In June, the United States Supreme Court handed down its ruling in United States v. Windsor – the highly publicized Defense of Marriage Act (DOMA) case. While the Supreme Court’s ruling was very specific regarding changes required in the areas of the law it addressed (i.e., inheritance tax issues for same-sex spouses), there are still many questions as to the application of this decision to employee benefit plans – predominantly group health benefit plans.
The Supreme Court’s opinion dealt only with the constitutionality of Section 3 of DOMA – the section that defined marriage as “between one man and one woman” – and the application of that definition to inheritance taxes. What is missing is clear guidance as to how this decision applies to spousal coverage under employee benefit plans – particularly whether or not health and retirement plans must be amended to make same-sex spouses in these plans eligible for coverage. This question is particularly vexing in states that already recognize same-sex partners. Several entities, including the American Benefits Council, have made formal requests of the Tri-Agencies (HHS, IRS, DOL) to issue interpretive guidance on this very issue.
Making things even more confusing are the many attorney newsletters and blog postings interpreting the Supreme Court’s decision for group health plans. In some cases, these firms have indicated that, for self-funded plans in states that do NOT recognize same-sex spouses (such as Ohio), plan sponsors will now be forced to decide whether they will cover any spouses at all. It is their contention that if these employers do cover ’spouses’ but continue to exclude same-sex spouses, the employer may risk litigation or discriminatory action – particularly if the plan specifically states that only opposite-sex spouses are covered. Such language could be determined, through litigation, to violate the Supreme Court’s ruling.
While we await further guidance on the spousal eligibility question, there are a host of other issues that will have to be reviewed in light of the decision. These are as follows:
Among the keys to reducing health care costs is reducing the “care gap” that results from plan members missing recommended wellness exams and screenings. MedBen, in conjunction with Verisk Health, offers a unique reporting platform that calculates a group’s Care Gap Index (CGI) – a score that assesses the type and degree of care gaps for individuals in a population.
Using a Predictive Modeling System, MedBen clients can see for themselves the potential economic impact of closing care gaps. The smaller the CGI, the higher the likelihood of a healthier workforce – which, in turn, increases productivity while improving your bottom line.
Furthermore, reducing the care gap can theoretically add years to the lives of your employees. A new report from the Centers for Disease Control and Prevention (CDC) says that nearly one-quarter of the deaths from cardiovascular disease could be prevented with basic lifestyle changes. By knowing where care gaps exist and encouraging plan members to schedule regular checkups, you can help your employees avoid heart disease, stroke and other serious conditions.
To learn more about how MedBen can help your group detect and close care gaps – and how advanced reporting tools will allow you to calculate the resultant savings – please contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
The 2013 Employer Benefits Survey released last month by the Kaiser Family Foundation shows that the popularity of self-funding continues to grow steadily. According to Passion for Subro, 61% of covered workers are in a self-funded plan – up slightly from 60% in 2012 and 59% in 2010. In the past decade, self-funding has seen an upward trend, rising over 10% since 2000.
One interesting, if not wholly unexpected finding, was the difference in coverage levels between large employers (200 or more workers) and smaller ones (3-199 workers): 83% of covered workers in the former groups are in a self-funded plan compared to just 16% in the latter.
Why the disparity? Many smaller firms believe they lack the resources to adequately cover their employees. But at MedBen, our experience tells a different story.
MedBen has provided self-funded administration for over two decades, saving money for groups both large and small in the process. And now, MedBen Split Solution is available as a true self-funded product for groups with as few as 20 employees.
If you work hard to contain your health care costs, “making the Split” is ideal for your group. You benefit from potential claims savings while still getting protection you from high claims activity. And you maintain plan design flexibility!
You are not too small to self-fund. To learn how Split Solution enables you to share in the savings that come from reduced employee claims, contact Brian Fargus, MedBen Vice President of Sales & Marketing, at email@example.com.
The staff of MedBen would like to wish you and your family a safe and relaxing Labor Day!
MedBen will be closed on Monday, September 2 and will reopen at 8:00 a.m. the following day. But even when we’re out of the office, our online customer services stay open around the clock.
MedBen Access: Plan members can use this site to check the status of a health claim, review benefit coverages, and more. To visit, simply visit MedBen.com and click on the MedBen Access link.
Rx Resources: This useful feature, available through MedBen Access to plan members who use PDMI as their pharmacy benefits manager, allows individuals to review personal prescription detail and benefit coverage, and compare lower cost alternatives. Click a plan member name under “My Rx Claims” on the MedBen Access sidebar to open.
