by US Rx Care | Oct 13, 2021 | Uncategorized
Thousands of American families have been affected by the tragedy of someone with a substance abuse problem.
For many, especially during the COVID-19 pandemic, finding available and affordable treatment has been difficult or impossible. Recently, however, virtual treatment options have become available, and some insurance companies are beginning to pay for them.
This is an important development for both the group health insurance arena as well as the individual health insurance market. For employers, this is another lifeline that they can highlight for their staff as so many people have been affected by the stresses of the pandemic. For individual policyholders, they could have access to convenient and timely treatment.
Start-up companies across the country are offering virtual substance abuse treatment, including:
- Boulder Care, which provides digital opioid-addiction treatment.
- Pear Therapeutics, which provides software-based disease treatments; its lead product is a treatment for substance abuse disorders approved by the U.S. Food and Drug Administration.
- Ria Health, which employs 45 clinicians who can prescribe treatments online for alcohol-addicted patients.
These start-ups have attracted the attention of group health insurance companies, some of which are starting to cover their treatments for people insured under their health plans. For example:
- Ria Health has contracts with at least four insurers covering millions of people.
- Boulder Care has a partnership with Anthem.
- Pear Therapeutics has contracts with regional health plans in three states.
- An opioid-addiction treatment provider in Massachusetts has partnerships with UnitedHealth Group and Kaiser Permanente.
Virtual treatments for addiction are becoming popular for several reasons. Patients may feel a social stigma from receiving in-patient treatment at rehabilitation centers.
Instead, virtual treatment in their homes permits them to keep their conditions private. It also provides flexibility. Ria Health offers its services on demand while enabling patients to customize their goals.
Receiving treatment faster
Demand for substance abuse treatment has grown during the pandemic.
Studies show that a quarter of American adults reported drinking more alcohol during the health emergency, including more than half of parents of elementary school children. As a result, space has been at a premium at in-patient rehabilitation facilities. Some have had lengthy waiting lists.
Virtual treatment gives new options to patients who cannot get admitted to rehab centers.
Because of the pandemic:
- Some states made new rules for prescribing medicine via telehealth visits less restrictive.
- The federal government started requiring payment parity for physician visits done via video.
Both of these factors have encouraged the growth of these start-ups.
These solutions are attractive to insurers because they reduce costs. Substance abuse patients who cannot get into rehab centers may overdose and end up in emergency rooms.
ERs are often the most expensive places to obtain care. Planned treatments over periods of time reduce the need for ER visits.
Multiply the savings over hundreds of thousands of patients, and it should be no surprise that insurers are signing seven-figure contracts with these providers.
Employers see these new plan features as an additional way to retain valuable employees. In any large group of employees, there will be some who are suffering from addiction or have family members who are, and they will value this benefit.
If you are an employer who offers these plans, you may want to check with your health insurers to see if they’ve changed coverage terms for this type of treatment. If so, you may want to consider spreading the word among your staff.
For some of your employees or their family members, life-saving help may be just a video chat away.
by US Rx Care | Oct 7, 2021 | Uncategorized
The IRS has announced the new affordability requirement test percentage that group health plans must comply with to conform to the Affordable Care Act.
Starting in 2022, the cost of self-only group plans offered to workers by employers that are required to comply with the ACA, must not exceed 9.61% of each employee’s household income.
Under the ACA, “applicable large employers (ALEs)” — that is, those with 50 or more full-time employees (FTEs) — are required to provide health insurance that covers 10 essential benefits and that must be considered “affordable,” meaning that the employee’s share of premiums may not exceed a certain level (currently set at 9.83%). The affordability threshold must apply to the least expensive plan that an employer offers its workers.
The threshold has been reduced from the 2021 level because premiums for employer-sponsored health coverage increased at a lower rate than national income growth this year. That was largely the result of a large reduction in non-emergency health care services as many people stayed away from hospitals when COVID-19 cases were surging.
With this in mind, you will need to balance out any potential premium rate hikes with the affordability level for employees and make sure that you offer at least one plan with premium contribution levels that will satisfy the new threshold. Some employers may need to boost their contributions in order to avoid penalties.
Example: The lowest-paid worker at Company A earns $25,987 per year. To meet the affordability requirement, the worker would have to pay no more than $2,497 a year in premium (or $208 a month).
