Monday, November 24, 2014

One final blog post…and the future of health reform

Thanks to you, our readers, for reading Health Reform Talk, for the past five and a half years. We’ve enjoyed bringing you the latest news and developments on health reform. From the initial legislative process to the impact of the Patient Protection and Affordable Care Act (ACA) on employers and others, we’ve covered it all, in an attempt to inform and educate our readers about the nuances and the effects of health reform legislation.

However, at this time, we’ve made the difficult decision to end this blog. Previous posts will remain accessible online but no new additional content will be added.

Thank you for your support over the years!!

What’s ahead? With the Republicans taking control of the U.S. Senate in the 2014 mid-term elections, the future of the ACA remains uncertain. A complete repeal seems unlikely, but legislative efforts to chip away at the law are a definite possibility, particularly in situations where there is some bipartisan support for change. Changing the definition of “full-time employee” for purposes of the employer mandate is one possibility. There’s also been much speculation about an effort to repeal the unpopular medical device tax, an ACA funding mechanism. Another possibility is the introduction of a “copper level” plan on the Exchanges which might contain higher deductibles and out-of-pocket costs for patients.

So as you can see, discussions about health reform will continue. While this blog won’t be along for the journey, we hope you’ll consider consulting other Wolters Kluwer sources for your future legal and compliance information needs. Thanks again for joining us on our blogging voyage.

Friday, November 21, 2014

Mental Health Parity information is updated on EBSA website

The Employee Benefits Security Administration (EBSA) has updated its website with revisions to the Mental Health Parity web page. Material on the web page now includes a revised Mental Health Parity Part of the Self Compliance Tool and a revised Mental Health Parity Provisions Questions and Answers in an updated Compliance Assistance Guide that includes new provisions for the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

Self-Compliance Tool. The Self-Compliance Tool contains a summary of the statute, recent regulations, and other departmental guidance. It assists group health plans, plan sponsors, plan administrators, and health insurance issuers, among others, in determining if their group health plan complies with certain provisions of Part 7 of ERISA. It is only meant to give users a basic understanding of ERISA in order to carry out plan-related responsibilities, and it is not to be considered legal advice.
Compliance Guide. The Compliance Guide contains information for group health plans and issuers regarding the ACA, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Mental Health Parity Act (MHPA). The Mental Health Parity provisions for the latter contain new material in a question-and-answer format. The Compliance Guide also contains information on the Newborns’ and Mothers’Health Protection Act of 1996 (the Newborns’ Act), the Women’s Health and Cancer Rights Act of 1998 (WHCRA), and the Genetic Information Nondiscrimination Act of 2008 (GINA).
Updated mental health parity material. Final regulations implementing the MHPAEA were issued by the EBSA, the HHS, and the IRS on November 8, 2013, and they are applicable for plan years beginning on or after July 1, 2014. While the MHPA required parity for aggregate lifetime and annual dollar limits between mental health benefits and medical/surgical benefits, the MHPAEA expanded on that required parity to include substance use disorder benefits, although the ACA now prohibits lifetime and annual limits on essential health benefits. The MHPAEA also obliges group health plans to make copays and deductibles, along with visit limits no more restrictive for mental health or substance use disorder benefits than they are for medical/surgical benefits.
Although the MHPAEA applies to most employment-based group health coverage, it contains an exemption for group health plans of small employers. Nevertheless, HHS final regulations (78 FR 12834) provide that coverage in the individual and small group markets must provide all categories of essential health benefits, and these would include mental health and substance use disorder benefits. Those benefits must, in turn, be provided in compliance with the MHPAEA.
The Compliance Guide explains that group health plans may still apply financial requirements and treatment limitations to mental health and substance use disorder benefits in any classification, but not if the limitations are more restrictive than the predominant limitations of that type applied to substantially all (2/3 or more) medical/surgical benefits in that same classification. The six classifications of benefits under the MHPAEA are: (1) inpatient in-network, (2) inpatient out-of-network, (3) outpatient in-network, (4) outpatient out-of-network, (5) emergency care, and (6) prescription drugs.
The Compliance Guide also explains that plans may impose a copay for mental health or substance use disorder benefits, but the determination of the portion of medical/surgical benefits in the relevant classification subject to the copay would be based on the dollar amount of all plan payments for medical/surgical benefits in that classification expected to be paid under the plan for the plan year.
Sub-classifications can be used within the six classifications listed above in only two ways. First, plans can sub-divide the outpatient classification into office visits and all other outpatient services. Second, in-network classifications for plans with multiple network tiers can be sub-divided if the tiering is based on reasonable factors without regard to whether a provider is a mental health and substance use disorder provider or a medical/surgical provider.
Prescriptions and deductibles. With regard to prescription drug benefits, plans may apply different levels of financial requirements to different tiers, but only under the following conditions: (1) the tiering must be based on reasonable factors, including cost, efficacy, generic versus brand name, and mail order versus pharmacy pick-up; and (2) both the tiering and financial requirements must be made without regard to whether or not a drug is prescribed for a medical/surgical condition or a mental health or substance use disorder condition.
Separate deductibles for medical/surgical benefits and mental health or substance use disorder benefits are no longer allowed. However, the Compliance Guide advises that plans can choose how to implement a combined deductible, so that, for example, if a plan used to have a $500 deductible for each, it can now have a combined $750 deductible for all benefits. 
Nonquantitative treatment limitations. Nonquantitative treatment limitations may not be imposed on mental health or substance use disorder benefits in any classification more stringently than they are applied to medical surgical benefits. Nonquantitative treatment limitations include, but are not limited to: (1) medical management standards limiting benefits based on medical necessity or appropriateness or the experimental or investigative nature of a treatment; (2) formulary design for prescription drugs; (3) network tier design; (4) standards for provider admission to a network; (5) the determination of usual, customary, and reasonable charges; (6) fail-first policies requiring a showing that a lower-cost therapy is ineffective before a higher-cost therapy is paid (7) exclusions based on failure to complete a course of treatment; and (8) geographic, facility type, or provider specialty restrictions limiting the scope or duration of benefits.



