Medicare Part D Changes May Impact Creditable Coverage Status of Employer Plans

Compliance, Employee Benefits, Employee Benefits Adviser, Employee Communications, Health Care Reform, Medical, U.S. Department of Labor

Medicare Part D Changes May Impact Creditable Coverage Status of Employer Plans

The Inflation Reduction Act of 2022 (IRA) includes several cost-reduction provisions affecting Medicare Part D plans, which may impact the creditable coverage status of employer-sponsored prescription drug coverage beginning in 2025.

Employers that provide prescription drug coverage to individuals who are eligible for Medicare Part D must inform these individuals and the Centers for Medicare and Medicaid Services (CMS) whether their prescription drug coverage is creditable, meaning that the employer’s prescription drug coverage is at least as good as Medicare Part D coverage.

CMS’ Draft Part D Redesign Program Instructions state that given the significant changes that the IRA made to Medicare Part D, one of the methods for determining whether employer-sponsored prescription drug coverage is creditable will no longer be valid as of calendar year 2025. These draft program instructions are subject to change, and CMS will issue final program instructions for 2025 after considering the public comments received in response to the draft program instructions.

Creditable Coverage Determination

A group health plan’s prescription drug coverage is considered creditable if its actuarial value equals or exceeds the actuarial value of standard Medicare Part D prescription drug coverage, as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS guidelines. In general, this actuarial determination measures whether the expected amount of paid claims under the group health plan’s prescription drug coverage is at least as much as the expected amount of paid claims under the Medicare Part D prescription drug benefit. For plans that have multiple benefit options (for example, PPOs, HDHPs and HMOs), the creditable coverage test must be applied separately for each benefit option.

Under existing CMS guidance, there are a few different ways for an employer to determine whether its …

By Jessica Rogers|March 26th, 2024|Compliance, Employee Benefits, Employee Benefits Adviser, Employee Communications, Health Care Reform, Medical, U.S. Department of Labor|Comments Off

Legal Alert- Medicare Part D Disclosures due by Feb. 29, 2024 for Calendar Year Plans

Compliance, Employee Benefits, Employee Benefits Adviser, Medical

Legal Alert- Medicare Part D Disclosures due by Feb. 29, 2024 for Calendar Year Plans

Each year, group health plan sponsors are required to complete an online disclosure form with the Centers for Medicare & Medicaid Services (CMS), indicating whether the plan’s prescription drug coverage is creditable or non-creditable. This disclosure requirement applies when an employer-sponsored group health plan provides prescription drug coverage to individuals who are eligible for coverage under Medicare Part D.

CMS Disclosure Deadline

The plan sponsor must complete the online disclosure within 60 days after the beginning of the plan year. For calendar year health plans, the deadline for the annual online disclosure is Feb. 29, 2024 (since 2024 is a leap year).

In addition to the annual disclosure requirement, the disclosure to CMS must be made whenever any change occurs that affects whether the coverage is creditable. More specifically, within 30 days after any change in the plan’s creditable coverage status or after the termination of a plan’s prescription drug coverage.

Online Disclosure Method

Plan sponsors are required to use the online disclosure form on the CMS creditable coverage website. This is the sole method for compliance with the disclosure requirement unless the entity does not have internet access.

The disclosure form lists the required data fields that must be completed in order to generate the disclosure notice to CMS, such as types of coverage, number of options offered, creditable coverage status, period covered by the disclosure notice, number of Part D-eligible individuals covered, date the creditable coverage disclosure notice is provided to Part D-eligible individuals, and change in creditable coverage status.

CMS has also provided guidance and instructions on how to complete the form.

Action Steps

To determine whether the CMS reporting requirement …

By Jessica Rogers|February 5th, 2024|Compliance, Employee Benefits, Employee Benefits Adviser, Medical|Comments Off

What Employers Need to Know About Medicaid Redeterminations

Broad Reach Benefits, Employee Benefits, Employee Benefits Adviser, Employee Communications, Human Resources, Medical, Private Health Care Exchange, U.S. Department of Labor, Wellness

What Employers Need to Know About Medicaid Redeterminations

In 2020, the U.S. Congress passed the Families First Coronavirus Response Act in response to the COVID-19 pandemic, requiring states to maintain Medicaid coverage for most enrollees during the public health emergency (PHE). During this period, individuals receiving Medicaid did not have to reapply to remain eligible for benefits. In December 2022, the 2023 Consolidated Appropriations Act was passed, uncoupling Medicaid redeterminations from the PHE and establishing a timeline for states to restart the Medicaid redetermination process. As a result, as many as 15 million Americans may soon no longer be eligible for Medicaid because of redeterminations, according to U.S. Department of Health and Human Services estimates.