ALEs with a large low-wage workforce might decide to utilize the federal poverty line affordability safe harbor to automatically meet the ACA affordability standard, which requires offering a medical plan option in 2022 that costs FTEs no more than $103.14 per month.
Failing to offer a plan that meets the affordability requirement to 95% of your full-time employees can trigger penalties of $4,060 for 2022 per FTE receiving subsidized coverage through an exchange. That’s the full-year penalty and the actual penalty prorated depending on how many months an employee received subsidized coverage.
The penalty is triggered for each employee that declines non-compliant coverage and receives subsidized coverage on a public health insurance exchange.
Since most employers don’t know their employees’ household incomes, they can use three ways to satisfy the requirement by ensuring that the premium outlay for the cheapest plan won’t exceed 9.61% of:
- The employee’s W-2 wages, as reported in Box 1 (at the start of 2022).
- The employee’s rate of pay, which is the hourly wage rate multiplied by 130 hours per month (at the start of 2022).
- The individual federal poverty level, which is published by the Department of Health and Human Services in January of every year. If using this method, an employee’s premium contribution cannot be more than $104.52 per month.
Out-of-pocket maximums
The IRS also sets out-of-pocket maximum cost-sharing levels for every year. This limit covers plan deductibles, copayments and percentage-of-cost co-sharing payments. It does not cover premiums.
The new out-of-pocket limits for 2022 are as follows:
- Self-only plans — $8,700, up from $8,550 in 2021.
- Family plans — $17,400, up from $17,100 in 2021.
- Self-only health savings account-qualified high-deductible health plans — $7,050, up from $7,000 in 2021.
- Family HSA-qualified HDHPs — $14,100, up from $14,000 in 2021.
by US Rx Care | Sep 28, 2021 | Uncategorized
With the COVID-19 pandemic continuing to throw a wrench into the economy and the workplace, employers are gearing up for another unusual open enrollment for their group health plans for the 2022 policy year.
As a result of the pandemic, your employees’ priorities may have changed and some of them may be looking at enhanced benefits, or to change their plans’ deductibles or out-of-pocket maximums.
The coronavirus is obviously not in the rear-view mirror, so employers need to consider workers’ new priorities when choosing health insurance plans and other employee benefit offerings.
Employees’ new priorities
Here’s what’s become a priority for many workers today:
- Mental health support
- Access to telehealth
- Higher interest in health savings accounts (HSAs).
Employers should consider their staff’s new priorities when designing health and benefit programs. If you decide to make changes to your plans or if your health plans have changed, you’ll need to effectively communicate those changes to your workforce.
More health plans are rolling out more and improved access to mental health support, the demand for which has surged during the pandemic as many people struggled with the sudden changes and isolation spawned by stay-at-home orders.
Additionally, because many people were afraid or because of doctor’s office restrictions, many tried telehealth video-conferencing services for the first time in 2020 or in 2021. Insurers see telehealth as a viable option for reducing the cost of care, and they have invested heavily in the infrastructure to enable health plan enrollees to meet virtually with their doctors.
More health plans are also covering mental health video-conference sessions as well.
Many plans have expanded these services, but you’ll need to check to see if the ones you are offering include these enhancements.
Additionally, the pandemic has resulted in more employees looking for ways to set aside funds during the year to pay for health care and medications. This can be done through HSAs and flexible spending accounts (FSAs). which are funded by the employee using pre-tax dollars. The funds in those accounts can be used to reimburse for a wide variety of qualified medical expenses.
HSAs, however, can only be offered to employees who are enrolled in a high-deductible health plan (HDHP). HSAs can be kept for life and can be transferred from one employer to the next if a worker switches jobs. FSAs are easier to set up, but they are not kept for life and cannot be transferred to another employer when an individual leaves your employ.
There are some changes to these plans that you should know about.
The Coronavirus Aid, Response and Economic Security (CARES) Act, signed into law in March 2020, allowed HSA-qualified HDHPs to cover telehealth services before plan enrollees reached their deductible. This provision expires Dec. 31, 2021.
However, another change brought by the CARES Act is permanent: Employees with HSAs, health reimbursement arrangements or health FSAs are now allowed to use those accounts to reimburse for over-the-counter medications without a prescription, and for certain menstrual care products, such as tampons and pads.
Communications and planning
During your open enrollment meetings and in your communications material, you’ll want to highlight any new services that the health plans you are offering your staff will cover.
