Yearly Archive: 2014

Rulemaking would allow employers to offer part timers ancillary benefits to supplement individual plans

The federal government has issued proposed rules apparently intended to help put health benefits offered to low wage, part time employees more on a par with those offered full time employees in terms of coverage and affordability. The proposed rulemaking recognizes that part time employees may find their premium share for group coverage offered full time workers unaffordable and will thus turn to subsidized individual coverage sold in the state health benefit exchange marketplace in order to meet the Patient Protection and Affordable Care Act mandate to have health coverage.

The proposed rules would allow employers to offer ancillary, non-group health benefits to part time employees (those expected to work on average of 30 hours a week or less) and their dependents. The ancillary benefits would supplement or “wrap” individual health plans but could not cover out of pocket cost sharing or work in a coordinated manner with individual health plans. Examples include expanded in-network medical clinics or providers; benefits for long-term, nursing home, home and community-based care or any combination thereof; coverage for specific diseases or illnesses and hospital indemnity or other fixed indemnity plans. These are “excepted benefits” that don’t fall within the definition of group health plans under the Employee Retirement Income Security Act of 1974.

The proposed rules would limit the annual amount of the wraparound ancillary benefit coverage to the maximum for flexible spending accounts (FSAs) — $2,500 for 2014. In addition, the cost of the coverage cannot exceed 15 percent of the cost of coverage for an employer’s primary health plan offered to employees eligible for the ancillary benefit wrap coverage.

Comment on the proposed rules is due by January 22, 2015.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Doubts over wellness programs could unravel employer health coverage

Questions over the effectiveness of employer wellness programs intensified this month and could mark the beginning of the end of employer-sponsored health benefits that have already been eroding from the bottom up in the small group market segment. Wellness programs seek to improve the health status of large employer risk pools in order to reduce the utilization of high cost medical services and to hold down premiums for large insured employers. Now that their efficacy has been called into question, it also begs the larger question of the degree of control large employers have over health care costs. The experience with wellness programs suggests little if any. As Bill Leonard writes for the Society For Human Resource Management:

Even with the modest rise in health care costs over the past several years, sources familiar with the issue believe businesses have reached a tipping point and that the expense of providing medical benefits to workers has become unsustainable. Cost-containment efforts therefore are putting more pressure on wellness programs to deliver on the promise of reducing health care expenses. However, as the CHRO survey and other recent studies have shown, wellness plans may not be producing the return on investment (ROI) that employers expect and need.

The sense of no control over rising costs could prompt large employers to increasingly throw up their hands and cease offering health benefits. The money saved could then be redirected to higher earnings and compensation that couldn’t be done when the U.S. government established wage and price controls during World War II and employers first began offering employee health benefits in lieu of higher compensation. That in turn would create pressure to repeal the Patient Protection and Affordable Care Act’s mandate that employers with 50 or more employees offer health coverage.

There would also be a philosophical motive. Employers and employees alike could rightly declare health is an individual responsibility. Accordingly, the role of employing organizations would shift from a medicalized view of wellness – one that wellness program critics equate to nannying — to one that promotes a culture of wellness that supports healthy lifestyle choices and affords their members sufficient schedule control to engage in health promoting behaviors such as adequate sleep and exercise. Those behaviors require time and commitment in order to become healthy lifestyle habits. For office-based knowledge workers where the greatest occupational hazard is sedentary lifestyles that lead to preventable chronic health conditions, giving them greater control over when and where they work would provide a mutually beneficial tradeoff for taking responsibility for their health. That could pay bonuses in the form of increased engagement and staff attraction and retention.

Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

California readies strategies to address rising unfunded health care costs of retired state workers

The Los Angeles Times reports California Gov. Jerry Brown plans to address the growing unfunded liability of health care for retired state workers when he releases his 2015-16 fiscal year budget in January. That comes on the heels of a report by California State Controller John Chiang showing the unfunded liability of providing health and dental benefits for retired state workers is $71.8 billion, up $7.2 billion from $64.6 billion as of June 30, 2013. An actuarial study accompanying the report found retirees are living longer than expected, thereby imposing higher than expected liability on the state, which pays these costs as they are incurred.

