Click Here to Participate in the 2012 Survey and Receive a Detailed Benchmarking Analysis

The 2011 survey gathered results from 16,421 health plans from 10,744 employers — making it the largest benchmarking survey of employer-sponsored health care plans in the country.  The results provided critical national and regional benchmarks that enabled companies to compare their plans alongside those of peers and competitors.   While past surveys have primarily targeted large employers, the focus of the UBA survey is to report results that are applicable to the small and mid-size companies who represent the overwhelming majority of the nation’s employers. With employer health plan information reported for over 3,100 cities from 48 states and the District of Columbia, differences in plan design and plan costs between various regions and industry groups become apparent.  All survey responses are confidential and reported only as aggregate benchmarks.

We encourage that you take advantage of this unique opportunity to gain invaluable information and help you manage your health plan costs more effectively.  Thank you in advance for your participation and should you have any questions regarding the survey please contact Innovative Benefit Planning at (888) 427-7383.

Click Here to Receive a Brief Benchmarking Synopsis of the 2011 Survey Findings

The ACA provision on automatic enrollment requires certain large employers (those with more than 200 full-time employees) to automatically enroll new full-time employees in one of the employer’s health benefit plans (subject to any legally permissible waiting period), and to continue the enrollment of current employees in a health benefit plan.  It further requires notice and an opt-out opportunity for employees who have been automatically enrolled.

The Department of Labor had previously indicated that it intended to issue regulations on the automatic enrollment rules before 2014.  In what will likely come as welcome relief to many large employers, Notice 2012-17 indicates that, in order to ensure coordinated guidance and a smooth implementation process, the DOL has concluded that regulations implementing the ACA’s automatic enrollment provisions will not be ready to take effect by 2014.  Until such regulations are finalized, employers are not required to comply with these automatic enrollment provisions.

Great job by Innovative’s Jeannine Bandiera, who found a way to make a member’s medication affordable!  Recently one of our members was made aware of a tier change for the medication that she needs to treat her condition.  The insurance carrier moved the medication to the Specialty Drug list from the Third Tier Formulary list, making the medication unaffordable to the member at $250 per month.  After contacting the insurance carrier, who said there wasn’t anything they could do, Jeannine decided to contact the manufacturer, Glaxo, Smith & Kline directly.  Jeannine discovered that Glaxo Smith & Kline has a co-pay assistance program that bases the cost of the medication on means. For this member the drug cost was reduced to $75, a savings of $175 monthly.  Way to go Jeannine, that’s the Innovative way!

There are similar programs offered by other manufacturers as well.  If you would like to learn more about this particular program follow this link to the Glaxo website:
http://www.rxassist.org/pap-info/company_detail.cfm?CmpId=125

A new report by Milliman Inc. says that high-deductible health plans, including those with health savings accounts (HSAs), will likely be more adversely impacted by the medical loss ratio requirements under PPACA than other types of comprehensive medical plans.  Consumers who rely on HSA-qualified plans to finance their health care may experience greater costs in their current health plans and may eventually have to find more expensive replacement coverage.

The primary issues of concern for high-deductible plans are that:

-The medical loss ratio formula doesn’t take into account contributions to HSAs.  Many high-deductible health plans are accompanied by an HSA, which covers much of the first-dollar costs before the plan’s deductible is reached. HSA contributions are currently not reflected in the medical loss ratio calculations.

-High-deductible health plans may not be able to raise rates fast enough to keep up with rising costs.  High-deductible health plans will require larger annual rate increases than typical medical plans because medical inflation will have a greater impact on claim levels than plans with lower deductibles.

-Every plan has fixed expenses that it covers with premiums.  Since high-deductible health plans have lower premiums than other plans, a greater percentage of the premium must be used to pay these fixed expenses.

-High-deductible health plans have less predictable claims experience that could increase the risk of paying rebates.  High-deductible insurance plans pay fewer claims than plans with low deductibles.  But when high-deductible health plans pay claims, the claim dollar amounts tend to be larger.  This lower-frequency/high-payment creates less actuarial predictability which can result in high claims in one year and low claims in another.  If the plan has low claims, it may not meet the 80 percent medical loss ratio and be required to pay rebates.  If the plan has high claims, it may lose money that it cannot “make up” in other years.

