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.

Dealing with the Effects of PPACA

We think it’s pretty important to stay on the forefront of the research, and we like it even more when the research parallels what we’re finding in our day to day work with your clients. Last week, the International Foundation of Employee Benefit Plans (IFEBP) released results from the third survey in a series dealing with the effects of PPACA on single employer plans. The responding 968 employers were asked questions about the actions they’ve already taken and anticipate taking in the next two years as a result of PPACA. We reviewed the results and would like to share some of our insights.

Eliminating Coverage

A key finding was that only 1% of respondents stated they will definitely not provide coverage to all full-time employees in 2014, with 95.3% at least somewhat likely to continue to offer coverage. This is a dramatic shift from the 30-50% of employers likely to drop coverage reported in the June 2011 McKinsey Quarterly and more consistent with what we’ve seen from the over 600 employers on our CHROME Compass platform.

Doing the footwork

Curiously, employers have shifted their view on offering benefits coverage but many have not conducted an analysis on the impact of health care reform on their organization. The findings in the survey are somewhat conflicting with a reported 47.2% of respondents stating they “have conducted an analysis on how health care reform legislation will impact their health care plan costs,” but only 24.9% of respondents stating they “have modeled the impact of reform on our organization.”

Regardless, even in a best case scenario, slightly more than half of all employers have done nothing to anticipate the impact of health care reform. 

Nearly 70% of respondents expect increased benefits costs in 2012 due to health care reform, and even more interestingly, “those reporting their organizations had analyzed costs are slightly less likely to predict a cost increase”. In other words, slightly more than two thirds of employers surveyed are expecting a cost increase, but those expecting an increase are more likely to have not conducted a cost analysis. Perhaps this is because, in our experience, if employers do the math at a very granular level, they gain insights about health care reform that might actually allow them to lower their health benefits costs. Employers who have not done the analysis are influenced by the political debate instead of the facts as they apply to their particular situation.

Anticipating the Costs

Also consistent with what we have seen, respondents are already making changes to deal with increased costs, either thru increased contributions or plan design changes, and if they haven’t, they are planning to do so in the next two years.

The most popular strategy currently in use is increasing participant premium contributions (23.1% of employers). In the next two years, the most popular strategy employers plan on using is increasing contributions for dependent coverages (20.1%).

Despite the popularity, or perhaps because of it, we do issue a caveat on that strategy alone: PPACA has provided employers with new benchmarks as to what is considered “affordable” contributions. With somewhere between only 24% and 47% of employers having conducted an analysis, some of these employers may be making shifts blind to the impact it will have on their plans in 2014. While their decision to increase contributions may be the correct strategy, if they have not conducted the analysis, they might not fully appreciate the implications in light of the affordability benchmarks of PPACA.

Extending coverage to adult children (up to age 26) was identified as the top cost driver by 38.7% of respondents, more than any other one driver. Three major carriers recently stated that, regardless of the Supreme Court’s decision, they will continue to allow coverage for adult children, putting pressure on employers to continue to offer this popular and costly benefit to their employees.

Employers are also taking other measures to contain costs such as plan audits or analyses, with the most popular tactic being dependent-eligibility audits. Of the employers surveyed, 18.7% had already conducted a dependent audit and 14.7% are planning on conducting one in the next two years. These findings are consistent with the growth in dependent audits we have seen at ContinuousHealth:  100% growth year over year in initial audits, and nearly 200% growth in ongoing audits since PPACA. As we mentioned a few weeks ago, contrary to the pervasive belief that PPACA has decreased the need for dependent audits, we’ve seen average rate of ineligibles grow from 6.5% to 7.99%. Survey results seem to indicate that employers see this continued need as well.

Proactive, not Reactive

Based upon the current law, the major changes established in health care reform will take place in 2014, but employers have to make changes to their benefit plans now as a response to continuing price increases in excess of inflation. For most employers, there are still two open enrollments left before the bulk of the changes become effective. This survey highlights the fact that the majority of employers are making tactical decisions about their benefit plans without informed analysis regarding the single greatest external event to affect employee benefits in our lifetimes.

As Mark Bertolini (CEO of Aetna) said recently in a Wall Street Journal interview, PPACA has provided a catalyst to change the conversation around employee benefits. While not all employers will specifically change their strategies based upon healthcare reform, feedback from our clients leads us to believe enough employers will make adjustments. These adjustments are likely to influence the overall marketplace.  We believe the employers who “sit this one out” will be at a disadvantage as they attempt to align their investment in employee benefits with their recruitment and retention programs.