State and local governments are concerned over burgeoning retiree health costs as they work to regain their financial footing following the sharp economic downturn of the previous decade. Two articles last year by Bloomberg and Governing magazine discuss a cost control strategy of directing retirees who don’t yet qualify for Medicare to state health benefit exchanges where many public pensioners would qualify for federal tax subsidies. This could represent a sizable portion of retirees since many public sector workers retire well before they turn 65 and become eligible for Medicare, often in their early 50s.

There is no indication that the strategy has widely caught on or that it is under consideration by Brown, a fiscal conservative who has been a strong supporter of California’s state-run exchange. If Brown were to propose the idea in his 2015 draft budget, it would likely generate strong resistance from California’s politically powerful state employee unions.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Blue Shield pares individual market presence in California localities

From Fremont, Monterey, Nevada City and Point Reyes Station, wealthy and poor areas alike can no longer buy an individual insurance policy from Blue Shield. The gaps are particularly felt in Northern California, in areas where there is only one choice of insurer in the exchange.

“I have had clients from other areas of California, and they live in the bay area or here or there, and I do it for them and, wow, there’s six insurance companies or seven insurance companies,” says Lomas. “I think that was when I first realized how truly we were getting the shaft up here.”

Blue Shield of California declined an interview, but said it’s not selling in certain areas because it couldn’t find enough providers willing to accept payments that would keep premiums low. The company also said it is not selling in areas where there is no contracted hospital within 15 miles.

via After Blue Shield Pulls Out of Zip Codes, Consumers See Limited Insurance Options –

When networks narrow, it can be hard to find enough providers in a given local market willing to work for lower narrow network reimbursement rates employed to hold down premium rates. This development shows how difficult it is for health plans to achieve both affordable premiums and access to providers and what happens when that balance can’t be struck and the network begins to fray.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Utah: Medicaid expansion would save large employer penalties, use SHOP exchange for individual plans

Approval of its proposed Healthy Utah Medicaid expansion program would allow large employers of low wage workers avoid penalties when those workers enroll in subsidized individual health plans though the state’s health benefit exchange, according to a document describing the program. The proposed 3-year pilot program is pending approval of a Section 1115 waiver of Medicaid rules from the U.S Department of Health and Human Services.

Utah is served by a federally facilitated exchange (FFE) in the individual market and operates a state-based exchange (SBE) serving small employers of 1 to 50 employees under the Small Business Health Options Program (SHOP) of the federal Patient Protection and Affordable Care Act. A notable component of Utah’s proposed Medicaid expansion program is those in the expansion population would receive federal Medicaid share funding to purchase commercial plans sold via the state’s small business exchange, Avenue H, and not the FFE, Those earning more than 100 percent of federal poverty levels (FPL) are eligible to purchase coverage in the FFE.

“Beginning in 2016, large businesses in Utah will likely face $11 to $17 million less in tax penalties each year if their employees making between 101 percent and 133 percent FPL are enrolled in a state-sponsored program rather than a Health Insurance Marketplace plan with a tax credit,” the document states. Employers of 50 or more full-time employees must offer health insurance to 95 percent of their workforces starting in 2016.

In addition, children who currently receive Medicaid would have the option to enroll in the same commercial plan their parents select through Avenue H. “Medicaid would continue to provide cost sharing and wrap-around coverage for these children to ensure they continue to receive the same level of coverage they do today,” the Healthy Utah plan states. “It is hoped that having a single primary health plan for the family will simplify coverage for the family. The federal government has previously denied Utah’s requests to use Medicaid funding to purchase these private plans. However, through the Healthy Utah negotiations, Utah was able to obtain approval for this type of assistance.”


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Are high deductibles truly a barrier to necessary medical care?

One of the goals of opening the government exchanges was to enable more Americans to get health insurance to help cover the costs of needed medical treatments. While many Americans have gained insurance, there has been no downturn in the percentage who say they have had to put off needed medical treatment because of cost. This may reflect high deductibles or copays that are part of the newly insured’s plans, although separate research has shown that most of the newly insured in 2014 are satisfied with their health coverage. (Emphasis added)

Variation in the pricing for medical treatments, not to mention differences in how much insurance plans cover, could be confusing Americans or making them fear a needed treatment is too expensive. And while the costs of medical procedures aren’t rising as rapidly as they once were, it is still too early to tell if that is an effect of the Affordable Care Act and how prices may change in the future

via Cost Still a Barrier Between Americans and Medical Care.


