Spousal Carve Out Still An Option

You might remember reading our May 2012 newsletter on whether or not spousal carve out would be allowed after 2014.  At the time, we were unsure how spousal carve outs would be affected and our debate was centered around two main points: The PPACA requirement that coverage must be offered to all employees and their dependents and the fact that legislative intent does not mandate how the final law is interpreted. Now that we now the PPACA definition of “dependent” specifically excludes spouses, disallowing or charging extra for spouses who have access elsewhere is a good way to make sure employers can continue to offer compensation by way of rich benefits right now.

There are several different options for employers looking to save benefit dollars by implementing some type of spousal carve out.

·    Spousal surcharge – employees are charged a fee each pay period when they choose to enroll a spouse that has access to group coverage from their own employer

·   Spousal Exclusion with a monetary limit – spouses can enroll in coverage only if their own employer sponsored coverage is more expensive

·    Spousal Exclusion – spouses can enroll in coverage if they are unemployed or they do not have access to group coverage from their own employer

As you may expect (and have probably already noticed) more and more employers are choosing to implement one of the options above.  Once an employer decides which type of spousal carve out will best fit their needs, the next question becomes “how do we ensure compliance?” Without a full documentation verification (including a Spousal Affidavit signed by the Spouses Employer AND page one and two of a redacted Tax Return), studies suggest that only 44% of employees will “tell the truth” and comply with the new policy.

Over our five year history of verifying dependent eligibility for employers, we have dozens of working spouse verifications under our belt—we may have even verified a plan for one of your clients. Here, you’ll find three client case studies outlining some best practices and significant learnings. 

Client A: Spousal Surcharge

Operational Goal:

To implement new spousal surcharge as cost saving option in the wake of health care reform.

Business Challenge

As a brand new auto-manufacturing plant, Client A had a benefit program that was appropriately rich for its industry but significantly better than the majority of other employers in the region. Client A wanted to set the stage as a caring and responsible company in the way it treats its employees without becoming the default insurer for the area.

Implementation:

Client A determined that it would offer coverage to working spouses with a spousal surcharge. Spouses with access elsewhere who enroll in Client A’s coverage must pay $46 per pay period, which served to push spouses toward their own coverage while still offering the option to be on the client’s plan if the spouse’s employer plan was more expensive.

Spouses can have coverage without a surcharge if…

·         they are not employed.

·         they are also employed by Client A

·         they don’t have access to medical benefits at their employer.

Verification:

ContinuousHealth’s DA² dependent verification. The audit identifies ineligible dependents as well as informing on spousal coverage using proprietary software.

A spousal affidavit included in each audit packet required sign off from the employee, the spouse and the spouse’s employer. That reduces the likelihood of confusion or fraud, since the spouse’s employer is answering questions about current coverage rather than the spouse. ContinuousHealth also suggested requiring the second page of the tax return to generate more accurate representation of spouse unemployment/employment status.

Results:

As a fully-insured plan, cost savings are greatest when ineligible dependents resulted in tier changes.

○        21.8% of those who were in EE+ Spouse tier changed to EE Only

○        14% of those in EE+ Children changed to EE Only

○        5.3% of those in Family moved to EE Only

       With those tier changes, Client A saw extended savings of $635,000, in addition to any increased plan dollars from the spousal surcharge. After the success of the project, the client decided to integrate the ContinuousHealth software to verify both dependent eligibility and spousal exclusion in-house. This ensured HIPAA-compliance and streamlined the enrollment process.

Client B: Spousal Exclusion with Monetary Limit

Operational Goal:

To implement a spousal exclusion in order to continue to offer an affordable and rich benefits plan.

Business Challenge:

As a well-respected leader in the grain industry, Client B is very focused on providing just business practices, including having a compliant plan, and on treating employees well.

Implementation:

Client B’s consultant walked the client through best options and they decided to offer coverage for working spouses if the employer’s coverage was more expensive than being on Client B’s plan. This would apply only to traditional major medical coverage, which also serves to encourage adoption of the new consumer plan.

Spouses can have coverage if…

·         they don’t have access to major medical at their employer.

·      they have access, but the least expensive single plan offered costs the spouse more than $190 per month.

·         they are also employed by Client B.

·         they are unemployed.

·         they are on secondary coverage and are enrolled in their own employer’s coverage with no contributions to an HSA.

Verification:

ContinuousHealth’s DA2 dependent verification. The audit identifies ineligible dependents as well as informing on spousal coverage using proprietary software. A spousal affidavit included in each audit packet requires the employee, the spouse and the spouse’s employer’s signature and proprietary technology notes all results.

Results:

The audit identified 9.2% of dependents on group plan as ineligible for coverage, a first year savings of $658, 000. That represents 3.8% of Client B’s total annual budget for health care. Spousal verification identified that 11.3% of spouses are only eligible for secondary coverage and about 8% are only eligible for dental and vision, based on the response of the spouses’ employers.

Rather than burdening Human Resources with the project after the initial verification ended, Client B decided to continue using ContinuousHealth to verify dependent eligibility and spousal exclusion. Ongoing costs are minimal compared to an initial project, and the transition to ongoing was seamless.