Wednesday, November 19, 2014

Boehner isn't the only Obamacare customer who's returning for seconds

As you may have heard, House Speaker John Boehner plans to "continue to purchase" his ACA coverage through the Marketplace, despite becoming eligible for Medicare this week, according to Politico's website. Boehner's decision shouldn't be entirely surprising, because it looks like people who purchased insurance through the ACA Marketplace last year are extremely likely to renew their coverage this year. Seventy-four percent of individuals newly covered by Marketplace plans for 2014 rated the quality of their health care as "excellent" or "good" in a recent Gallup poll, and 71% gave the same rating to their health care coverage. Seventy-five percent of respondents with Marketplace coverage  say they plan to either renew their current policy or obtain a different policy from an Exchange.

Enrollees not only like their benefits, they're using them

In addition, pharmacy benefits have already been used by nearly half of Americans enrolled in the Marketplace, according to data published by Express Scripts and included in the second Express Scripts Exchange Pulse™ Report. This is the case even for those who enrolled relatively late (April 2014). The Express Scripts analysis is based on a national sample of more than 80 million de-identified pharmacy claims administered by Express Scripts between January 1, 2014 and July 31, 2014.
Satisfaction and use rates match other coverage. The Gallup poll results reveal satisfaction rates among Obamacare enrollees to be similar to covered Americans in general. About 4% of the adults surveyed by Gallup identified themselves as having coverage through the ACA Marketplace. While the percentages of Marketplace enrollees who were happy with the quality of their health care and with their coverage were marginally smaller than those for insured Americans across the board, Marketplace enrollees were happier with the cost of their plan - 75% were satisfied versus 61% of all respondents who have health insurance.