Medicaid provides health insurance to millions of eligible Americans with limited income and resources. Each state administers its own Medicaid program, and enrollees must apply annually to qualify for Medicaid benefits. This process is known as redetermination, renewal or recertification. The Medicaid redetermination process helps evaluate whether Medicaid enrollees are eligible for continued health coverage. Eligibility for continued health coverage depends on various factors, including changes in age, disability status, household size and income. States were able to resume annual Medicaid renewals starting April 1, 2023. This means coverage terminations have resumed for Medicaid enrollees who have been redetermined by state agencies as ineligible for Medicaid, resulting in the loss of their health care coverage. The precise date of resuming coverage terminations will vary by state.

A Primer on Stop-loss Contracts

Stop-loss insurance is coverage self-funded employers purchase to manage their health care costs and protect against unexpected or catastrophic claims by establishing a limit for the amount they pay in health claims. This coverage is not a form of medical insurance, and employers can add stop-loss insurance to an existing …

By Jessica Rogers|May 15th, 2023|Broad Reach Benefits, Employee Benefits, Employee Benefits Adviser, Employee Communications, Human Resources, Medical, Private Health Care Exchange, U.S. Department of Labor, Wellness|Comments Off

Insurers Take Steps to Overhaul Prior Authorization Processes

Broad Reach Benefits, Employee Benefits, Employee Benefits Adviser, Human Resources, Medical

Insurers Take Steps to Overhaul Prior Authorization Processes

Insurers, such as UnitedHealthcare, Cigna, and Aetna, are announcing plans to revamp their prior authorization processes. These decisions were made as insurers await an impending federal regulation that will shorten prior authorization decision time. Prior authorization, also known as preauthorization, is when a physician must get approval from an insurer for medication or treatment before administering it.

A proposed Centers for Medicare and Medicaid Services (CMS) rule would limit the time insurers have to approve prior authorization requests. The rule is expected to be finalized in the near future. Starting in 2026, the CMS rule will require plans to respond to a standard request within seven days—instead of the current 14-day time frame—and within 72 hours for urgent requests. Physicians argue that the additional administrative steps associated with the preauthorization process can delay necessary services and increase the administrative burden.

The Changes

Major health insurers plan to revamp their prior authorization processes by boosting automation and speeding up decision-making. Starting this summer, UnitedHealthcare will reduce the use of its prior authorization process by 20% for nonurgent surgeries and procedures. The company will also implement a national “gold card” program in early 2024, allowing certain eligible providers to perform most procedures without authorization.

Cigna has removed prior authorization reviews from nearly 500 services since 2020. Around 6% of medical services for their customers are subject to prior authorization and Cigna continuously reviews the need for prior authorization on services.

Similarly, Aetna continues to review and assess utilization and the need for prior authorization requirements on select services.

What’s Next?

The CMS is expected to soon finalize its rule to streamline the prior authorization process, easing the burden on providers and patients. We’ll keep you apprised of any notable …

By Jessica Rogers|April 4th, 2023|Broad Reach Benefits, Employee Benefits, Employee Benefits Adviser, Human Resources, Medical|Comments Off

Family and Medical Leave Act (FMLA): Serious Health Condition

Compliance, Employee Benefits, Employee Communications, Human Resources, Legislation, Medical, U.S. Department of Labor

Family and Medical Leave Act (FMLA): Serious Health Condition

The federal Family and Medical Leave Act (FMLA) requires covered employers to provide eligible employees with unpaid, job-protected leave for qualifying reasons. Qualifying reasons include needing time off due to the employee’s own serious health condition and caring for a spouse, son, daughter or parent who has a serious health condition.

Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider. It does not include routine medical examinations, such as a physical, or common medical conditions, such as an upset stomach unless complications develop.

Types of Serious Health Conditions

Inpatient care means an overnight stay in a hospital, hospice or residential medical care facility and any period of incapacity or subsequent treatment in connection with the overnight stay.

Health conditions are also considered serious if they require continuing treatment by a health care provider. Such conditions include:

Incapacity plus treatment involving a period of incapacity of more than three consecutive, full calendar days, with follow-up treatment;
Any period of incapacity due to pregnancy or prenatal care;
Any period of incapacity due to a chronic serious health condition requiring health care provider visits at least twice a year and recurring over an extended period;
A period of incapacity due to a permanent or long-term condition for which treatment may not be effective but requires the continuing supervision of a health care provider; and
Conditions requiring multiple treatments, which specifically include surgery after an accident or other injury, or a condition that would likely result in incapacity of more than three days without treatment.