Client C: Spousal Exclusion with Employer Premium Percentage Limit

Operational Goal:

To find a third party solution for current spousal exclusion practices.

Business Challenge:

The Architecture and Planning company had tried to do a dependent verification last year with a well-known audit company, but Client C had been displeased

Implementation:

Client C had a policy in place that offered coverage for working spouses only if the employer portion of spouse’s premium was low.

Spouses can have coverage if…

●        they are not employed.

●        they don’t have access to group coverage at their employer.

●   they have access, but the spouse’s employer’s group plan requires that the spouse contribute more than 50% of total annual premium.

Verification:

ContinuousHealth’s DA2 dependent verification. Client C was interested in feedback about ContinuousHealth’s responsiveness and educate/assist approach, something it had not found in the last firm. The process would identify ineligible dependents while streamlining the current working spouse verification. A spousal affidavit included in each audit packet requires the employee, the spouse and the spouse’s employer’s sign off.

Results:

The audit identified 7.70% of dependents on the group plan as ineligible for coverage. Despite the recent verification with the other audit company, 4.4% of the dependents were self-identified as ineligible once the plan requirements were outlined to them with the offer of amnesty. Employees opted out 8.4% of the spouses on the plan after reviewing the spousal carve out requirement, even though these were known requirements that had been in effect for over one year.

After the success of the project, Client C decided to continue using ContinuousHealth to verify both dependent eligibility and spousal exclusion on an ongoing basis.

If you’re working to implement a working spouse policy for one of your clients, let us know if we can help. We would love to talk through the options with you and help you serve your client through that transition.

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Need to provide medical coverage to everyone over 30 hours? Maybe not.

Who is a full-time employee? The answer might be worth millions of dollars.

On August 31, regulators issued long awaited guidance for employers on who must be treated as a full-time employee under the employer responsibility provisions of the Affordable Care Act. With over 700 employers on our CHROME Compass Platform, we are able to provide an initial assessment of the impact of this guidance on employers in various industries. The bottom line? At first blush, it appears that these regulations continue the trend of being "employer friendly". The mandated expansion of coverage to all employees above 30 hours a week has been the single largest budget issue for employers. This is especially true in multi-site retail, hospitality, staffing, and non-union manufacturing. The Look Back\Stability Safe Harbor outlined in the latest regulations potentially provides a means for employers to mitigate the costly effects of expanding coverage through at least the end of 2014. Like so many other things in the ACA however, navigating the most successful strategies to accomplish a particular outcome may be more complex than they appear.  In the same way that we have proven "Play or Pay" analysis to be an overly simplistic and largely unhelpful approach, a simplistic view of this latest regulation may leave employers with a strategy that is sub optimized (or even inconsistent) with their human resources and compensation strategies for segments of their population. Our Certified CHROME Compass Consultants are uniquely positioned to help their clients and prospects take advantage of the nuances created by this latest regulation. Let's take a brief look at several of the issues and definitions that create potential opportunity for many Employers for whom expanding coverage creates a budgetary challenge.

The regulation introduces several new definitions which will necessarily cause employers to thoughtfully reconsider their eligibility guidelines. In a nutshell, the regulations allow the employer to establish a Standard Measurement Period during which they will evaluate whether or not the Variable Hour Employee worked, on average, more than 30 hours a week. The Standard Measurement Period can be not less than three months or not greater than 12 months. If it is determined during the Standard Measurement Period that the employee worked more than 30 hours a week they must be eligible for medical benefits (or the employer is subject to a penalty). Furthermore, they must be offered benefits for the entire length of a Stability Period that is at least six months but not less than the total length of the Standard Measurement Period regardless of the average number of hours they work during this subsequent period. If they don't work more than an average of 30 hours a week during the Standard Measurement Period, then they can be excluded for coverage during the length of the associated Stability Period without the Employer being subject to a penalty – even if the employee enrolls in subsidized coverage in the Public Exchange during this period. Confused yet? Additionally, the employer has the ability to insert an Administrative Period that may neither reduce nor lengthen the Standard Measurement Period or the Stability Period. This Administrative Period can be up to 90 days.  The rules are slightly different for ongoing employees and newly hired employees after January 1, 2014.

Now that we have this guidance, what should an employer do? As we have continued to say since the passage of Health Care Reform, there is no single right or wrong answer. Rather, there are a number of viable strategies to implementing this provision, which need to be evaluated in light of the actual makeup of the employer's workforce and their human resources and budget objectives. Of particular interest to human resources executives will be the desire to balance between administrative simplicity and cost optimization. At least one of our CHROME Clients has already observed that they are likely to adopt a simplistic approach primarily driven by the fact that their existing benefits administration technology is not capable of tracking these issues.  But is the simplest answer the most correct answer? In what we feel is a departure from the apparently "one-size-fits-all" spirit and intent of the Affordable Care Act, this latest regulation allows the employer to use Measurement Periods and Stability Periods that differ either in length or in their starting and ending dates for different categories of employees. While the allowed categories are limited, it is interesting that one of the categories allows an employer to have different rules for employees of different entities or employees that are located in different states. Based upon our initial analysis with several existing CHROME Compass employers, we believe this provision creates some "opportunity" for employers to customize their eligibility guidelines to more specifically meet their human resources and cost objectives. The degree of customization will necessarily increase administrative complexity but the trade-off may be well worth the effort.  We have been making the observation for quite some time that Health Care Reform will place new requirements on employers’ benefits administration platforms, this regulation appears to highlight some of those new requirements.