This article was first featured in the June 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.

Dependent Audit Case Studies, after PPACA

Client A is a small company in transportation and manufacturing.  Anticipating the changes required after 9/23, Client A modified its policy into a non-grandfathered plan with extended child eligibility to 26 at their 9/1/2010 plan renewal, in advance of the PPACA requirement.  At the time of verification, the company had been following the Age 26 rule for four months.  As a small company that had already implemented the health care reform changes, leadership expected to see low ineligible dependent numbers.  Instead, the Dependent Eligibility Verification found that 14.5% of dependents on the plan were ineligible.

Client B is a large retail chain with mostly white collar employees in a low-income tax bracket.  Its plan renewal was 2/1/11, and under its Ongoing Verification procedures, the company began verifying for the new health care reform categories in mid-January.  Client B implemented a grandfathered policy with an Adult Child Exclusion policy:  if an adult child was eligible for coverage under his or her own employer’s policy, that dependent was not eligible for the policy of Client B.  Open Enrollment numbers showed a 20% increase of enrollees to the policy, which fit with its expectations for the 2011 year. 

The big surprise, though, was the upswing of ineligibles:  during the original verification, between October 2009 and January 2010, the ContinuousHealth Dependent Eligibility Verification Audit found that 1,851, or 16.56%, of Client B’s 11,175 dependents enrolled were ineligible; during the first four months following the implementation of PPACA regulations, the ContinuousHealth ongoing dependent eligibility verification audit found 549, or 30.57%, of the 1,796 newly enrolled dependents to be ineligible for the new policy. This number was nearly double the findings of the original project, when the eligibility criteria were more stringent. Throughout the whole 2011 year, ineligible numbers came down, but were still considerably higher than the findings of the initial project, as between January and December 2011, ContinuousHealth identified that 26.84% of dependents did not meet the requirements to verify their eligibility for the plan. With the change in plan requirements under PPACA, Client B regularly found an increased rate of ineligibility by between ten and fourteen percent.

Client C is a major automotive manufacturing company with a non-grandfathered plan and a February plan renewal.  The company began verifying for new categories in mid-February.  Prior to health care reform provisions, the Dependent Eligibility Verification Audit identified 10.55% of enrolled dependents as ineligible. 

After enacting the Age 26 requirement and removing a residential requirement for stepchildren, the Ongoing Dependent Eligibility Verification found that 27.91% of new enrollees were ineligible during the first four months of PPACA.  For the 2011 year, Continuoushealth identified 24.1% of dependents on the plan were ineligible for coverage, a slight drop from the first few months.  Overall, Client C has found an increase of more than double the rate of ineligibles since PPACA.

Client D is a large hospital management system with 15 localized hospitals.  The management system did a Dependent Eligibility Verification Audit in 2010, prior to implementing health care reform at their July 1, 2011 plan renewal, with 13 of its 15 hospitals. The two hospitals who did not participate initially were both located in Massachusetts and were excluded because they were covered under “RomneyCare,” a set of provisions that representatives of President Obama have cited as a model for PPACA[1] and which have been called an “ObamaCare preview.”[2]

After the leadership team reviewed the results from the initial verification, the two hospitals in Massachusetts decided to undergo a ContinuousHealth Dependent Eligibility Verification Audit as well. The results were comparable with their non-Massachusetts counterparts:  the original verification found 10.1% ineligibles for hospitals that were not yet subject to PPACA; one Massachusetts hospital discovered that 6.34% of dependents were ineligible and the other found 9.64% of dependents were ineligible under the current plan guidelines.[3]

After the first plan renewal for the entire system under PPACA (7/1/2011), leadership requested that all hospitals undergo another dependent eligibility review.  The hospitals all had similar plan eligibility, all non-grandfathered with no spousal exclusions or surcharges. During that post-PPACA review in fall of 2011, ContinuousHealth identified 21.01% of the active dependents on the plan were unable to satisfy eligibility requirements. Specifically, the two hospitals in Massachusetts each found 10.29% and 16.19% ineligible during the second review. All hospitals saw an increase in ineligible dependents. The post-PPACA verification savings for Client D totaled more than $5 million in claims cost reduction. 

Client E is a national restaurant chain with hourly and salaried employees throughout the US. At the time of review, Client E had been following PPACA guidelines for 12 months. The Human Resources team systematically requested documentation for any new enrollees, but the client had not done full documentation verification. ContinuousHealth identified 6.08% of the plan participants were ineligible for coverage under the non-grandfathered plan guidelines. Ineligible dependents were primarily over the age of 18 years old and may have been added on the plan as “spouses” or “adult children,” though they were, in fact, unable to verify their eligibility as such.