By Jessica Rogers|March 13th, 2023|Compliance, Employee Benefits, Employee Communications, Human Resources, Legislation, Medical, U.S. Department of Labor|Comments Off

Over Half of U.S. Private-sector Workers Are Enrolled in HDHPs

Broad Reach Benefits, Employee Benefits, Human Resources, Medical, Private Health Care Exchange, Voluntary Benefits

Over Half of U.S. Private-sector Workers Are Enrolled in HDHPs

More than half (55.7%) of American private-sector workers were enrolled in high deductible health plans (HDHPs) in 2021, according to the Kaiser Family Foundation’s recent 2022 Employer Health Benefits Survey. The 5.3% increase from 2020 is the highest on record, and 2021 is the eighth straight year an increase has occurred.

The top three states with the highest HDHP enrollment were Maine (76.2%), Tennessee (68.7%) and Nebraska (67.6%), all of which were not seen breaking the top 10 in HDHP enrollment in 2020.

HDHPs are on the rise because of the growing costs of health insurance. These plans create a more flexible way for someone to spend their health care dollars and require more active involvement in the management of health care spending. HDHPs also allow enrolled individuals to set aside pre-tax dollars for out-of-pocket health care expenses when combined with health savings accounts and health reimbursement arrangements.

What’s Next?

Employers continue to prioritize HDHP plans over preferred provider organization (PPOs) and health maintenance organization (HMOs), most likely due to cost savings in a time of economic uncertainty. Employers must consider implications of their offerings in the midst of a tight labor market.

To stay in tune with employee needs, employers should stay up to date with HDHP trends in the upcoming years.

Contact Alera Group for more information on trends near you.

By Jessica Rogers|March 8th, 2023|Broad Reach Benefits, Employee Benefits, Human Resources, Medical, Private Health Care Exchange, Voluntary Benefits|Comments Off

President Biden Announces Anticipated End of COVID-19 National and Public Health Emergencies

Employee Benefits, Employee Communications, Health Care Reform, Human Resources, Legislation, Medical

President Biden Announces Anticipated End of COVID-19 National and Public Health Emergencies

On January 30, 2023, President Biden issued a Statement of Administration Policy announcing his intent to extend the COVID-19 national and public health emergencies (collectively, “COVID-19 Emergencies”) set to expire on March 1 and April 11, respectively, until May 11, 2023. While the COVID-19 Emergencies have not officially been extended at this time, if they are extended through May 11, 2023, then they will end on that date.

This announcement comes more than 3 months prior to the anticipated end of the COVID-19 Emergencies, and is intended to ensure that states, group health plans, health insurers, health care providers, and health plan participants, among many others, have sufficient advance notice, as the end of the COVID-19 Emergencies may trigger significant changes for health plans and employee benefits which are described in more detail below.

Employee Benefits Provisions Tied to COVID-19 Public Health Emergency

COVID-19 Testing

The Families First Coronavirus Response Act, which was enacted on March 18, 2020, requires group health plans (self-funded, fully insured, grandfathered, and non-grandfathered plans, but not excepted benefits such as dental or vision) and health insurance issuers to cover testing or certain other items or services intended to diagnose COVID-19 without cost sharing (deductibles, copays, or coinsurance), prior authorization, or other medical management requirements. It also permits federal agencies to implement the FFCRA through sub-regulatory guidance, program instruction, or otherwise. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which was enacted on March 27, 2020, expanded the FFCRA to, among other things, include a broader range of reimbursable COVID-19 diagnostic items and services that must be covered without cost-sharing, prior authorization, or medical management during the public health emergency, including testing provided by out-of-network (OON) providers.

As COVID-19 pandemic progressed and …

By Jessica Rogers|February 9th, 2023|Employee Benefits, Employee Communications, Health Care Reform, Human Resources, Legislation, Medical|Comments Off

Record Number of Americans Delayed Medical Care in 2022 Due to Cost

Employee Benefits, Human Resources, Medical, Wellness

Record Number of Americans Delayed Medical Care in 2022 Due to Cost

The annual Gallup poll found that a record number of Americans postponed medical care last year. In the survey, 38% of respondents said they or a family member postponed care in 2022, compared to 26% in 2021. The 2022 percentage is the highest figure since Gallup began tracking Americans’ postponed medical care in 2001.

The survey, conducted from Nov. 9 to Dec. 2, 2022, asked respondents about medical treatment within the past 12 months. Given the poll’s timing, most Americans said inflation is creating hardships for them, impacting their decisions to receive medical care. Moreover, it remains to be seen how quickly inflation will return to normal after a year and a half of unusually rapid increases. A full deceleration may well be a long process, pushing Americans to continue making health-related decisions based on cost.