What actions do employers need to take now? First of all, not all employers have a "Fair Access Index" exposure. Said another way, many employers are already offering coverage to all employees who work more than 30 hours a week. Over half (54.8%) of the employers on the CHROME Compass platform offer acceptable coverage to all of their employees above 30 hours. But for employers who don't, this regulation suggests some immediate analysis, and perhaps some changes in 2013, may be warranted.

The analysis begins by applying a dynamic computer model to hour and wage data for all likely variable hourly and seasonal employees over a 24 month period. Because ongoing employees and new hires can be treated differently, the model must perform analysis that segregates the current employee population by hire date. The dynamic model then illustrates the impact of different length measurement periods and stability periods for each population.  Because of the ability to analyze the employee data in separate categories, consultants also need  the ability to analyze the information to determine whether different periods by employee category might be worth the increased administrative complexity. Depending on the outcome of the analysis, it may be prudent for the employer to make some tactical changes in the way they classify employees in 2013, in order to better reinforce the position they would like to take of the Variable Hour Employees on January 1, 2014.

One of the critical definitions outlined in the regulation is for Variable Hour Employees. "For the purposes of this notice, a new employee is a variable hour employee if, based on the facts and circumstances at the start date, it cannot be determined that the employee is reasonably expected to work on average at least 30 hours per week.  A new employee who is expected to work initially at least 30 hours per week may be a variable hour employee if, based on the facts and circumstances at the start date, the period of employment at more than 30 hours per week is reasonably expected to be of limited duration and it cannot be determined that the employee is reasonably expected to work on average at least 30 hours per week over the initial measurement ."  How does the employer currently refer to job classes that are likely to fit into the Variable Hour Employee definition? Does their current treatment reinforce the employer taking the desired position with regard to the facts and circumstances and the reasonable expectation that these employees will not work over 30 hours over the course of the initial measurement? How will typical employee turnover affect this analysis? What changes need to be made to recruitment materials, employee handbooks, and management training?

As we move closer to January 1, 2014, there will continue to be a series of regulations that we expect will be much like this one. They will provide much-needed clarification around the legislative mandates created by the Affordable Care Act. While these regulations may be complex, we believe they will also create opportunities for leading employers to pragmatically apply them to specifically meet their human resources and budget objectives. A consultant that has laid the groundwork in regards to the conceptual framework and issues brought on by ACA, supported by dynamic financial modeling, will be in the best position to guide their clients’ decision-making over these next 12 months. As always, ContinuousHealth is here to help. We are grateful for the opportunity to deploy our analytic tools across a wide variety of employer environments. Our Certified CHROME Compass Consultants continue to challenge us to provide the most relevant and useful planning platform available. We plan to continue to work tirelessly to be up to this challenge. 

This article was first featured in the September 19th edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Why Are Your Highest Paid Employees Paying the Least Amount for Their Benefits?

How ACA Turns the Current System on Its Ear

Today, everyone who has employer-provided insurance is receiving a federal tax subsidy. You don’t often think of employee benefits that way, but it’s true. Employers get to exclude their contributions as a business expense under IRC §105, §106, and §162. The employees get to deduct their portion of the premium from their wages pre-tax under IRC §125, reducing their FICA liability. Employers also see a matching benefit under FICA when employees deduct pretax, even not-for-profit employers, who typically don’t get the benefit of deducting benefits as a business expense because their marginal tax rate is zero.

This current system of federal tax subsidy towards employer provided insurance is a significant incentive for employers to allocate a portion of employee compensation in the form of benefits, especially contributions towards medical plans. Because of the current tax system, a dollar of compensation paid in the form of benefits is worth more than a dollar. It is worth more than a dollar for the employer and it is worth more than a dollar for the employee.

Most employers have a single contribution structure for all wage classes. This contribution strategy creates a regressive tax situation. The highest income individuals receive the greatest benefit, because they have the highest marginal tax rates. As a result, your highest paid employees are paying the least amount for their benefits.

    Let’s look at an actual employer on our CHROME Compass platform:

In this example the employee contribution for Employee Only coverage is $150 a month ($1,800 annually). A single employee at 100% of the Federal Poverty Line (roughly $11,000) , would pay $1,460 for that coverage after we account for the benefit of pre-tax deduction. A single employee at 600% of the Federal Poverty Line (roughly $67,000) would pay $1,316 after-tax for the same exact coverage. That’s a benefit of $144 – almost a full month’s contribution.

    

The effects are magnified when we look at family coverage. For the same employer plan, the Family coverage contribution is $480 a month ($5,760 annually). An employee with a spouse and two kids at 100% of the Federal Poverty Line (roughly $23,000) would pay $4,667 for that family coverage, after-tax. An employee with a spouse and two kids at 600% of the Federal Poverty Line (roughly $138,000) would pay $4,283 after-tax for the same exact coverage. That’s a benefit of $384.