On Feb. 13, 2012, the Department of Health and Human Services (HHS) stated a health insurance issuer that has received a waiver of the annual dollar limit requirements pursuant to Section 2711 of the Public Health Service Act for a group health insurance product can sell that product to a self-insured grandfathered group health plan that has itself been granted a waiver and wishes to switch from being a self-insured plan to a fully insured plan, as long as the following criteria are satisfied:

1. In all cases, the plan sponsor must have been offering group health coverage to its employees before Sept. 23, 2010, for which it obtained from HHS a waiver of the annual limits requirement;

2. The issuer from which the group health plan is now obtaining the insured policy must have obtained a waiver from HHS for the newly purchased policy;—

3. The annual limits of the new policy may not be lower than the annual limits of the previous policy, except in the situation outlined in No. 4;

4. The plan sponsor may obtain a replacement policy with a lower annual limit only if other comparable coverage is not available.  If a plan purchases a lower annual limit policy due to lack of comparable coverage, this change would cause a loss of status under 45 CFR 147.140(g)(1)(vi)(C), relating to status as a grandfathered health plan.-

5. The health insurance issuer must obtain from the plan sponsor an attestation that the criteria outlined above are satisfied, and the attestation must be accompanied by documentation outlining the terms of the prior coverage. Issuers shall retain this information in accordance with the data retention requirements of the Sept. 3, 2010, and Nov. 5, 2010, annual limits guidance documents.

6. To the extent not superseded here, all prior HHS guidance regarding annual limits waivers continues to apply to the plan and policies described here.

As explained in our August 2011 article, the health care reforms enacted in March of 2010 will require employer health plans to provide a uniform “summary of benefits and coverage” (SBC) to all plan participants and beneficiaries.  The agencies charged with implementing this requirement have now finalized the regulations they proposed in August of 2011.  The final regulations ease certain of the more onerous requirements, and they also grant a six-month delay in the statutory effective date.

Compliance Deadlines
As enacted, this SBC requirement was to apply as of March 23, 2012.  This recent guidance allows compliance to be deferred until the first open enrollment period beginning on or after September 23, 2012.  For participants who are not a part of the open enrollment process (such as new hires or special enrollees), the compliance deadline is the first day of the first plan year beginning on or after September 23, 2012.

To comply with this requirement, an SBC must be included in any application materials provided as a part of the open enrollment process.  If there are no such materials, the deadline for providing an SBC is the first day on which a participant is eligible to enroll.  Plans have additional time to provide an SBC to any special enrollee.  The deadline in that case is 90 days after the participant’s enrollment date (i.e., the same as the deadline for providing a summary plan description).

Covered Plans
These SBC rules apply to both insured and self-funded plans.  The plan administrator (typically, the sponsoring employer) is responsible for providing the SBC.  In the case of an insured plan, however, the insurer is equally responsible.  Moreover, if an insurer provides a timely and accurate SBC, the plan administrator is not required to do so.

This is another health care reform requirement to which even “grandfathered” plans are subject.  The same is true for even stand-alone health reimbursement arrangements, as well as “mini-med” plans that have received a waiver from the prohibition on annual benefit limitations.

Certain employer plans are exempt from this SBC requirement, however.  These include HIPAA “excepted benefits,” such as stand-alone dental and vision plans and most flexible spending arrangements.  Health savings accounts are also exempt.  The agencies note, however, that even exempt FSAs or HSAs may need to be referenced in an SBC for a comprehensive medical plan, as a way of explaining that plan’s deductibles and other co-payment features.

Recent Changes
Although the final regulations track most of the August 2011 proposals, certain changes should make it somewhat easier to comply with this SBC requirement.  These include the following:

• An SBC need not disclose information concerning premiums.
   
• An SBC may be combined with other plan materials, such as a summary plan description, so long as the SBC is prominently displayed.  In the case of an SPD, the agencies suggest that the SBC immediately follow the SPD’s table of contents.
•  Although the agencies continue to emphasize the importance of using the published template when preparing an SBC, they now acknowledge that certain modifications are permissible.  These might be needed to describe discounts available through provider networks, benefits that vary with the type of facility, multi-tier drug formularies, or incentives for participation in wellness programs.
   
• The proposed regulations described three examples to be included in the “Coverage Facts” portion of each SBC:  maternity care, management of type 2 diabetes, and treatment of breast cancer.  Responding to concerns raised by various commenters, the breast cancer example has now been removed.  However, the agencies have specifically reserved the right to require up to six different examples, so future guidance may require examples of more acute medical conditions.
   