Since COVID-19 is still present and is raging in some communities, you may want to consider:
Holding a ‘virtual benefits fair’ — In these virtual fairs, employees and families can go online and check out the offerings of all the plans available to them, so they can learn more about their offerings and provider networks. These events can be done on the employees’ and families’ own time.
Conducting virtual open enrollment meetings — Consider holding teleconference open enrollment meetings to go over the employees’ health plan choices, and the deductibles, copays, premium amounts and what the maximum out-of-pocket is for each choice.
Sending out more frequent and targeted communications — Targeted communications can be sent to various cohorts of your employees, such as information on plans that would be of most interest to people in their 20s and 30s. What you send them in terms of recommended options would be different than what you send older employees, who have other priorities.
Using technology for enrollment — Some health plans offer apps through which employees can choose and sign up for the plan of their choice. Talk to us about what’s available to you.
Schedule it
The Society for Human Resources Management recommends that you do the following in the two months prior to open enrollment (September through October). This is the time to get the word out about the upcoming open enrollment. Consider:
- Distributing a pre-enrollment flier (printed and online) in September.
- Holding a virtual benefits fair in mid-to-late September.
- Distributing the enrollment packet at the end of October (printed and online).
by US Rx Care | Sep 21, 2021 | Uncategorized
If you want to provide your employees with the one voluntary benefit that can give them peace of mind should tragedy strike, critical illness coverage is the answer.
Demand has grown for critical illness insurance over the last year thanks to the pandemic and as a result of employees taking on more of the cost burden in their employer-sponsored health plans.
According to the Kaiser Family Foundation’s “20120 Employer Health Benefits Survey,” the average deductible for self-only plans of all types was $1,644 in 2020, up from $917 a decade earlier. And many employees have deductibles upwards of $6,000 if they are in certain high-deductible health plans, which have become increasingly common.
As a result, many employers have begun enhancing their voluntary benefits offerings to include critical illness or cancer coverage to help offset the risk for employees and increase satisfaction and retention.
Interest grows
In part, employee interest in critical illness insurance stems from the chain of events that may have cut back their benefits and caused their deductibles to skyrocket. They are looking for peace of mind should they be stricken by a serious illness.
In addition, advances in medicine and technology that have prolonged life also make critical illness coverage more attractive.
Finally, the COVID-19 pandemic put into sharp focus just how quickly someone can be sidelined by a sudden and serious illness.
Consider that out-of-pocket costs for treating a critical illness can start at around $15,000 and climb from there, and that lost income can be as much as $60,600, according to a 2020 MetLife study.
In other words, battling a critical illness could be just the tip of the iceberg. If someone’s lucky enough to survive a critical illness, they may still suffer major financial damage due to high medical bills and restricted income.
To stave off debt, some people dip into, or deplete, their retirement savings and end up paying extra due to resulting taxes, fees and reduced health insurance subsidies.
However, other adults don’t even have enough, or near enough, of a nest egg saved to cover all the costs.
Enter critical illness coverage
Critical illness coverage provides a lump-sum payment that a policyholder can use for any expense if they’ve been diagnosed with a serious illness.
Mostly, this insurance only pays out for one occurrence of a listed condition. And once that payment is made, the policy is terminated.
But insurers have started offering policies that cover a wider variety of conditions and allow beneficiaries to receive multiple payouts if they suffer from a reoccurrence or another condition entirely.
As a result, more employers are offering voluntary critical illness coverage. According to Mercer’s “2020 National Survey of Employer-Sponsored Health Plans,” more organizations are offering this insurance in a direct response to the COVID-19 pandemic.
And Willis Towers Watson’s “2021 Emerging Trends in Health Care Survey” found that 57% of employers polled were offering critical illness coverage to their staff in 2021, and that 75% were planning to offer it by 2022 or beyond. That’s an increase of nearly one-third.
Often offering this coverage costs the employer nothing or very little. Call us for more information on this valuable benefit that more workers are demanding.
by US Rx Care | Sep 14, 2021 | Uncategorized
Regulations are slated to take effect over the next few years that will greatly increase the transparency requirements for group health plans.
The regulations issued under the Trump administration will require health insurers in the individual and group health markets to disclose cost-sharing information upon request, make cost-sharing information available on their websites and disclose negotiated rates with in-network providers.
The rules are designed to help health plan enrollees choose the plan that is best for them and their family, as well as to give them a full picture of what they can expect to pay for services as part of their deductibles, copays and coinsurance.