Currently, individual health insurance does not receive tax favorable treatment; ACA created a system of tax favorability for the individual insurance market. It took this current system, which disproportionately favors higher income individuals, and flipped it on its ear. In 2014, when the largest of the provisions under Health Care Reform take place, there will be a new system of federal tax subsidy towards insurance. The new system will be available to those with household incomes below 400% of the Federal Poverty Line ($44,680 for a single and $92,200 for a family of four today) as long as they meet certain eligibility criteria.

Those eligible employees will receive subsidy in two forms. Premium Credits that will limit the amount they pay for their health insurance and Cost-Sharing Subsidies that will cover some of the out-of-pocket expenses not covered by the health insurance plan. This new system operates on a sliding scale with those at 100% of the Federal Poverty Line, the lowest wage individuals, receiving the greatest benefit.

So, the compelling question is, “so what?” If your clients are in this situation, do they care? Did they do this on purpose or, when presented with this data, are they interested in pursuing a different strategy. We have often said that health care reform presents the greatest opportunity in our lifetimes to get employers to think differently about how they allocate compensation toward benefits. For Certified CHROME Compass Brokers and Consultants, this outcome presents a tremendous opportunity to keep current clients loyal and attract new clients. While some competitors are just now figuring out how to run a rudimentary “play or pay” analysis, CHROME Certified Brokers and Consultants are helping their clients craft intentional strategies that are aligned with their corporate objectives and values.  The journey has just begun.

This article was first featured in the July 17th edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Turn Health Care Into A Competitive Advantage - Not a strategic threat

As many of you know, CHROME Compass is our proprietary modeling and planning platform providing a strategic framework for employers to understand and evaluate the impact that health care reform will have on their group health plans. In technology terms, it’s a crowd-sourced tool:  every consultant we work with, every ERISA attorney or benefits specialist we engage, introduces new and useful components to the tool. As a result, this predictive health care reform modeling tool is the best in the market. You know this, because many of you have had us analyze your clients’ plans. For those of you who have not yet gotten the chance to work with the CHROME Compass tool, continue reading for a case study that highlights the technology’s capabilities.

Current Direction

A certain de-identified company has 1,203 employees who work more than 30 hours per week, with current benefits eligibility beginning at 32 hours per week. They have 940 employees participating in their single plan, with 140 waiving coverage and 123 ineligible. They have a BCBS PPO plan that is fully insured and considered non-grandfathered. An initial review with the Compass tool revealed that their total plan cost is less than the national average while their employee contributions are higher, especially on family coverage.

Compass Heading

The CHROME Compass pointed the way to a three-year strategy to address plan savings and requirements of health care legislation. CHROME Compass recommended gradually adjusting the actuarial value of the plan to the mandated 60% by 2014, which would reduce possible adverse selection among employees eligible for subsidies. Compass also suggested offering excepted benefits as a way to enhance the overall compensation value despite a decrease in the major medical. They had already added voluntary benefits and employer-paid basic life in 2010, plus long-term disability for the higher paid in 2011. Strategies for “fair” employee access include creating coverage provisions for spouses who have access to other benefits, conducting full documentation verification for dependents added to the plan and moving to eligibility management integration with vendors to reduce theerror (and fiscal consequences) of manual eligibility management.

Results

·         Health care budget reduced by 33^%/3 years

·         21^% Employer/Employee combined savings

In this case, CHROME Compass points to a three

year plan that has potential to reduce the employee

benefits budget by 33% for the employer. Employer

and employee savings combined represent 21%

savings.

The Compass-optimized plan for 2014 would save this company over $1 million dollars compared to maintaining their current plan and nearly $3.5 million compared to terminating.

Competitive Advantage

ContinuousHealth and our CHROME Compass  are here to help turn health care into a competitive advantage for your clients rather than a strategic threat.

Contact us today for more information about this powerful tool:

    Jennifer Riley: (678) 335-0448 

    Rachael Foster: (678) 397-0071

or email: chrome@continuoushealth.com

This article was first featured in the July 17th edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Feds Can’t Force Medicaid Expansion – Good or Bad News for Employers?

As many of you know, we try our best to be apolitical when it comes to interpretation of various legal and regulatory updates. There are plenty of other outlets for that. We are focused on the impact on employers and their employees. So when the most significant new development created by the SCOTUS decision centers around Medicaid expansion, we immediately analyzed the potential impact on employers.  Let’s walk through the ruling and the potential outcomes and what it means to you and your clients.

While I was personally surprised with the SCOTUS outcome (and impressed by the nuanced maneuvering around the Commerce Clause issue), I want to focus on the “new” stuff we must now consider because of the ruling. Specifically, will states opt in to the expanded definition of Medicaid? And if they don’t, how will employers in those states be impacted?

In a bit of a surprise, the majority opinion, authored by Chief Justice Roberts, found the Medicaid expansion to be constitutional in part and unconstitutional in part. The opinion upheld Congress’s right to stipulate the conditions under which federal funds are used by states; however, the opinion also found the threat of a state losing all of its existing Medicaid funding if it elected not to participate in the expansion to be unduly coercive. Consequently, the decision maintains the expansion of Medicaid provided for under PPACA as optional to all states, by prohibiting the Secretary of Health and Human Services from discontinuing funds for existing Medicaid programs for those states that choose not to participate in the expansion.