This excerpt is from a Gallup poll released last week. Being that this is a public opinion poll, a more nuanced view of the results is called for.

First, it is important to distinguish between individual health plans sold on state health benefit exchanges and employer-sponsored plans. Many of the latter category are increasingly coming with high deductibles. The distinction is important because employer-sponsored plans do not come with premium and out of pocket cost sharing subsidies for low and moderate income households like those sold in the exchange marketplace.

Second, according to the poll, 22 percent of Americans say they have put off medical treatment for a “very” or “somewhat serious” condition in 2014, the percentage having increased slightly since 2013. This is based on a subjective but undefined “serious condition,” so it’s not clear as to the nature of the underlying “serious” condition. If a serious condition was defined in terms of having a serious adverse affect on daily life functioning, it’s unlikely care for the condition would be deferred due to out of pocket costs so this is probably a highly subjective measure.

High deductible plans are being cited by the U.S. Health and Human Services Department’s Centers for Medicare & Medicaid Services (CMS) as a contributing factor to slowing spending on health care in 2013. (Click here for news release). This is based on the conventional wisdom that health care is like other consumer goods and services is subject to the economic principle of price elasticity: demand falls as cost increases and vice versa. But is it really? Do people reason, “Oh, I’ve got a low deductible plan. I think I’ll schedule a few medical appointments?” Highly doubtful since going to the doctor isn’t as an attractive form of spending as, say, going shopping at a retailer to take advantage of a sale providing an inducement to shop. 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Workplace wellness flash point of large employer frustration with rising medical costs

Frustration among large employers over the continued high and rising cost of providing medical coverage for their workforces nearly five years since the Affordable Care Act’s 2010 enactment is reaching a flash point. The flash point is workplace wellness programs amid questions over their ability to reduce medical utilization costs by improving the health status of their employees. And specifically whether large employers who require biometric testing of employees are running afoul of rules promulgated to implement Patient Protection and Affordable Care Act provisions governing the programs.

The Affordable Care Act sanctions two types of wellness programs employers can offer as part of employer-sponsored health plans. In addition to the traditional participatory wellness programs such as discounts on fitness club memberships, health assessments and seminars, employers can also offer — on a voluntary basis — contingent wellness programs that require participating employees to take part in health improvement plans designed to help them reach health status goals such reducing weight, body mass index (BMI), blood pressure, or cholesterol levels. Employers can provide those achieving their goals economic incentives in the form of reduced health plan premiums.

However, the U.S. Equal Employment Opportunity Commission (EEOC) has sued some large employers, charging they are requiring all employees and not just those participating in voluntary, contingent wellness programs to undergo biometric testing. That goes beyond contingent wellness program rules and violates Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA) since the testing is not job-related or consistent with business necessity, the EEOC claims.

Reuters (via Yahoo News) reports the federal government litigation has ticked off large employers to the extent that they are now politically turning against the Affordable Care Act and may work to undermine it in Congress and the courts.

The application of the workplace wellness rules isn’t the real issue. Large employers have known the how the rules governing voluntary and contingent wellness programs work for two years. Their real beef is over the fact that they’re not seeing their health costs being meaningfully reduced by the Affordable Care Act. Nor are they likely to without reforming their organizations to support a culture that truly respects the health and wellness of their members and affords them ample opportunity to engage in health promoting behaviors.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Idaho mulling reforming Medicaid to use blend of DPC and “Arkansas plan”

Idaho is considering restructuring its Medicaid program to use state funds to directly cover primary care (DPC) for Medicaid eligibles earning less than 100 percent of federal poverty levels while using federal Medicaid funding to cover their major medical costs. Those with household incomes between 100 and 138 percent of federal poverty under the Patient Protection and Affordable Care Act’s Medicaid expansion would be eligible to purchase commercial health plans through the state’s health benefit exchange marketplace. That strategy is referred to as the “Arkansas Plan” in recognition of that state’s obtaining a waiver from the U.S. Department of Health and Human Services last year approving of the use of Medicaid dollars to help those new Medicaid eligibles buy exchange plans. The state’s Medicaid Redesign Workgroup estimates implementing both would save $1 billion over 10 years.