Americans were more than twice as likely to report the delayed treatment in their family was for a serious rather than a nonserious condition or illness. In 2022, 27% of respondents said the treatment they delayed was for a “somewhat” or “very” serious condition, while 11% said it was “not very” or “not at all” serious.

Lower-income adults (an annual household income under $40,000), younger adults (aged 18 to 49) and women have consistently been more likely than their counterparts to say they or a family member have delayed care for a serious medical condition.

Takeaway

Not surprisingly, many Americans are deciding to hold off on medical care for financial reasons. This behavior is expected to continue as inflation strains Americans’ finances. Employers can help workers struggling with health care costs by sharing the following tips:

Use in-network providers to control the cost of health care services.
Consider the deductible and opt for …

By Jessica Rogers|February 2nd, 2023|Employee Benefits, Human Resources, Medical, Wellness|Comments Off

Assembling an Inflation-proof Benefits Package

Broad Reach Benefits, Employee Benefits, Employee Benefits Adviser, Human Resources, Medical, Voluntary Benefits

Assembling an Inflation-proof Benefits Package

Employers are becoming increasingly concerned about inflation’s impact on their employees, especially as the U.S economy faces the very real prospect of an upcoming recession. Many employers are searching for creative solutions to better support employees while navigating a competitive labor market. Many employers are building inflation-proof benefits packages to help employees counter inflation’s impact and address their attraction and retention struggles.

This article outlines employer strategies for assembling inflation-proof benefits packages.

Focusing on Comprehensive Benefits Packages

Many employers’ budgets are shrinking due to the current economic downturn. As a result, employers have fewer resources to allocate to employee compensation and benefits at a time when employee expectations remain high. With limited resources, employers can strategically invest in the benefits employees want and value most, such as cash incentives, flexible stipends, mental health support, enhanced leave options and financial wellness resources. Shifting to a holistic approach allows employers to provide employees with comprehensive benefits packages that can ease current inflationary pressures.

According to a recent Mercer survey, HR managers reported that they are considering expanding benefits offerings to maximize employee benefit spending in response to inflation. These benefits offerings include:

Financial wellness programs—Financial wellness programs go beyond retirement preparedness to focusing on all aspects of an employee’s financial well-being. These programs attempt to reduce financial stress as well as repair and increase an employee’s financial health by providing individualized financial guidance. Eighty percent of employers have started addressing employee financial wellness, and 63% expect to increase their financial wellness budget in the next one to two years, according to the Employee Benefit Research Institute’s 2021 Financial Well-being Employer Survey.
Voluntary benefits—Increasingly, employees expect their employers to provide voluntary benefits as part of a competitive benefits package. Many employers are …

By Jessica Rogers|October 25th, 2022|Broad Reach Benefits, Employee Benefits, Employee Benefits Adviser, Human Resources, Medical, Voluntary Benefits|Comments Off

Legal Update- FAQs Clarify Posting Requirement for Machine-readable Files

Compliance, Employee Benefits, Employee Communications, Human Resources, Medical

Legal Update- FAQs Clarify Posting Requirement for Machine-readable Files

On Aug. 19, 2022, federal agencies released FAQs implementing certain health care transparency requirements, including the requirement that health plans and health insurance issuers disclose on a public website detailed pricing information in three separate machine-readable files (MRFs). The files must be publicly available and accessible free of charge without any restrictions.

Health Plans Without Public Websites

The FAQs address the common situation where a group health plan does not have its own public website for posting the MRFs (or providing a link to where the MRFs are publicly available). According to the FAQs, health plans are not required to create their own public website for purposes of providing (or linking to) the MRFs. This guidance applies even when an employer maintains its own public website but does not have a public website for its health plan. The FAQs clarify that a plan may satisfy the MRF disclosure requirements by entering into a written agreement under which a service provider (such as a TPA) posts the MRFs on its public website on behalf of the plan. However, employers should monitor their service providers to ensure they comply with this requirement. According to the FAQs, a health plan violates the MRF disclosure requirements if its service provider fails to comply with a written agreement requiring it to publicly post the MRFs on the plan’s behalf.

Enforcement Dates

While the MRF requirements are applicable for plan years beginning on or after Jan. 1, 2022, federal agencies deferred enforcement of the first and second MRFs related to disclosing in-network and out-of-network data until July 1, 2022. Enforcement of the third MRF relating to prescription drugs is delayed until further notice.

By Jessica Rogers|September 26th, 2022|Compliance, Employee Benefits, Employee Communications, Human Resources, Medical|Comments Off