So, what does this mean?

Well, this means that the twenty-six states that brought suit gained a partial victory: they won’t lose any existing funding if they choose not to participate in the expansion. Elected officials for many states have already issued statements regarding the ruling. The governor of Washington, one of the 26 plaintiffs that brought suit, has indicated that her state most likely will participate.

This, however, does not necessarily mean that all twenty-six will choose to participate. Lieutenant Governor Tate Reeves has expressed serious doubt about Mississippi’s likelihood of opting to expand Medicaid. "An expanded Medicaid program would add almost 400,000 new enrollees and cost the state an estimated $1.7 billion over the next ten years. Mississippi taxpayers simply cannot afford that cost, so our state is not inclined to drastically expand Medicaid.” Nebraska Governor Dave Heineman also expressed concerns about the impact the Medicaid expansion would have on other state programs, calling the expansion “unfunded.” As of the date of this newsletter, other participating states, such as Idaho, have not yet released statements regarding the decision. Just yesterday, Rick Scott from Florida said they won’t expand while certain Republican members of the legislature said they would. I guess we are in store for some more wrangling over the next several months.

But back to the point - how will this affect employers?

In states that elect to expand Medicaid eligibility, all individuals with household incomes below 138% of the federal poverty line (FPL) are eligible to receive coverage through Medicaid. When they enroll in this coverage, employers are not penalized.

In states that elect not to expand eligibility, all individuals between 100% and 138% FPL would be eligible for premium tax credits and out-of-pocket subsidies at the Exchange if the employer’s coverage is deemed unacceptable or unaffordable. If an individual receives a tax credit, their applicable employer will be subject to the $3,000 tack-hammer penalty.

So, by not expanding Medicaid eligibility, a state may be increasing the potential liability for their employers. This will especially be true for businesses with lower wage part-time employees such as retail and hospitality.

How will this affect you?

States now find themselves in a tenuous situation where, if they choose not to expand eligibility, the lowest income working adults will not have access to affordable insurance, and employers in that state will potentially be subject to higher penalty. For the first 3 years, the eligibility expansion is 100% federally funded, tapering off to 90% by 2020; however, the federal funding is for coverage only and does not extend to increased administrative costs. The administrative burden of handling the new potentially eligible Medicaid recipients can prove costly, as expressed above by Mississippi Lieutenant Governor Tate Reeves.

In short, while the Supreme Court’s decision provided some clarity around the fate of PPACA, it also raises many questions and increases the likelihood of future changes. We anticipate that most states will develop projections to examine the impact of both expanding and opting out, as either decision carries significant impact. Based on those decisions (*Opportunity Alert*), employers will look to their brokers for guidance and strategy. As you would expect, we have already modified our CHROME Compass platform to model the various scenarios and the impact on employers.  Over the next couple of months we’ll discuss strategy and outcomes in more detail.

This article was first featured in the July 3rd edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Health Care Reform: Let's Not Wait and See

A March Wall Street Journal Article, “Health-Care Law’s Many Unknown Side Effects,” quotes Paul Keckley, the head of the Deloitte Center for Health Solutions, as saying, “If my competitor drops benefits, I’d want to be out the door just behind them.”

Would your clients agree? Where do they stand with changes that health care reform will bring? Are they planning to make changes once you let them know what other companies are doing, post factum? Are they approaching health reform by watching their competitors? Monkey see, monkey do?

We’ve been stewing ever since we read that March article, which closed with a completely unhelpful warning:

“Beware the facile, confident prediction about what the health-care law will yield. Nobody really knows.”

That line goes against everything we believe about competitive strategy. The health care law has significantly altered the structures and incentives which influence employer benefit plans. The primary tools of reform – where people get their coverage and how much money the federal government subsidizes – are going to be with us for the long haul. As one of your clients recently commented, “I cannot be 100% certain where the cost of cotton is going to be in twelve months either, but it doesn’t keep me from critically looking at different cost models and determining how our strategy should change.” 

The macro trends which have affected employer plans over the past 10 years (excessive inflation, changing tax policy, and changing importance of alternative markets) were with us before health care reform and will be with us regardless of the outcome of the election. Doug Elmendorf of the Congressional Budget Office stated, as he testified before Congress in March 2011, “Many of the effects of the legislation may not be felt for several years, because it will take time for workers and employers to recognize and to adapt to the new incentives.”

Our argument is that leading employers will not be the last to know. If they are, they will no longer be leading employers. We believe that health care reform provides the single greatest opportunity in our lifetime for businesses to rethink how they allocate compensation toward benefits. Leading brokers and consultants are talking to their clients (and prospects) about how they can turn benefits into a competitive advantage, instead of a competitive threat. Cost containment and risk management strategies are still important, but understanding the underlying strategic levers that have been highlighted in the latest reforms provides “real” differentiation. 

So do what we’re doing: counter the “facile, confident predictions” with the arduous but profound work of scenario-based modeling. Get strategic plans in place for each of your clients, because our argument is true for you, too: leading consultants will not be the last to respond to health care reform, and if they are, they will no longer be leading consultants.

Eric Helman

This article was first featured in the June 5th edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services

Who can say if PPACA changed benefits for the better?