There are a few different parts to the rules: one focuses on personalized cost-sharing information and another focuses on other pricing and information that insurers are required to post on their websites.
The new rules require health plans to provide personalized estimates for enrollees upon request, so they can calculate their potential out-of-pocket expenses prior to receiving medical treatment.
The following must be provided to a plan enrollee upon inquiry ahead of receiving care:
Estimated cost-sharing liability — This covers how much the enrollee would have to pay out of pocket under their plan for deductibles, coinsurance and copays for a specific medical service. These estimates must be specific to the individual that’s inquiring and not a general estimate.
Accumulated out-of-pocket payments — Enrollees can inquire to their health plans about how much they’ve paid out towards their deductibles and their plan’s out-of-pocket maximums as of the date requested.
In-network rates — Upon request, the plan must divulge how much the enrollee will have to pay out of pocket in relation to the rates it has negotiated for a specific procedure by an in-network provider.
The plan or insurer must disclose the negotiated rate, expressed as a dollar amount, even if it is not the rate the plan or insurer uses to calculate cost-sharing liability. The plans must also disclose out-of-pocket liability for an individual as well as the negotiated rates for prescription drugs. The health insurer does not have to disclose drug discounts or rebates as part of the inquiry.
Out-of-network allowed amount — The insurer must disclose the maximum amount its plan will pay for an “item or service” from an out-of-network provider.
Notice of prerequisites to coverage — If the service the enrollee is inquiring about prior authorization, concurrent review or step-therapy, the insurer must include this information in the answer to the request.
This part of the regulation will take effect in two phases:
- 1, 2023: Insurers will be required to provide personalized cost-sharing information on 500 specific services.
- 1, 2024: Insurers will be required to provide personalized cost-sharing information on all specific services.
The new regulations also require health plans (not including grandfathered ones) and health insurers to post on their websites machine-readable files with detailed pricing information. They must post this information starting Jan. 1, 2022.
The website must include the following information, which has to be updated on a monthly basis:
- Rates for all covered items and services that the plan has negotiated with its in-network providers.
- Historical payments the insurer has made to out-of-network providers, as well as the billed charges.
- The plan’s in-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level.
by US Rx Care | Sep 8, 2021 | Uncategorized
A temporary rule that allowed covered employees to make mid-year election changes to their health plans and revisit how much they set aside into their flexible spending accounts (FSAs) will sunset at the end of the year.
The rules gave employers the option to allow their employees to make changes to their health plans, including choosing a new offering, but it did not require that they allow them to make these changes.
The more relaxed rules were the result of provisions in the Consolidated Appropriations Act, 2021, which was signed into law in December 2020 by President Trump, and subsequent regulatory guidance by the IRS.
In response to the COVID-19 pandemic, the IRS liberalized the rules for cafeteria plan mid-year election changes for health plans and FSAs in the 2021 plan year. During 2021, employers may permit employees to make election changes without affecting their status. The rules that were relaxed:
- Allow employees who had declined group health insurance for the 2021 plan year to sign up for coverage.
- Allow employees who have enrolled in one health plan option under their group health plan to change to another plan (such as switching insurance carriers or opting for a silver plan instead of a bronze plan).
- For health FSAs, allow participants to enroll mid-year, increase or decrease their annual contribution amount, or pull out of the plan altogether and stop contributing.
- For plan years ending in 2020 and 2021, employers are permitted to modify their health FSAs to include a grace period of up to 12 months to spend unused funds from the prior policy year.
- Allow for a higher carryover amount than the typical $500.
But, all plans that take effect on or after Jan. 1, 2022 will revert to the old rules that bar mid-year election changes and limit the grace period for spending unused FSA funds to just two and half months after the end of the prior policy year.
The takeaway
The rules coming to an end will only affect those employers who opted to allow their employees to make changes to their health plan choices and/or their FSAs. If you didn’t make this move, there is nothing you need to do.
If you did permit your staff to make these mid-year changes, you will need to communicate to them as soon as possible and before and during open enrollment that mid-year changes will not be possible in 2022.
When telling them about the rules change, make sure to inform them of the permanent rules and when they take effect again.
Also, if you extended the grace period and/or the carryover amount for FSAs, inform them that the carryover grace period will revert to two and half months and that the maximum carryover amount will revert to $500.