(H/T to Liz Osius of Manatt Phelps & Phillips LLP for the heads up in her weekly health care reform roundup)



Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Proposed rules for 2016 and post individual, small group and exchange marketplace issued

The U.S. Department of Health and Human Services last week issued a proposed rulemaking governing the individual and small group health insurance markets and the state health benefit exchange marketplace for plan year 2016 and later years. Happy holiday reading: comment on the proposed rules (Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016, CMS-9944-P) is due December 26, 2014.

There’s a lot to digest in the rulemaking with some of the key proposed rules summarized below. As usual, Timothy Jost has taken his customary deep dive into the rulemaking with posts on the Health Affairs blog that can be viewed here and here.

  • Plan issuers must publish up-to-date, (updated at least monthly) accurate, and complete provider directories including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. Directories will be considered easily accessible when the general public is able to view all of the current providers for a plan on the plan’s public website through a clearly identifiable link or tab without having to create or access an account or enter a policy number. The general public should be able to easily discern which providers participate in which plan(s) and provider network(s) if the health plan issuer maintains multiple provider networks and the plan(s) and provider network(s) associated with each provider should be clearly identified on the website.
  • For the purposes of the employer shared responsibility mandate, large employer-sponsored plans must meet both minimum actuarial value and minimum standard of benefits. Plans must provide substantial coverage of both inpatient hospital services and physician services.
  • Health plan issuers must establish pharmacy and therapeutics (P&T) committees to ensure plan formularies cover a sufficient number and type of prescription drugs. P&T committee standards that must be met for prescription drug coverage meet prescription drug essential health benefits requirement for individual and small group plans.
  • New special exchange enrollment period for individuals in non-Medicaid expansion states when their household income increases to meet exchange minimum income eligibility standard, i.e. 100 percent of federal poverty.
  • Individual market open enrollment period for plan years 2016 and later: October 1 to December 15.
  • Expansion of special enrollment period to individuals enrolled in non-calendar year individual health insurance coverage when their policy year ends in 2014 to all years.
  • Small employers participating in state exchange Small Business Health Options Programs (SHOP) can elect to offer SHOP coverage to former employees, retirees and also provide required continuation coverage via the SHOP.
  • Exchanges, QHP issuers, and web brokers must provide oral interpretation services to include telephonic interpreters in at least 150 languages.
  • Health plan issuers may optionally count cost sharing for out-of-network services toward annual cost sharing limits.



Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Health exchanges’ finances face test in 2nd year – US News

PROVIDENCE, R.I. (AP) — The federal government shelled out billions of dollars to get health insurance marketplaces going in the 14 states that opted to run their own. Now they must act like true marketplaces and start paying for themselves.

Under President Barack Obama’s Affordable Care Act, state-run health insurance exchanges need to be financially self-sustaining starting in January. Some appear to be on that path, while others have shaky funding models or even none at all.

Some states, prohibited from using state money, are imposing fees on plans sold on the marketplaces. Others are spreading costs more widely — which, in one instance, has drawn a federal lawsuit.

via Health exchanges’ finances face test in 2nd year – US News.

The AP reports state-based exchanges (SBEs) present a mixed outlook of their ability to operate financially independent of the federal government when federal exchange establishment grant funding ceases January 1, 2015. The less than certain finances of some SBEs could alter their relationship with the feds. In order to gain initial federal approval, SBEs were required to submit operational “blueprint” plans by January 1, 2013 showing how they intended to fund their operations after the grant funding ends.

Lacking adequate funding to be financially self-sufficient could put SBEs technically in violation of federal rules. States operating SBEs “must ensure that its Exchange has sufficient funding in order to support its ongoing operations beginning January 1, 2015…” (45 Code of Federal Regulations 155.160(b) – Financial support for continued operations.)


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

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