Employer-sponsored health insurance market has been eroding subtly and gradually over the past decade. Most employers have noticed the downward spiral in their plans, but they’ve been unable to effectively identify or counteract the issues. Changes to the health insurance market have been (and will continue to be) inevitable, regardless of the decision on health care reform. But many of your clients are now modeling one to three year strategies for their plans, using predictive modeling tools like our CHROME Compass.  These tools that were created as a response to health care reform, but they are also revolutionizing the way that employers see compensation.

Health care reform has changed the way everyone thinks about benefits programs… regardless of the decision.  Hear us out, and let us know if you agree.

While many in the employee benefits business are taking a “wait and see” attitude toward the Supreme Court deliberations and inevitable announcement in late June, others are taking a fresh look at their benefits program in light of the new opportunities and incentives created by health care reform. Is this a waste of time or are they gaining valuable insights leading to strategies that may increase their competitive advantages in their total employee rewards program? Won’t the game change entirely if health care reform is overturned?

Employer-sponsored health insurance was eroding long before health care reform

The rising cost of health insurance over the last ten years has significantly changed where people receive their coverage, how much they pay for it, and how much protection the benefit provides. Let’s start with a brief look at where people are receiving their coverage and how this has changed over the past decade. 

From 1999 to 2010, according to information from the U.S. Census, the number of people in the U.S. grew 10.6%. Surprisingly, the number of individuals who accessed health insurance at their employer dropped by 4.7%. Now, before you jump to a conclusion about changing demographics and the aging population, consider that when we look at the same data for the non-elderly (<65) population, we see an overall growth rate of 10.8% but a reduction in employer-sponsored health insurance of 5.7%. While the overall growth rate is within .2%, the reduction in the number of non-elderly individuals who accessed health insurance at their employer is greater by 1%.

Older people are staying on their employer plans longer. This is surprising, especially in light of the significant migration in benefits away from retiree health programs during this same time period.  Unfortunately, the corollary is that younger employees must be leaving their employers’ plans at a disproportionately high rate, accelerating the impact of rising health care costs on employer plans.

The second conclusion you might want to explore is whether the most recent recession and the reduction in employment is a major contributor to this erosion. Here again, the data says otherwise. Using the same period from 1999 to 2010, the Bureau of Labor Statistics reports the number of employed Americans actually grew from 133.5 million to 138.9 million (4.1%). While this obviously did not keep pace with population growth, it was still positive growth and does not explain the sharp reduction in employer-sponsored coverage over this time period.   

So, if people are leaving employer-based coverage, where are they going?

The answer, in terms of percentage growth from highest to lowest, is Medicaid (+78%), military (+51%), uninsured (+32%) and Medicare (+20%).

And remember, this is without health care reform. 

The erosion of the employer sponsored health insurance market has been both subtle and gradual. For this reason, most employers have been unable to effectively identify or counteract this downward spiral in their plans. Changes to the health insurance market have been (and will continue to be) inevitable as long as the growth in cost outpaces overall growth rates.

Enter health care reform.

In the words of Doug Elmendorf from the Congressional Budget Office, “Many of the effects of the legislation may not be felt for several years, because it will take time for workers and employers to recognize and to adapt to the new incentives.” Employers who were drawn to model the impact of the dramatic reform changes are not only better prepared for health care reform, but they have also gained insights into the erosion they have been experiencing over the past ten years. 

Health care reform changes the mandated eligibility requirements in three of the five health insurance markets (Medicare, employer and individual) while at the same time significantly changing the tax structure in all three of these markets. Among other things, health care reform attempts to reduce the number of uninsured people in this country by offering new opportunities and incentives which affect three existing markets. Health care reform mandates expanded eligibility for both Medicaid and the employer markets. The individual market, too, is significantly reformed with the elimination of medical underwriting and, for the first time ever, significant tax subsidies for individual premiums are equal to or greater than those available in the employer market. 

By analyzing the potential impacts of these accelerated market shifts brought on by health care reform, employers are gaining valuable insights into what has been happening to their plans for the past 10 years. Whether health care reform is overturned or not, these employers are leveraging these insights to plot new strategies that are more proactive and intentional – transforming them from victims of health care inflation to strategic players in the allocation of employee compensation.

The light switch

Over 600 employers are now using our proprietary CHROME Compass planning platform to conduct the detailed analysis required to truly understand the intricate interdependencies of alternative insurance markets and tax policy changed by health care reform. In light of the upcoming Supreme Court decision, we asked many of these customers what insights they are gaining from the detailed modeling around health care reform and what value they see in it if heath care reform is overturned by the high court.

The most common responses we received across our diverse group of clients were:

We had never really looked at where all the dollars were going, especially in the area of favorable tax treatment.

We had been feeling the erosion of our benefit plan over the years, but, with this, it was like someone flicked on the light switch and we saw where we are in an entirely new light.

We now know how to ask ourselves, “Is this where we want to be? If not, how do we begin to work ourselves into a new place?”

These employers were only moved to review their benefits program because of the legislation. Once these tools made them aware of the possibilities in overall compensation strategy, though, their benefits programs will never be the same. The light switch is on.