 

	Client A	Client B	Client C	Client D	Client E
Industry	Transportation / Manufacturing	National Retail Chain	Automotive Manufacturing	Hospital Management System - 15 hospitals	National Restaurant Chain
# Dependents	350	11,000+	3,500	17,000+	1,300
Grandfathered or Non-Grandfathered	Non-grandfathered	Grandfathered:  Adult Children eligible for own employers’ plans were ineligible	Non-grandfathered	Non-Grandfathered; 2 Hospitals under “RomneyCare”	Non-Grandfathered
First Plan Renewal	9/1/2011, but implemented on 9/1/2010; Age 26 compliant for 4 months at verification start	2/1/2011; started verifying for HCR in mid-January	2/2011; started verifying for HCR in mid-February	7/1/2011	1/1/2011
Results	14.5% of dependents were ineligible, far higher than leadership expected	·  20% increase in Open Enrollment numbers ·  Original project in 2009-2010 found 16.56% of 11,175 dependents were ineligible ·  First 4 months of PPACA showed that 30.57% of the 1,796 newly enrolled were ineligible ·  2011 showed that 26.84% of the 2,724 newly enrolled were ineligible	·  Original DEVA found 10.55% of enrolled were ineligible ·  Post-HCR DEVA found 27.91% of new enrollees were ineligible ·  2011 showed 24.1% of the 1,229 newly enrolled were ineligible	·  Initial project:  10.1% ineligibles ·  2 “Romneycare” hospitals excluded from initial verification did a DEVA after seeing other 13 hospitals’ results ·  Results were comparable: RomneyCare project:  6.34% ineligibles in one and 9.64% in the other ·  Post-PPACA found 21.01% ineligible overall	·  Identified 6.08% of active dependents were ineligible
Financial Exposure Reduction	Over $184,960	·  Original project:  $4,995,000 ·  First 4 months of PPACA: $1,482,300 ·  2011 verification: $1,462,000 (with a decrease in claims cost)	·  Original project:  $1,114,345 ·  First 4 months of PPACA: $1,500,442 ·  2011: $929,144	Total savings:  $4,165,246	Total savings:  $262,833

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[1] Carol E. Lee, “White House Again Jabs Romney on Health Law,” Washington Wire, Wall Street Journal, http://blogs.wsj.com/washwire/2011/05/13/white-house-again-jabs-romney-on-health-law, (May 17, 2011).

[2] “National Health Preview:  RomneyCare’s bad outcomes keep coming,” Wall Street Journal, http://online.wsj.com/article/SB10001424052748703864204576313370527615288.html?KEYWORDS=national+health+preview+romneycare, (May 10, 2011).

[3] The hospitals from the original verification were also not doing document checks, while the two Massachusetts hospitals believed their employee document records were up to date, checking student status as well as IRS dependency, per their SPD.

Fact or Fiction? Health Care Reform Eliminates the Need for Dependent Eligibility Verification

Last week, I was on the phone with one of our broker partners from the Midwest and he made a comment along the lines of “with health care reform, a lot of the appeal of dependent eligibility verification projects was taken away.” Well, at the risk of being argumentative, I shared with him the results of our post health care reform study* that showed, rather convincingly, that dependent verification projects are more valuable than ever.

Since that study was produced, our total number of audits conducted has grown to over 1,100. We have completed twice as many audits this year as last and the number of clients signing up for our Ongoing Dependent Eligibility Verification Services has risen above 70%. Moreover, we are now executing projects where the client has already conducted an internal audit (or used another firm) and are seeing significant savings. Dependent eligibility audits remain one of the only ways to take 3-5% out of health care expenses without any changes to the plan or contribution strategy. Brokers across the country are using this “weapon” as a way to win new business.

I think you owe it to yourself to do a top to bottom evaluation of your current book to be sure you have gotten them to seriously consider doing a project. And, if you are prospecting during this summer season, incorporate dependent eligibility verification into each sales presentation. Read on to review a reprise of our article on how the rate of ineligible dependents has increased from 6.5% to 7.99% with the passage of healthcare reform. 

*Report originally published on the Employee Benefit Advisor blog and November’s print issue of Employee Benefit Advisor magazine.

Rate of Ineligible Dependents Increases to 7.99% with health care reform

One of the first changes brought on by health care reform was the mandatory extension of health plan eligibility to adult children up to age 26 without regard to student status or other dependency upon the employee. Many experts predicted that the rate of ineligible dependents would decrease after this provision took effect and lower the effectiveness of Dependent Verification Projects.