FSA/HRA Online System: MedBen FSA and HRA members can use this site to review claim submissions, check payments issued, see total deposits posted to date and get answers to a variety of questions. In MedBen Access, select the “FSA/HRA Online Inquiry” option under the “My Plan” section on the sidebar. Alternately, you may log in directly to the site (using a separate User ID and PIN) by going to MedBen.com, clicking on the “Plan Members (Insureds)” button and selecting “FSA-HRA Account Information” from the “Online Services” drop-down menu.
Of course, the recently revamped MedBen.com itself offers a variety of resources, including links to additional online services, downloadable forms and network directories. Separate areas are available for employers, insureds and providers – just select the appropriate button to enter!
The Obama administration has announced another delay in implementation of the Affordable Care Act. The signing of final agreements with insurance plans to be sold on federal health insurance exchanges has been postponed from the original dates of September 5-9 to mid-September.
According to Reuters, sources cited “technology problems involving the display of insurance products within the federal information technology system” as a possible reason for the delay.
While the hold-up may be brief, experts warn that it could affect the October 1 start date for open enrollment into the exchanges. The Department of Health and Human Services fully expects the insurance marketplaces to open on time – but even prior to the announcement, several states said they’re scaling back their exchange launches, or considering doing so.
“[H]aving everything ready on October 1 is not a critical issue,” said a former Obama administration official who worked to implement the Affordable Care Act. “What matters to people is January 1, which is when the coverage is supposed to start. If that were delayed, it would be a substantive setback.”
MedBen is not participating in the exchanges, and the delay does not affect employers that carry private group insurance or self-fund their coverage.
The Affordable Care Act (ACA) requires that health plans providing medical benefits provide a uniform summary of their benefits to eligible individuals to be used in comparing any different coverage options that are available to these individuals. When a plan change is made that affects the summary of benefits and coverage (SBC), there are certain requirements on when the updated SBC should be provided to plan participants.
Per mandates promulgated under the ACA, any mid-year plan changes or amendments that affect your plan’s existing SBC (i.e., changes made at any time other than the first day of the plan year) must be provided to plan participants no later than 60 days prior to the date the change or amendment takes effect. This means that MedBen will need advance notice of any such mid-plan year benefit changes. In a best case scenario, MedBen would like to get such plan changes at least 90 days before the change is to become effective. This will allow MedBen the time needed to get appropriate stop-loss approval, prepare the plan amendment, make any necessary SBC changes and provide the plan sponsor with the required documents in time for distribution 60 days before the effective date of the change.
Likewise, SBC’s that contain plan changes that will be effective on the first day of a new plan year must be provided to plan participants no later than 30 days prior to the date the change takes effect. Again, MedBen would like advance notice of any changes that take effect on the first day of the plan year at least two months prior to the first day of the plan year so that MedBen can obtain appropriate stop-loss quotes and make the necessary changes to the SBC, in order to meet the ACA deadline.
In order to provide clients with continual access to online information regardless of bad weather or heavy web traffic, MedBen will be upgrading its Internet connection on the evening of Friday, September 13, beginning at 7:00 p.m.
Work on the upgrade is expected to last 3.5-4 hours, during which MedBen.com, MedBen Access, MedBen Secure and our other websites, as well as e-mail, will be unavailable. But we think you’ll find the brief break in services will be worth it!
Once online capacities have been fully restored, MedBen will offer redundant Internet connections; that is, two Internet companies will now provide service for our websites. Our new Internet company will serve as our primary connection, offering even faster retrieval of your claims and benefit data, while our existing company will provide backup.
So what does this mean to our clients? In the event of a storm or other event that causes the primary connection to do down, our access to MedBen websites and e-mail will automatically route to the backup, to allow an uninterrupted flow of information. Or should our primary connection get busy, the backup will be there to manage the additional visitors.
With redundant Internet connections, MedBen ensures that you have access to around-the-clock customer service. Clients with questions about the upgrade may contact Vice President of Information Systems Rose McEntire at firstname.lastname@example.org.
MedBen has just completed a seven-week Affordable Care Act Webinar Series. Led by MedBen Vice President of Compliance Caroline Fraker and offered exclusively to clients, each one-hour session focused on a different aspect of the Affordable Care Act and how it will affect employers in the coming months and years. Presentations were followed by an open question-and-answer period.