This article was first featured in the May 22nd edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Client Quote

“For the first time ever, I understand what the future holds for health care, and it’s not what I thought. There might be other reasons that I won’t want to grow by 120 units next year, but now that I have this data, health care reform isn’t one of them.”

CEO of a major children’s apparel company, after undergoing a CHROME Compass analysis

The C-Suite Engaging HR

In the fall, our firm was approached by a national CEO organization to write an article for CEOs on confronting the rising costs of health care. This group had heard overwhelming feedback from their C-suite members wanting help reducing costs for their health care plans.

Health care reform is already having consequences beyond plan reorganization. PPACA is transforming the landscape of compensation, and, as a result, is inciting action in the leadership that had previously left health care to human resources. The C-suite, and particularly the CFO, brings unique abilities to the dialogue on benefits that can direct a company toward success. It is critical that management, both functional and executive, understands the implications of health care reform in 2014 and beyond.

Increased collaboration between Finance and Human Resources

The number one issue facing businesses today is ambiguity about the future around health care. Ambiguity in changing regulatory guidelines and rising costs causes executives to feel uncertainty about growing their businesses. Business Finance Magazine, in the recent article, “Bridging the CFO-HR Divide,” by Trent Beekman, notes that the average company diverts 1/3 of its finances towards human capital, including benefits. CFOs should be familiar with such a significant portion of company cost.

As health care costs rise year over year, CFOs are recognizing their fiscal responsibility to research the effects of PPACA on their companies. C-level executives (who may have traditionally only stepped in once a year to review rising plan rates) are engaging in the health care discussion. They’re finding that even after necessary cost shifting to employees, changing plans and reducing benefits, health care costs are higher than ever, and they want answers on how to combat this.

One of the answers is coming in the form of changing total compensation programs. Despite rising health care costs, benefits offering must remain competitive in order to retain high-value employees. Compensation strategy must be created with health care reform tax incentives and mandates in mind, and, to quote Beekman, “It will require an all-hands-on-deck mentality.”

Understanding the options

The implications of PPACA will be different for every company. PPACA is transforming the marketplace, both in benefits strategy and in employee opinion of benefits. There are myriad options to best set up a plan strategy for 2014 and beyond, while at the same time offering great coverage to retain top talent. For a company to stay competitive in the years to come, it is crucial that it fully comprehends these options at their deepest level. Finance executives may be more receptive than their HR counterparts to new benefit approaches that take advantage of new structures and incentives created by health care reform. The Business Finance Magazine article points out:

“Historically, CEOs and presidents have made all decisions on human capital expenditures [such as health care], and while they often consult HR as part of that process, more often than not, CFOs are kept out of the loop. Giving CFOs a greater presence and voice in the process could help ensure that such important decisions are more fully vetted.”

Benefits plans are like any other aspect of the business: someone needs to be steering the ship to make sure it goes the right direction. My dad always said, “If the boat misses the harbor, rarely is it the harbor’s fault.” Benefits planning requires more than just setting a budget at the beginning of the year and relying on a human resources team to determine the specifics. The C-Suite has plans for managing every other aspect of the business—a strategic road map is necessary for benefits, too.

Remaining at the forefront

Our company works with senior executives every day to help them optimize their investments in employee benefits. In doing so, we see that, across industries, regions and business sizes, business leaders don’t have the most basic working knowledge about the new structures and incentives embedded in health care reform. Everything else is inconsequential until executives truly understand the implications of health care reform.

As we have been saying for several months, we believe health care reform is the single greatest opportunity in our lifetime to get employers to think differently about how they allocate compensation to benefit programs. The entity (whether a consultant or a carrier) that helps the C-suite with a health care reform response plan will have an excellent opportunity to prescribe a package of products and services to better meet the employer's needs (and escape the potential “trap” of fighting over the scraps left behind after major medical decisions are made).

Now is the time for employers to recognize and implement changes that will set them apart from their competition. The Towers article points out that "savvy organizations need to act now to responsibly assess the business implications, model different scenarios and consider the impact of each reform option on their entire reward program." Leading employers will not be the last to figure out the implications of health care reform. If they are, they will no longer be leading employers.

The CHROME Compass is the leading platform to facilitate this response plan. Certified CHROME Consultants are in the lead position to take advantage of the opportunities created by health care reform. But, as my Dad always says, “Eventually, even the dummies will figure it out.” There is a window of opportunity here. Let’s not miss it!


Eric Helman
CEO and Founder
ContinuousHealth
www.continuoushealth.com

This article was first featured in the March 13th edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.

Insights on the Uninsured in the Workplace

PPACA is designed to encourage the 51 million uninsured to enter the marketplace in 2014. Since this population has been largely unexplored, the management consulting firm Oliver Wyman did a survey of the uninsured in September, in efforts to uncover their demographics, healthiness, attitudes and preferences towards health care. Because we focus on employers and their benefit plans, we thought it would be interesting to look at these survey results in light of the currently “Waived” and “Ineligible” populations within employer environments. Of course, the number one source of “Waived” is likely to be employees opting to participate in their spouse’s employer-based plan, but let’s explore what insights this survey provides about those who are truly “Opting Out.”