Express Scripts says that the pharmacy use rate for Marketplace enrollees is similar to the use rate of Americans with so-called “traditional” insurance (55%) during the same period, which is a bit surprising, since the latter are more likely to have been insured since January 2014 and are most likely more familiar with health insurance.

Consistency in the Marketplace. "It's important to see this type of consistency in how new exchange members are using their pharmacy benefit, especially those who enrolled more recently," said Julie Huppert, Express Scripts Vice President of Healthcare Reform. "They are paying premiums, seeing their physicians and filling prescriptions."

Express Scripts offered some more specifics on enrollees' use of their pharmacy benefits.

Generics and silver plans are popular. The use of generic medications outpaced that of the traditionally insured population by six percent, the data revealed. Through July 2014, 87% percent of Exchange plan prescriptions filled were for generic medications. "The Silver-rated plans – those with lower premiums but higher out-of-pockets costs for brand-name medications – have been the most popular among consumers on the Exchanges, particularly among those eligible for subsidies," said Huppert. "By preferring generic medications over more expensive brand-name alternatives, these members are using their plans in the way they were designed."

Differences in medications. Express Scripts also found that the use of pain medications is 39% higher in the Exchange plans, and the use of antidepressants is 12% higher. The use of contraceptives is 32% higher in traditional health plans, however. Both groups filled more prescriptions to treat hypertension than any other condition.

Medications to treat such chronic conditions as heart disease and diabetes are being obtained by Exchange enrollees at rates similar to other insured individuals.

Specialty medications. The Express Scripts data show that 59% percent more prescriptions for specialty medications are filled by Exchange enrollees than for other insured individuals, and Exchange enrollees aged 18-34 fill twice as many specialty medications than similarly aged individuals insured in a traditional health plan. This has a relatively important financial effect, because specialty medications consume 38% of the total pharmacy spend for the Exchange plans, despite accounting for only 1.3% of the number of total pharmacy claims. By comparison, Express Script points out, only 28% of the total pharmacy spend for traditional health plans is attributed to specialty drugs.

Nearly three out of every five specialty prescriptions filled by an Exchange member is for an HIV medication. HIV patients can also have a substantial effect on an insurer’s bottom line, because, according to Express Scripts, compared to Exchange enrollees not taking an HIV medication, Exchange patients currently taking an HIV medication are more than 3.5 times more likely to take a hepatitis C medication, are more than 23 times more likely to take a hepatitis B medication, and are nearly three times more likely to take a medication for non-HIV viral infections.

"Given the increased prevalence of specialty conditions, it's vitally important for these Exchange plans to provide patients with clinical programs that ensure appropriate management of these complex, high-cost medications," said Huppert. "Express Scripts' HIV specialist pharmacists have in-depth knowledge and experience helping patients with HIV manage their complex therapies and the co-morbidities commonly associated with their condition. These patients often need strong clinical support and care to ensure they use their medication properly and remain on therapy."

Monday, November 17, 2014

Should you get Obamacare insurance this year?

Trying to decide whether or not to enroll in Marketplace coverage this year and you’re wondering what to expect? Now that open enrollment has started users report that, although the system is still presenting minor technical problems, the process has been smoother so far than it was last year.

Good, bad, and different. It should be easier to enroll this year, especially for those who have already been through the process.The Center for Consumer Information & Insurance Oversight (CCIIO) stated in October 2014 that end-to-end issuer testing of the FFM Individual marketplace launched 10/7/2014, and health plan issuers were able to test against their own submitted QHP 2015 plan data. According to HHS Secretary Sylvia Mathews Burwell, writing on the HHS website, improvements to the process include the fact that around 90% of returning customers’ enrollees’ will be prepopulated using last year’s information. Plans have changed this year, and, although many plans that are the same or the closest thing to what enrollees chose last year have gone up substantially in price, more plans have been added, adding to choice. For example, the Illinois Department of Insurance (DOI) recently announced the number of Qualified Health Plans (QHPs) offered under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) has more than doubled from 165 plans offered in 2014 to more than 400 plans being offered in 2015.