All seven meetings are now available for viewing on YouTube:
Webinars are just one way MedBen is keeping clients aware of the latest health care reform developments. Throughout the year, Fraker and other members of our MedBen University team have traveled the Midwest to explain how employers can best navigate their responsibilities under the ACA, and stay ahead of the latest federal rules. And we will continue to keep our clients informed during the rest of 2013 and beyond.
MedBen clients with questions regarding any of the information shared in these webinars are welcome to contact Caroline at email@example.com.
“Partly blaming the health law, United Parcel Service is set to remove thousands of spouses from its medical plan because they are eligible for coverage elsewhere.
“Rising medical costs, ‘combined with the costs associated with the Affordable Care Act, have made it increasingly difficult to continue providing the same level of health care benefits to our employees at an affordable cost,’ UPS said in a memo to employees.
“The company told white-collar workers two months ago that 15,000 working spouses eligible for coverage at their own employers would be excluded from the UPS plan in 2014. The Fortune 100 firm expects the move, which applies to non-union U.S. workers only, to save about $60 million a year, said company spokesman Andy McGowan.”
While UPS’ policy shift has made headlines nationwide, nothing explained in this article is new to MedBen clients. In fact, seven years ago, MedBen started advising its clients to encourage workers’ spouses to get coverage through their own employers. And those who have done so have experienced significant cost savings as a result.
MedBen’s clients have been learning about leading-edge plan design ideas that save money – and the majority have implemented those ideas and saved year after year.
Regardless of whether or not UPS was forced to change its medical plan in the face of health care reform, the reality is that it makes smart financial sense to remove spouses from employer coverage when outside coverage is readily available.
For additional information about how changes to spousal coverage can benefit an employer’s bottom line, contact MedBen Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
In an effort to reduce the overprescribing of opioids, CVS Caremark Corp. announced that it has taken the step of cutting off dispensing privileges, Reuters reports. The company said its stores and its mail-order pharmacy will no longer supply controlled substances for 36 doctors and other health care providers who it said could not justify their prescribing habits.
“This isn’t a definitive solution to the problem,” CVS Chief Medical Officer Troyen Brennan told Reuters. “We wanted to share what it was that we did and have other people in health care, including other pharmacies, look at what we did and discuss what some more comprehensive solutions might be.”
Brennan said the drugstore chain began revoking access for certain providers in late 2012. CVS took the action in response to a request by U.S. Drug Enforcement Administration for help in stemming the flow of prescription drugs where abuse is suspected.
Abuse of opioid prescription painkillers like Oxycontin ranks as the No. 2 cause of accidental death in the United States, CVS said. In 2009, painkiller use was cited in more than 15,500 overdose deaths, according to the U.S. Centers for Disease Control and Prevention.
A recent news item about a “largely unnoticed” delay for out-of-pocket cost limits under the Affordable Care Act created some confusion as for whom it was intended. As it happens, the one-year postponement affects only a small portion of health insurance plans.
While the maximum out-of-pocket limits will still apply to individual and (non-grandfathered) group health plans, employer-sponsored plans that have “separately administered” benefits have been granted a delay until 2015. As Sarah Lueck, Senior Policy Analyst of the Center on Budget and Policy Priorities, explains it:
“The Administration provided the exception in February for these plans, in which an employer has one insurer or administrator for its primary package of health benefits and a different insurer or administrator for discrete benefits, such as prescription drugs. Because employers and insurers have claimed it will be difficult to coordinate an overall maximum out-of-pocket limit across separately administered benefits, they sought and received the ability to avoid full compliance for one year.”
MedBen made clients aware of this transition relief earlier this year, and has also found a work-around for 2015. Clients who have questions regarding out-of-pocket limits under the health care reform law are welcome to contact Vice President of Compliance Caroline Fraker at email@example.com.
Premiums for employer-based health insurance continue to grow slowly, say researchers from the Kaiser Family Foundation.
The New York Times reports that, according to the KFF survey, the average annual premium for family polices purchased through an employer rose 4% in 2013, to $16,351, while premiums for individual policies rose 5%, to $5,884. The increases are similar to those that occurred in 2012.
The Kaiser researchers say the moderate climb can be attributed in part to employees paying higher out-of-pocket costs – about 4 in 10 members now belong to a health care plan with a deductible of at least $1,000. The slower growth also appears to reflect slower growth of health care spending in general following a down economy.