Engaging coverage

The survey finds that when asked to choose between buying insurance and paying a penalty, 76% of the uninsured would elect to purchase coverage. The study based their analysis on the presence of an individual mandate and the commensurate penalties, provisions which may change in June, and the authors chose to model the full penalties under the individual responsibility provision of health care reform, which don’t take effect until year three.

Accepting future adjustment of the numbers after the Supreme Court rules, this 76% election, about 39 million of the currently uninsured, says something about our opt-in rates for currently waived and currently ineligible employees. The study notes that while “uninsured Americans overwhelmingly see value in coverage, few really understand their options…” This is true of health care today, including employer-sponsored coverage. Education can equal participation. As employers determine the best route for their plans in 2014, it is vital that consultants can assist employers as they communicate options to employees, both opted in and waived, in a way that will align with the benefits strategy. 

State exchange:  innovation or limitation?

The study’s authors make some interesting assertions about how this rapidly expanded individual market may cause a boom in product innovation.  Their argument is based upon the fact that we will have 39 million new “customers” making individual purchase decisions based upon their individual preferences.  This is in opposition to the current environment, where the majority of health insurance is purchased through an employer who has taken a “one-size-fits-all” approach to benefits. 

The study goes on to test the sensitivity of uninsured consumers as to their willingness to spend more based upon differences in product design.  The study outlines options that could reduce health care costs which interest different segments of the individual market, including wellness options that are currently part of some plans, like maintaining a healthy body weight or quitting smoking.  It also polled this group’s interest on options that are not widely available, like receiving a majority of medical care at retail clinic in a pharmacy or retail store to reduce costs, or paying extra for 24-hour-a-day, seven-day-a-week access to doctors. The authors conclude that this “is a promising situation for a retail market intended to push health care toward better, cheaper coverage.”  

But, as the authors accurately state, “It remains to be seen whether any or all of these specific alternatives will ultimately be permitted in the exchanges.”  It is equally possible that this marketplace innovation will be inhibited by the regulatory controls on the distribution mechanism.  Said another way, the fact that these new individual products must be distributed through public health insurance exchanges may act as a limiting factor on the innovation which would otherwise occur in a marketplace less regulated.

Income and subsidies

Not surprisingly, the single most determining factor as to whether the uninsured would purchase insurance (even in the presence of an individual mandate) was the net cost of the insurance premiums after subsidies, relative to family income.  (See the chart here for a breakdown that the survey details.)  Based upon the way the premium subsidies are constructed, the study found that middle income consumers are less likely to purchase insurance than the lowest income group. 

The study authors again insert an opinion as to how the future of health care reform may roll out.  They assert that there will be “significant pressure to reduce subsidies.”  They note this:

This price sensitivity could work against ACA.  Health care costs are rising… faster than the Consumer Price Index and the tax revenue that ultimately pays for government programs.  It will be difficult for the federal government to increase subsidies at the same pace as medical trend – especially if the eligible uninsured numbers continue to grow through layoffs and continued unemployment.

Health care is becoming more expensive at a rate faster than people are generating the income to pay for it. As a result, even though the affordability measure is set to index, which this article fails to mention, there is a chance that it won’t keep pace with medical inflation unless medical inflation slows.  More and more individuals can be expected to push over the 9.5% affordability threshold and be eligible for subsidized exchange coverage. To keep the total cost to the government system of providing subsidies, the threshold would have to rise year-over-year to make sure more and more people don’t become eligible. Incidentally, a provision for this was added during the reconciliation process.

The Three Groups of Uninsured

What we found most interesting was the identification by the authors about three distinct segments within the uninsured population. The segments they note are “Struggling and Unengaged,” “Want to be Healthier,” and “Engaged to Save.” (The chart below gives a summary of the information included in the article.) They highlight that the former two are similar to segments found in the employer-sponsored market.

We wonder, however, about the presence of the “Engaged to Save” segment in the employer-sponsored market today, as non-participants. This group contains uninsured who are lower middle class, a bit younger than the other two segments. They are healthy but price-sensitive, willing to do nearly anything to reduce their health care costs.  These are individuals who may have waived coverage in the employer-sponsored market, a decision that was likely spurred by cost-consciousness and a lack of education on the benefits. This is the group that employers can key in to if the best version of their plan in 2014 requires participation.

The survey authors draw an interesting conclusion about the differences among the three segments of uninsured Americans, stating that some of them “might be willing to trade the traditional broad network of doctors for discounts on healthy groceries.”  For employers who need to keep their employees on coverage to best optimize their plans, this could have implications for increased employer-sponsored options in wellness programs and excepted benefits. 

Looking ahead

As 2014 approaches, and as the decision from the Supreme Court in June looms ahead, employers must begin considering how PPACA will affect their company’s benefits strategies.  It is vital that employers have a tactical strategy in place, rather than reacting in response to the changes after they are in place.  Surveys like these will allow consultants and employers to be aware of the changing demographic, especially as it relates to waived and currently ineligible employees.

This article was first featured in the March 6th edition of our e-newsletter, Directions. If you'd like to receive that weekly email, contact directions@continuoushealth.com. (Your email will never be shared, sold, or otherwise distributed, and you will receive only the type of content for which you sign up.)

Follow ContinuousHealth on LinkedIn or on Twitter @chealthupdate for interesting articles, industry insight, and a first look at new products and services.