• The version of the SBC template issued in August of 2011 was drafted by a task force organized by the National Association of Insurance Commissioners.  Perhaps for that reason, it spoke in terms of a “policy” or “insurer.”  Recognizing that these terms are not appropriate for self-funded plans, the revised template substitutes “coverage” and “plan” for these two terms.
   
• The final regulations make it somewhat easier to distribute an SBC via electronic means, rather than on paper.  The rules have not changed for participants and beneficiaries who are currently enrolled in the plan (for whom electronic delivery is permissible only in accordance with the DOL’s stringent requirements), but somewhat more liberal rules now apply to individuals who are merely eligible to enroll.  Assuming an SBC is in a “readily accessible format,” it may be posted on the Internet.  The plan or its insurer would then notify the eligible individual (either on paper or via e-mail) that the document is available online, providing both the Internet address and a statement that the SBC will be provided in paper form upon request.

The penalty for failing to comply with this SBC requirement is $1,000 for each participant and beneficiary who fails to receive a timely and accurate SBC.  Plan administrators should therefore take immediate steps to prepare appropriate SBCs (one for each benefit option), well in advance of the upcoming open enrollment season.  Administrators of insured plans will want to coordinate with their insurers, but self-funded plans should familiarize themselves with both the final regulations and numerous pieces of related guidance.  Follow this link for more information http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=25818.

The Department of Health and Human Services (HHS) provided illustrative information to complement its Dec. 16, 2011, bulletin on essential health benefits (EHB) under the Patient Protection and Affordable Care Act.  The information provides the names of the three largest products in the small group market in each state ranked by enrollment, as well as a list of the top three nationally available Federal Employee Health Benefit Program plans based on enrollment.

In an earlier bulletin released Dec. 16, 2011, HHS described the approach it intends to pursue in rulemaking to define these essential health benefits.  Under that approach, states would be able to select an existing health plan to set as a benchmark for the items and services included in the package. The options would be:

• one of the three largest small group plans in the state;
• one of the three largest state employee health plans;
• one of the three largest federal employee health plan options;
• the largest HMO plan offered in the state’s commercial market.

Plans could modify coverage as long as they do not reduce the value of coverage.  States must also ensure the essential health benefits package covers items and services in at least ten categories of care, including preventive care, emergency services, maternity care, hospital and physician services and prescription drugs.  

For additional information:
Fact sheet
ASPE Issue Brief - summary of individual market coverage
ASPE Research Brief - information on comparing benefits in small group products and state and federal employee plan

The Departments of Labor, Treasury and Health and Human Services have released final regulations under the Patient Protection and Affordable Care Act (PPACA) that require health insurers and group health plans to provide concise and comprehensible information about health plan benefits and coverage to those with private health coverage.  Under the rule, health insurers must provide consumers with clear, consistent and comparable summary information about their health plan benefits and coverage. The new explanations will be available beginning, or soon after, Sept. 23, 2012.

Specifically, these rules will ensure consumers have access to two key documents that will help them understand and evaluate their health insurance choices:  a short, easy-to-understand Summary of Benefits and Coverage (SBC); and, a uniform glossary of terms commonly used in health insurance coverage.

All health plans and insurers will provide an SBC to shoppers and enrollees at important points in the enrollment process, such as upon application and at renewal.  A key feature of the SBC is a new, standardized plan comparison tool called “coverage examples,” which will illustrate sample medical situations and describe how much coverage the plan would provide in an event such as having a baby (normal delivery) or managing Type II diabetes (routine maintenance, well-controlled). 

The rule’s effective date is 60 days after publication in the Federal Register (scheduled for Feb. 14, 2012).  The applicability date is generally Sept. 23, 2012 (or the first day of the first plan year after this date, or the first day of the first open enrollment period after this date).

• Final rule
• Guidance for Compliance
• Summary of Benefits and Coverage (SBC) Template | MS Word Format
• Sample Completed SBC | MS Word format
• Instructions for Completing the SBC – Group Health Plan Coverage
• Instructions for Completing the SBC – Individual Health Insurance Coverage
• Why This Matters Language for “Yes” Answers
• Why This Matters Language for “No” Answers
• HHS Information For Simulating Coverage Examples
• Uniform Glossary of Coverage and Medical Terms