October 29, 2019

How to Get the Benefits of Self-Funding without the Risks

There are typically two approaches to securing health coverage for your staff – group health insurance or self-funding.

Self-funding, however, can be costly and risky and is usually only done by larger organizations with thousands of employees. But there is a hybrid model that can help small and mid-sized employers provide their staff with affordable health coverage: partial self-insuring.

To understand how partial self-insuring works, we should start with the basics of what a self-insured plan is. In a fully self-insured plan, the employer bears the risk of all costs incurred under the plan for claims and administration.

In essence, the employer acts as the insurer and pays claims from a fund that it pays into along with employees, who pay their share of premiums into the fund.

Also, the employer will usually contract with a third-party administrator or an insurance company to process claims and provide access to a network of physicians and other health care providers.

How partial self-insuring works

Partially self-insured arrangements provide some of the benefits of being self-funded but without all the risks, while plans will have the same benefits as insured plans have. Here’s how they work:

  • Employers and their employees still pay premiums, a portion of which goes into an account that will be tapped to pay the first portion of claims that are filed. That means that the employer is acting as the insurer for those claims.
  • The other portion of the premium is paid to an insurance company. This is sometimes known as a stop-loss policy.
  • Plans have an aggregate deductible for all claims filed by employees, meaning that once that deductible is reached an insurer starts paying the claims instead.
  • Premiums are calculated to fund the claims to the aggregate deductible amount. In other words, the employer and employees are paying for the worst-case scenario in each policy year.
  • It is possible for the employer to get a refund at the end of the policy year if the total claims come in at a level that is less than expected. The employer can either be reimbursed for this amount or use those funds for the next policy year.

Lower risk than fully self-insured plan

Typically, an employer should have at least 25 workers if it is considering a partial self-funded arrangement, but we’ve seen plans with fewer enrollees.

Many employers will opt for a partially self-insured plan to save money, but these types of plans also allow an employer to design a more useful and valuable plan for its workers.

The key to making this work is cost control, without which claims can spiral and drive up premiums at renewal.

Knowing exactly how much to set aside for reserves and how much you should set your employees’ premiums, deductibles and other cost-sharing can be complicated.

But with the right mixture of benefits, plan design and education, you can control behavior, which drives claims, in order to keep renewal rates from increasing too much each year.

The fine print

That said, there are some reasons partial self-insuring isn’t for all employers:

  • There is additional responsibility, as the employer basically becomes an insurer or sorts.
  • There is additional paperwork for these plans since the employer also becomes a payer.
  • There are compliance issues that the employer needs to consider (ERISA and the Affordable Care Act, for example).
  • There is some additional risk to the employer, as it is paying claims.
  • If you have too many claims, you could face a non-renewal by your stop-loss insurer. If you are cancelled, it may be difficult to seamlessly enter the insured market.
October 22, 2019

As Specialty Drug Costs Bite, Employers Have Options

A new study has found that while group health plan costs will continue growing at the same rate as in the last few years (about 4% a year), the increases would be far less were it not for the spiraling costs of high-cost specialty prescription drugs. 

The 2020 “Segal Health Plan Cost Trend Survey,” which polled health insurers, third party administrators, pharmacy benefit managers (PBMs) and other payers, found that chemotherapy drugs and other specialty pharmaceuticals are having an outsized effect on overall health claims payments.

Unfortunately, this is forcing plan sponsors to figure out how to balance coverage of life-saving drugs with plan affordability. But there are steps you can take to rein in drug cost inflation.

Payers expect that pharmaceutical costs will increase by 7.1% in 2020 from this year and that the cost of specialty drugs will double that inflationary rate at 15.4%.

Rebates account for a significant part of the pharmaceutical equation. Survey respondents said that they expect the average impact of rebates would reduce overall drug price inflation by about 1.5%.

The rising cost of brand-name drug expenditures is due to drug price inflation primarily, although one-third of the increase is due to more prescriptions being filled.

Other findings in the report by Segal, a health and retirement consulting firm, are:

  • Price increases are the primary driver of medical and drug trends.
  • Double-digit specialty drug costs are mostly driven by price increases and the introduction of new and more expensive drugs.
  • Reimbursement rates for hospital networks are projected to increase at a higher rate than physician claims.
  • Plan cost trends continue to outpace both inflation and wage growth by a factor of more than two.

The study notes that projected costs in earlier surveys have always been lower than actual inflation of medical treatment and drug outlays. To deal with these increasing costs, Segal identified the top health plan cost-containment strategies that are in use in 2019:

  • Use of health care transparency tools.
  • Expanding pharmaceutical management for non-specialty drugs.
  • Expanding pharmaceutical management for specialty drugs.
  • Offering telehealth/virtual care.
  • Value-based contracting. 

What you can do

Segal recommends the following tactics for managing drug benefit costs, as well as for contracts with PBMs:

Aim for innovative contracting with PBMs ― Hold PBMs contractually accountable for controlling costs. Contract terms can include unique specialty-drug pricing guarantees, performance-based rebates, direct contracting with regional specialty pharmacies and adoption of value-based formularies.

Expand clinical checks ― Amend plan terms to include clinical safeguards like step therapy, targeted prior authorization for high-cost services and quantity-duration limits based on Food and Drug Administration guidelines.

Plan benefit design ― Use benefit designs to increase the use of generics and lower-cost brand-name drugs, in order to help manage drug cost inflation. This can include the use of tiered designs which place clinically effective, lower-cost drugs into lower tiers at lower cost-sharing. 
Also, more plan sponsors that charge drug coinsurance offer point-of-sale rebates that lower participants’ out-of-pocket expenses.

Auditing ― Conduct periodic audits of your PBM and carefully evaluate drug classification against contract terms and pricing guarantees. This is important because some PBMs continue to apply complicated pricing reclassifications that can increase your costs.

October 15, 2019

Trump Administration Decides Not to End PBM Rebates

The Trump administration has decided not to pursue a policy that would have put an end to rebates paid to pharmacy benefit managers, which could put the focus again on how drug companies set their prices.

The proposal would have barred drug companies from paying rebates to PBMs that participate in Medicare and other government programs. According to the administration, the proposed rules were shelved because Congress had taken up the issue to control drug costs.

The spotlight has been harsh on some of the country’s largest PBMs, which have been accused of pocketing a substantial portion of the rebates for themselves while passing on only a sliver of the rebates to the insurance companies that hire them and the health plan enrollees that pay out of pocket for the drugs.

Rebates had become a popular target of criticism in Washington after drug companies lobbied aggressively to cast them as the reason for high prices. PBMs negotiate drug discounts in the form of rebates, often keeping some of that money for themselves.

However, many pundits say that the rebate system put in place by large, national PBMs incentivizes drug companies to keep list prices high, which in turn defeats the purpose of the PBMs – that is, to reduce the out-of-pocket costs that health plan enrollees pay for their prescription drugs.

Like insurers and PBMs, some of which have sought to undermine the practice with accumulator adjustment programs, the Trump administration believes such coupons may be driving up health care spending by getting patients to opt for higher-priced name-brand drugs over generics.

The Centers for Medicare & Medicaid Services proposal unveiled in January would have essentially blocked drug manufacturer rebates from going to PBMs and health plans that serve Medicare and Medicaid patients, starting next year.

Now that the push to eliminate rebates has come to end, the focus looks like it’s shifting to how drug companies price their products. We will keep you posted if any legislation surfaces in this area.

October 9, 2019

Many Workers Struggle with Medical Bills, Despite Having Insurance

A new survey has found that many American workers are struggling with medical bills even though they have employer-sponsored health plans.

The good news from the survey was that 81% of respondents said they had health insurance, which meant they were 19% more financially fit than people without insurance. They were also happier.

The survey found that:

  • One in 10 employees who have insurance and pay part of the premiums, also have annual out-of-pocket medical bills of more than $10,000.
  • 33% of insured employees carry medical debts that they are trying pay down.
  • Insured employees that carry medical debt are 42% less financially fit than those who do not have such debt.

Carrying debts related to medical care also affects employees’ health. The survey found that workers with money problems are:

  • Three times more likely to suffer from anxiety and panic attacks.
  • Eight times more likely to have sleep problems.
  • Four times more likely to suffer from depression and have suicidal thoughts.

