You have to keep them all. Not doing so can result in penalties as well as losing the case.
The takeaway
The above are some of the main records you should be keeping. But there may be more, depending on where your business is located. Consult your counsel about any local or state requirements that may not be on your radar.
by US Rx Care | Mar 9, 2022 | Uncategorized
A new report has concluded that the Affordable Care Act, which took full effect in 2013, did not result in a significant change in the number of employers offering health insurance, although the rate at which small employers offered coverage declined slightly by 2.6 percentage points between 2013 and 2020.
The study by the Urban Institute found that the small-group health insurance market remained relatively stable during those seven years, a period marked by employers continuing to shift more of the premium burden to their employees.
As of 2020, about half of small employers (companies with fewer than 50 employees) offered health insurance to their staff, while 99% of large companies offered health plans.
Employers with fewer than 50 workers are not subject to the ACA’s employer mandate, which requires firms with 50 or more employees to provide affordable health insurance that covers a slate of benefits mandated by the landmark law.
The study found that smaller employers are still less likely to offer health coverage than their larger peers. The share of employers of workers with group health coverage in 2020 was:
- 81% for companies with 25-99 employees.
- 56% for companies with 10-24 employees.
- 30% for companies with fewer than 10 employees.
The study authors wrote that whether small firms offer health insurance coverage varies substantially. “Though many small firms such as restaurants and retail stores primarily employ low-wage and part-time workers, other small firms, such as professional services firms, primarily employ full-time and high-wage workers. Thus, average trends for all small firms may hide differences among them,” they said.
The pandemic effect
Notably, the COVID-19 pandemic had an effect on the number of small employers that offer group health insurance to their staff. Group health plan enrollment among workers in small firms dropped to 7.9 million in 2020, compared to an average of 9.2 million in the prior seven years.
The study authors say the drop was likely due to decreases in employment in small companies at the start of the pandemic.
Meanwhile, the average annual inflation rate for group health premiums remained steady between 2013 and 2020, with average increases of 3.2% in the small-group market and 3.7% in the medium- and large-group markets.
Despite that, most employers continued shifting the premium costs to their employees:
- Workers in firms with 1,000 or more employees contributed on average 26% in 2013 for family plans, and the same in 2020.
- Workers in firms with between 100 and 999 employees contributed on average 30.5% in 2014 and 32% in 2020.
- Workers in companies with fewer than 50 employees paid 29% of premium costs in 2013 for family plans, a rate that had risen to 35% in 2020.
- Employees working in firms with fewer than 10 employees have maintained the lowest contribution rates across all firm sizes for both single and family premiums over the past two decades (the report made this assertion, but provided no data).
The present
Despite early concerns that the ACA would result in many small employers dumping coverage for their workers, the changes were muted at best.
In fact, offer rates among small employers has remained steady in recent years, except for the blip in 2020. And during the 10 years prior to the enactment of the ACA, the number of small employers offering coverage had been dwindling rapidly.
Small employers have had to continue offering health benefits to remain competitive in the job market, and that shows no signs of abating now.
by US Rx Care | Feb 25, 2022 | Uncategorized
Starting Jan. 15, the nation’s health insurers have been required to cover the cost of up to eight at-home rapid COVID-19 tests per month for their health plan enrollees.
Insurers are taking different approaches to the mandate and, as an employer, you should communicate with your covered staff about this new benefit, how it works and other advice.
According to frequently asked questions posted by the Department of Labor, coverage for over-the-counter test kits must be covered by insurers without cost-sharing and without a doctor’s order or prescription. It laid out a series of rules insurers and health plans must follow. They:
- May require enrollees to submit reimbursement claims for OTC COVID-19 tests (the agency, however, “strongly encourages” plans to reimburse pharmacies directly instead).
- Must reimburse plan enrollees for tests they purchase outside of their preferred network up to $12 per test if they also offer coverage for OTC tests through a pharmacy network. Health plans are authorized to provide a more generous reimbursement from tests purchased through a non-preferred provider.
- Can limit the number of OTC tests covered without cost-sharing, as long as they cover eight per month per enrollee with no cost-sharing. That means a family of three on a family plan can be reimbursed for up to 24 tests per month.