And as for whether or not the health care reform law has contributed to the recent premium slowdown? “My general sense is it’s too early to take what’s happening with health care spending, whether it’s for good or bad, and assign it to the [Affordable Care Act],” said Martin S. Gaynor, a professor of economics and health policy at Carnegie Mellon University.
The survey results did suggest, however, that most employers will continue to offer coverage for the foreseeable future, even with the looming availability of insurance exchanges under the ACA. About 57% of all companies are offering health benefits this year compared with 61% last year, a difference that was not statistically significant.
Could a no-copay checkup mean the difference between high and low blood pressure? Possibly, a new survey finds.
According to the Associated Press, Kaiser Permanente in Northern California monitored patients with high blood pressure over an eight-year period (2001-09). In that time span, the proportion of patients who had their blood pressure under control went from 44% to 80% – well above the national average. The number of heart attacks and strokes in the group also fell substantially.
The researchers point to two factors they believe played a role in the program’s success:
“Patients really liked it because it was shorter, more convenient and more affordable,” said Dr. Marc Jaffe, the lead author and leader of a Kaiser heart disease risk reduction program. Jaffe acknowledged that it’s impossible to know if the blood pressure program can be credited for the declines in heart attacks and strokes, but he thinks it at least contributed.
While the issue of opioid painkiller abuse should naturally focus on getting help for those affected, there is also a financial factor that must also be acknowledged – for the employer, the doctor and the insurer, as well as the patient. That’s where a pharmacy benefits manager becomes a vital partner.
According to Employee Benefits News, respondents to a recent Survey of Prescription Drug Management said opioids were the biggest problem in workers’ compensation pharmacy management, with many agreeing that drug costs were more important than other medical cost issues.
But looking at cost alone doesn’t fully address the problem, says Dr. Brian Solow, chief medical officer of a national pharmacy benefit manager (PBM). Cheaper drugs can can be just as detrimental to the employer’s bottom line in addition to the patient’s health.
“You’re talking about two issues, of course,” Solow says. “The employer who’s worried about high-cost abuse, drugs, etc. But there are also drugs that are very inexpensive that are being abused, but that really don’t cost the employer anything in terms of monetary drug value. … I think people lose sight and think we’re always trying to catch it because it’s less expensive, but generic Codeine, generic Vicodin – these are actually pretty cheap. So, I think that’s where we’re going to have to turn to their pharmacy benefit manager.”
At MedBen, we team with pharmaceutical experts who dedicate themselves to keeping clients aware when red flags arise. Our selection of respected PBMs work with employers to track utilization patterns and associated costs of pharmacy plans, and notify physicians when circumstances suggest potential abuse.
For more information about MedBen pharmacy plan services, contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
The benefits of “good” cholesterol don’t stop with a healthier heart. It’s also is an effective cancer-fighter, a new study finds.
According to the Health Hub, researchers at Cleveland Clinic conducted tests on mice using a protein called apolipoprotein A1 (apoA1), a major component of HDL, the so-called good cholesterol. Intrigued by apoA1’s power as a cardioprotective agent, the team dwelved into other potential benefits – specifically, its ability to prime the immune system to fight off cancer.
The research showed that mice that had the apoA1 protein were more resistant to tumor growth and survived longer than their apoA1-lacking counterparts. More importantly, results show that direct injection of apoA1 as a therapy into mice with existing tumors and metastases not only inhibited the growth of tumors and the spread of malignant melanoma and lung cancer, but promoted regression of existing tumors and metastases.
“This is another example of where research in one field can yield exciting new discoveries that could benefit an entirely new pool of patients,” said Stanley Hazen, MD, PhD, section head of Preventive Cardiology at Cleveland Clinic’s Heart and Vascular Institute.
A Gallup poll released this week reports that 58% of Americans believe it’s okay to charge a higher health insurance rate to smokers, but only 41% agree overweight people should be charged more.
According to MedCity News, the reason that many Americans are okay with charging a higher rate to smokers is likely because so many American are overweight. Only 1 in 5 adults smoke.
This coming October, the Affordable Care Act will give states the option to charge higher rates to individuals that smoke, but does not allow them to charge higher rates to overweight individuals. Even so, the higher smoking rate is based on the honor system – and the policy cannot be canceled if later it was revealed that an individual is a smoker paying nonsmoker rates.
Many groups are outraged that carriers can charge more to smokers. Cigarette producers, the American Cancer Society and advocates for the poor and minorities believe that the extra charge singles many smokers out, and can actually produce an adverse effect on individuals purchasing policies.