Based upon a study my firm did in the fall comparing similar populations before and after the implementation of this provision, we can now conclusively state that the experts were wrong. The rate of ineligible dependents in the health plans analyzed in this study post health care reform has actually increased by approximately 1.5 percentage points.

Expectations prior to health care reform

When health care reform passed, many experts analyzed the data coming from dependent eligibility verification projects in order to predict the effect of health care reform on the efficacy of these projects. Using our data as an example, prior to health care reform in a sample set of over 113,000 dependents verified, 48% of the ineligible dependents were under age 20, 23% of the ineligible dependents were between the ages of 20 and 26 (the typical ages of full-time students), and 29% of the ineligible dependents were over age 26. Further investigation showed that half (11.5%) of ineligible dependents in the 20-26 age range were ineligible because they failed the “relationship” test. These wouldn’t be eligible for coverage regardless of their age.

It seemed reasonable to assume that with the dependent age limit increased to 26, about half of those who had been previously identified as ineligible dependents would now pass eligibility verification. The other half would still fail the relationship test and remain ineligible. Our own data led me to agree with the experts’ expectation of health care reform—that the average rate of ineligible dependents post health care reform would drop from 6.5% to 5.75% (a reduction of 11.5%).

That reduction, while significant, would have only partially mitigated the strong business case for an employer to conduct a dependent eligibility audit. There would be some employers, though, who anticipated falling at the lower end of the 5-12% average range of ineligible dependents. This 11.5% reduction may have been enough to discourage them from the project.

The real effects of health care reform

The fact is, our research since the passage of PPACA has proven that the opposite is true.  Using a statistically significant sample of recent audits conducted by ContinuousHealth, we’ve found that the average percentage of ineligible dependents has actually increased to 7.99% after implementation of the Affordable Care Act. 

A 19% increase!

Additionally, we’ve seen a shift in the ages of ineligible dependents. Our sample set had 10% fewer ineligibles under the age of 20 and about the same number of ineligibles between the age of 20 and 26. Ineligible dependents over the age of 26 grew by 11%.

What conclusions can we draw from increased ineligible numbers?

Certainly there were other factors in place during the time period studied.

Part of this shift could be a result of the continued softness in the employment environment. This affects the percentage of dual-earner households and contributes to the rate at which employees might attempt to have non-spouses or other adults added to their plan who lack access to coverage due to unemployment.

The publicity surrounding eligibility changes has been less than precise, even two years later. There is more potential that employees will attempt to enroll dependents that do not meet eligibility criteria. A person the employee calls “family” needs coverage (perhaps due to the softness of the market), and the employee therefore thinks he can cover them on “family” coverage.

With all of that, verification methods have been eradicated for most companies. For 70% or more of employers prior to health care reform, the only dependent verification procedure was full-time student status checks conducted annually or biannually by the health care plan administrator. PPACA’s changes eliminated the only stopgap against ineligible dependents.

A necessary response

Regardless of the root causes for this increase in ineligible dependent rate, I think the call to action is clear.

For years, we’ve seen that unless employers are making arrangements to verify dependent eligibility with a thorough process that includes both eligibility education and document verification, there are going to be ineligible dependents on every group plan, gratuitously driving up the cost of health care.

In fact, I’d say that the need is greater than ever to make sure ineligible dependents aren’t covered. The changes brought on by health care reform allow even more dependents to be eligible, so covering an ineligible dependent has a more significant exposure risk than ever.  With the prohibition on rescissions in PPACA, the financial exposure lands on the employer for ineligible dependents, since employers must prove employee fraud before exposure for high claims could be passed on.

I want your clients to be protected from the financial and compliance exposure of ineligible dependents, especially since that rate increased by 1.5% since implementing the provision. On top of all that, I’ll remind you again that dependent verification is a cost saving solution that regularly reduce plan expenses by 3-5% with no change in carriers or plan design. Our return on investment guarantee makes it a no-lose situation.  I think you owe it to yourself to do a top to bottom evaluation of your current book to be sure you have gotten them to seriously consider doing a project. And, if you are prospecting during this summer season, incorporate dependent eligibility verification into each sales presentation.

As you face a mid-market renewal season, propose a Dependent Verification Project with ContinuousHealth. It’ll be worth it.

If you’d like a copy of the original article or the case studies detailing report specifics, email directions@continuoushealth.com.

This article was first featured in the May 29th 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