- Cannot limit the number of covered tests if they are ordered by a doctor after a clinical assessment.
- Can require enrollees to attest that OTC tests they are reimbursed for are for personal use and not for work, that they are not being reimbursed for the tests by other sources and that they won’t resell the tests.
- Can require that enrollees provide receipts as proof of purchase.
Action items
Contact us or your group health insurer for guidance on how it will handle payment for OTC tests. It is important to:
- Check that it has pharmacy and retailer networks in place where covered individuals can obtain the OTC tests.
- Check if it has a direct-to-consumer shipping program for kits.
- Check if it has systems in place to handle claims and for reimbursing either participants or participating pharmacies that have point-of-sale test kits available.
- Ask the insurer whether it has any purchase or reimbursement limits if tests are purchased at a non-network pharmacy or retailer.
Once you have those details in hand, hold a meeting with your staff covering the following:
- An explanation of the new benefit and how their insurer will reimburse or pay for the kits.
- Go over the claims and reimbursement process if they pay out of pocket at a non-participating pharmacy.
- Provide a list of network pharmacies and retailers that will offer point-of-sale test kits that the insurer pays for direct. Also provide information on any direct-to-consumer purchase options.
- Tell them about any reimbursement limits if they purchase from non-preferred pharmacies, or other limits (like the eight tests per month limit).
- Advise your staff to keep receipts for any at-home test kits they have purchased since Jan. 15. They should also save the boxes the test kits come in as some plans may require them as proof of purchase.
by US Rx Care | Feb 8, 2022 | Uncategorized
The Equal Employment Opportunity Commission has issued guidance stating that employees suffering from “long COVID-19” may be protected under workplace disability discrimination statutes.
The guidance states that someone suffering from impairments resulting from long-haul COVID-19 symptoms can be considered “disabled” under the Americans with Disabilities Act and entitled to the same treatment as other disabled workers. But not in every case.
The EEOC emphasized that long-haul COVID symptoms can vary greatly from person to person and that eligibility would have to be determined on a case-by-case basis.
Employers should read the guidance, posted on the EEOC’s website on Dec. 14, to ensure they stay on the right side of the law if they are confronted with a worker who is battling COVID-19 symptoms for more than a few weeks and they ask for special accommodation under the ADA.
According to the guidance, a person infected with COVID-19 who is asymptomatic “or who has mild symptoms similar to those of the common cold or flu that resolve in a matter of weeks — with no other consequences — will not have an actual disability within the meaning of the ADA.”
But for those who have COVID-19 symptoms lasting more than a few weeks, and depending on their specific symptoms, a worker may have a “disability” if the illness is affecting them in any of the following ways:
Physical or mental impairment — The EEOC states that COVID-19 is a physiological condition affecting one or more body systems, which would be considered a disability under the ADA.
Substantially limiting a major life activity — “Major life activities” include both major bodily functions, such as respiratory, lung or heart function, and major activities, such as walking or concentrating. COVID-19 has been known to cause these issues. An impairment need only substantially limit one major bodily function or other major life activity to be substantially limiting.
Examples of COVID-19 cases that may be considered a disability under the ADA include:
- An employee who experiences ongoing but intermittent multiple-day headaches, dizziness, brain fog and difficulty remembering or concentrating, which their doctor attributes to the coronavirus.
- Someone who received supplemental oxygen for breathing difficulties during initial stages of treatment and continues to have shortness of breath, associated fatigue and other virus-related effects that last for several months.
- Someone with heart palpitations, chest pain, shortness of breath and related effects due to the virus that last for several months.
What to do
As a result of this guidance, an employee experiencing long-haul COVID with symptoms that could be considered a disability may ask for reasonable accommodation for work. To determine if the employee is eligible, the employer and the employee must enter into an interactive process.
The employer can ask the worker to provide backup documentation about their disability or need for reasonable accommodation, such as notes from doctors outlining restrictions. The employer can also request that the employee sign a limited release allowing the employer to contact the employee’s health care provider directly.
If the worker doesn’t cooperate in providing the information, the employer can deny the accommodation request.