It’s more important than ever to have coverage this year. If you opted to pay the penalty for not having health insurance in 2014 you will face a higher penalty for 2015 unless you obtain insurance. In 2014, it was 1% of household income (the amount of income above the tax filing threshold, around $10,000) or a total of $95 per adult plus $47.50 per child under 18, whichever is higher, for a maximum of $285. For 2015, however, the fee rises to 2% of yearly household income, again, for the amount of income above the tax filing threshold, or $325 per adult plus $162.50 per child under 18, whichever is higher, with a maximum penalty per family of $975.

It’s possible you may not have to enroll.You could qualify for a hardship exemption during the following, as well as the month before and the month after, unless otherwise specified: homelessness, eviction in the last 6 months, the receipt of a shut-off notice from a utility company, domestic violence, the death of a close family member, substantial damage to your property from a natural or human-caused disaster, bankruptcy in the last 6 months, medical expenses that you couldn’t pay in the last 24 months, unexpected increases in necessary expenses for the care of an ill, disabled, or aging family member, eligibility for enrollment or lower premium costs as the result of an eligibility appeals decision regarding the time period you weren’t enrolled, ineligibility for Medicaid based on your state’s decision not to expand Medicaid eligibility under the ACA (for which the hardship exemption would last a whole calendar year), the cancellation of your existing individual insurance plan and the apparent unaffordability of Marketplace plans, (in which case the exemption will be granted for the remaining months in that coverage year), or other hardships in obtaining health insurance.
You don’t have to pay the penalty for your child if you expect to claim his or her as a tax dependent who’s been denied coverage in Medicaid and CHIP, if someone else is required by court order to give medical support to the child.

You’ll have to include documentation with your submission for an exemption. For example, if you’re claiming that you received a shut-off notice, you’ll have to include a copy of the notice, and if you experience unexpected increases related to caring for a family member, you’ll need copies of receipts related to care.

You must fill out an exemption form to apply for a hardship exemption.

Friday, November 14, 2014

Cadillac tax will wallop retiree plans by 2020

Nearly twenty percent of benefit plans will trigger the “Cadillac” tax provision under the Patient Protection and Affordable Care Act (ACA) by the year 2020, according to a study from Truven Health Analytics™.
Beginning in 2018, the ACA requires employers to pay a 40 percent tax on the net cost of high-cost health plans. Plans with costs that total more than $10,200 for employee-only coverage and $27,500 for family coverage will be subject to this penalty, the so-called “Cadillac” tax.
According to the Truven Health study, which analyzed recent MarketScan® claims data for over 13 million active employees and early retirees in nearly 2,600 self-funded plans to identify real-world healthcare spending trends, 15 percent of active employee plans are projected to incur the tax upon its activation in 2018, a rate that is expected to increase to 19 percent by 2020. Truven Health researchers estimate the tax would result in a cost increase of up to $480 per employee per year (PEPY) for plans expected to incur the tax.
“It’s critical to effective planning for budgeting, collective bargaining and benefit strategy that employers begin now to gain a solid understanding of which plans are likely to incur the tax and when each plan’s costs may be likely to cross the excise thresholds,” said Chris Justice, senior director of practice leadership. “By implementing a combination of benefit plan changes, premium contributions, and health risk interventions, you can mitigate the impact of this new tax in 2018 and beyond.”
Retiree plans. The study also finds that early retiree plans are projected to incur tax at a much higher rate than active employee plans. Truven researchers found that 81 percent of early retiree plans for U.S. employers are likely to incur the Cadillac tax, and this rate is projected to increase to 84 percent by 2020. That would result in an annual per employee per year (PEPY) tax amount of $1,069, or 6.8 percent of total PEPY costs for plans incurring the tax.
Truven Health has conducted similar studies for industry groups such as health system, university and public employers; these analyses revealed that nearly 40 percent of active employee plans for health system employers and over 25 percent of active employee plans for university employers in this study are projected to incur the Cadillac tax by 2020.