Stress from medical debts can also affect worker productivity. Of employees with medical debt problems:

  • 24% have troubled relationships with co-workers.
  • 22% cannot finish their daily tasks.

Lost productivity from these two issues costs businesses up to 14% of payroll expenses, the survey found.

What can you do

Given that health care costs show no signs of abating, what can you do for your low-wage employees and also ensure that your own health insurance premiums don’t spiral out of control? Here are some options:

Vary premium level – If you have a mix of highly paid staff and lower-wage workers, you can create a tiered system where the latter receive greater premium contributions from you than do the former. About a quarter of large employers vary employee health insurance premiums. This is something that’s not feasible for all businesses, particularly if money is tight.

Offer plans with generous benefits – You can offer a slate of plans, from ones with larger copays and deductibles to those with low or no out-of-pocket costs for those employees willing to pay more in premium. This way, your low-wage workers have a choice of health plans which include lower deductibles and lower variability in potential out-of-pocket liability.

Offer skinny plans – Skinny plans still cover the 10 benefits required by the Affordable Care Act, but they typically have a narrow network of providers in exchange for low out-of-pocket costs for the enrollee. While this option is good for your younger and healthier worker, it is often a non-starter for those who have existing health issues.

Carefully review incentives and subsidies – Employers should design wellness incentives that do not penalize low-wage workers, who are more likely to smoke, (many employers impose a tobacco surcharge averaging $600 a year). Employers should couple tobacco surcharges with tobacco-cessation programs, and waive surcharges for employees who are trying to quit.

Offer plans with modern attributes – Telemedicine services can reduce health care costs, as they reduce the worker’s need to take time off for an appointment and also lower the cost of delivery of care.

Push for lower prices and costs – You should coordinate with us, so we can work with your health plans and providers to reduce costs.

October 3, 2019

Get an Early Start on Open Enrollment

As open enrollment is right around the corner, now is the time to make a plan to maximize employee enrollment and help your staff select the health plans that best suit them.

You’ll also need to make sure that you comply with the Affordable Care Act if it applies to your organization, as well as other laws and regulations.

Here are some pointers to make open enrollment fruitful for both your staff and your organization.

Review what you did last year

Review the results of last year’s enrollment efforts to make sure the process and the perks remain relevant and useful to workers.

Were the various approaches and communication channels you used effective, and did you receive any feedback about the process, either good or bad?

Start early with notifications

You should give your employees at least a month’s notice before open enrollment, and provide them with the materials they will need to make an informed decision.

This includes the various health plans that you are offering your staff for next year.

Encourage them to read the information and come to your human resources point person with questions.

Help in sorting through plans

You should be able to help them figure out which plan features fit their needs, and how much the plans will cost them out of their paycheck. Use technology to your advantage, particularly any registration portal that your plan provider offers. Provide a single landing page for all enrollment applications.

Also, hold meetings on the plans and put notices in your staff’s paycheck envelopes.

Plan materials

Communicate to your staff any changes to a health plan’s benefits for the next plan year through an updated summary plan description or a summary of material modifications.

Confirm that their open enrollment materials contain certain required participant notices, when applicable – such as the summary of benefits and coverage.

Check grandfathered status

A grandfathered plan is one that was in existence when the ACA was enacted on March 23, 2010, and is thus exempt from some of the law’s requirements.

If you have a grandfathered plan, talk to us to confirm whether it will maintain its grandfathered status for the next plan year. If it is, you must notify your employees of the plan status. If it’s not, you need to confirm with us that your plan comports with the ACA in terms of benefits offered.

ACA affordability standard

Under the ACA’s employer shared responsibility rules, applicable large employers must offer “affordable” plans, based on a percentage of the employee’s household income. For plan years that begin on or after Jan. 1 of next year, the affordability percentage is 9.86% of household income. At least one of your plans must meet this threshold.

Get spouses involved

Benefits enrollment is a family affair, so getting spouses involved is critical. You should encourage your employees to share the health plan information with their spouses, so they can make informed decisions on their health insurance together.

Also, encourage any spouses who have questions to schedule an appointment to get questions answered.