“We don’t want to create more barriers to quitting,” said Dianne Phillips, policy director for the Cancer Action Network in Pennsylvania, a state that will permit insurers to charge higher rates to smokers. “Making it more expensive (might) put insurance coverage out of their reach.”
Retail clinics at pharmacy and department store chains are a growing business – and it’s a trend that has some doctors concerned. While acknowledging their usefulness for minor ailments, the recent announcement by Walgreens that their clinics would diagnose and manage chronic conditions led Kevin Pho to question whether drugstore clinicians should double as primary care physicians:
“Consider the population most likely to have chronic conditions: Medicare patients. A New England Journal of Medicine study found that they already see an average of seven different physicians a year. Seeking care at a drugstore adds another provider, and further fragments care. According to Dr. Jeffrey Cain, president of the American Academy of Family Physicians, ‘it is more difficult to comprehensively manage a patient’s care if they are treated in multiple settings.’
“Indeed, I find managing diabetes or high blood pressure is far more effective after developing a relationship with patients and getting to know their individual preferences over time. Patients who go to retail clinics are more likely to see a rotating set of providers. And rather than personalize treatment, they follow standardized medical protocols to abide by the American Medical Association’s retail clinic policies.
“Poor sharing of medical information also fuels fragmentation. Electronic record systems of hospitals within blocks of each other often cannot speak to one another, let alone with one from a retail clinic. It’s unlikely that a drugstore provider can access a patient’s medical record, which would mean starting care from scratch.”
One in 10 Americans admits taking a prescription drug he or she has not been prescribed… and not everyone uses them for purely medicinal purposes, Reuters reports.
According to an ongoing Reuters/Ipsos poll, about six in ten Americans who used another person’s prescriptions did so for pain relief, while a fifth took them to sleep or to manage stress and anxiety. But a full one-quarter of respondents who used non-prescribed pills did so just to get high.
Also troubling is that gettng hold of another person’s drugs is a relatively simple matter. The poll indicated that about two-thirds of those who used other people’s prescribed drugs were given them by a family member, friend or acquaintance. Only about 14% were either taken without permission or purchased.
Dr. Wilson Compton, a division director at the National Institute on Drug Abuse, said dosage levels of prescription drugs are particular to an individual’s specific needs and warns against taking a medicine that has not been prescribed. “Simply because it’s a medicine that comes from a pharmacy does not mean it is without risk,” he said.
Prescription drug misuse has reached epidemic levels and it is now the second most abused category of drugs in the United States, after marijuana, according to a survey conducted for the U.S. government.
Ohio individuals and businesses that purchase health insurance through the state’s exchange will see significant increases in premium costs, according to the Ohio Department of Insurance.
Based on rates submitted by insurance companies that will participate in Ohio’s health insurance marketplace, individuals will pay an average of 41% more and businesses will pay an average of 18% more in health insurance premiums when the Affordable Care Act takes effect next year.
The lack of competitiveness inherent in the exchanges has led to higher costs, said Lt. Gov. Mary Taylor: “That level of diversity is essentially outlawed under Obamacare, so Ohio’s rates and premiums are going up significantly, and going up more than in other states where prices were already high.”
Gary Claxton, vice president of Kaiser Family Foundation, countered that while costs will go up because insurers will have to cover more sick people and offer more benefits, subsidies and tax credits will keep rates down for many people.
WebMD reports that 12 companies will offer plans for the individual market in Ohio, while six companies will offer plans for small businesses. MedBen is not participating in the state’s exchange.
As we posted on the blog earlier this year, the Affordable Care Act (ACA) will no longer allow employers to offer “stand-alone” health reimbursement arrangements (HRAs) effective January 1, 2014. We also noted that the rule does not apply to health flexible spending accounts (FSAs) – a fact that has led some employers to consider shifting their future contributions from an HRA to a health FSA.
But a word to the wise: While simply moving from one type of stand-alone account to another may seem an expedient solution, it can create a whole new set of problems. Many federal group health plan rules that don’t otherwise pertain to an employee-funded health FSA may apply when the employer makes the contributions.
Presently, benefits under many health FSAs qualify as “excepted” and therefore will not be subject to a variety of federal regulations. These include certain mandates under the ACA, as well as HIPAA portability rules. In addition, an employer whose health FSA is excepted may be able to take advantage of a special limited COBRA obligation.
However, if an employer contributes to an employee’s health FSA, this could affect its “exempted benefit” status. So in order to avoid an additional layer of bureaucracy, the health FSA must satisfy two conditions: