The 3 Keys of Stop Loss Insurance (Video)

stop loss carriers

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“Stop loss carriers are definitely not the same,” said Jeff Thornburg, Senior Manager for MedCost Underwriting. “Stop loss insurance should not be treated as a commodity. Price is important. It should be considered. But the quality of the carrier and their policy are actually more important than the price.

“As long as you are getting a good price, you want to drill down into the policy. The first key is:

1. Be sure your policy is going to mirror, or virtually mirror, stop loss carrieryour plan document, to avoid any gaps in coverage.

“When there’s a gap, there’s a denial. You might as well consider denied claims as additional premium. So if you bought the cheaper policy that had more exclusions, and you had a denial, you quite possibly ended up paying more than if you had just bought good quality stop loss from a good quality carrier.”

Senior Underwriter Jeff Woodburn explains the second key: look for these qualities to choose the best carrier.

2. What differentiates the good stop loss carriers from inferior ones?

             *Financial stability
             *The ability to be efficient in paying claims
              *Ease of doing business

“For example, a premature baby incurs a tremendous amount of expense,” said Mr. Woodburn, with over 10 years in the industry. “As you know, that is a totally unexpected expense. But when these unexpected events occur, that is when your stop loss insurance kicks in to cover expenses that exceed a certain threshold. This threshold is predetermined when we’re putting the health plan together for a prospective group.”

Mr. Thornburg has seen how important the third key is from his 28 years handling stop loss insurance.

3. Choose your benefits administrator wisely.

“As a self-funded employer, you’re going to have the same claims, regardless of which stop loss carrier you choose. Your claims are going to happen whether you are with Benefits Administrator A, B or C.

“In evaluating different benefits administrators, it’s important to nail down who is going to manage those claims the best. To limit the liability of the employer while still giving good service and excellent benefits to the employees.

“This is what it comes down to at the end of the day. Who is going to best manage your claims?”MedCost

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stop loss insurance

How Employer Plans Cover Prescription Drugs (Infographic)

An estimated 150 million Americans have employer-sponsored health insurance.[i] What is the complex system under which employer health plans cover the rocketing costs of prescription drugs?

employer prescription drugs

Members

Individuals covered by employer’s health plan. May pay premiums or copays for drug coverage.

Employer or Insurer

Employer or insurer pays PBM to develop preferred drug pricing & process prescription claims. PBM returns some or all rebates to employer or insurer.

Pharmacy Benefit Manager (PBM)

Negotiates discounts and rebates from manufacturer. Contracts with pharmacy.

Manufacturer

Negotiates rebates with PBM.
Sells discounted drugs to wholesaler from core price.

Wholesaler

Negotiates price with pharmacy.

Pharmacy

Pharmacy dispenses to members & collects copays.

For more resources, view: ”10 Pharmacy Terms Employers Need to Know” and “5 Factors in Employer Prescription Drug Costs” from Pharmacist Zafeira Sarrimanolis.MedCost

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[i Robert Galvin and Troyen Brennan, “Can Employers Take a Bigger Role in Controlling Drug Costs?” Health Affairs blog, February 17, 2017, http://healthaffairs.org/blog/2017/02/17/can-employers-take-a-bigger-role-in-controlling-drug-costs/ (accessed April 6, 2017).

 

IRS Reposts Revised Form 720 for PCORI Fee: Deadline 7/30/17

Michael BerwangerBy Michael Berwanger, JD, Director, Quality Management & Compliance

The IRS recently reposted the April 2017 version of Form 720 (Quarterly Federal Excise Tax Return) on its website.* While the form’s primary purpose is to serve as the quarterly return for various federal excise taxes, it also is used to report PCORI fees imposed under health care reform. (For more information on PCORI, see  “PCORI Fee for Self-Funded Employers”.)

Please note, the portion of the form related to the PCORI fees is unaffected. While Form 720 is filed quarterly for other federal excise taxes, the PCORI fee reporting and payment are only required annually, by July 31 of the year following the calendar year in which the applicable policy or plan year ended. The change noted at the beginning of the form is related to the excise taxes.

IRS form 720As background, PCORI fees, used to fund research on patient-centered outcomes, apply to plan and policy years ending before October 1, 2019. They are payable by insurers and sponsors of self-insured health plans, and are calculated by multiplying the applicable dollar amount for the year by the average number of covered lives. As announced in IRS Notice 2016-64, the fees owed in 2017 are as follows:

  • For plan years** ending on or after October 1, 2015, and before October 1, 2016: $2.17 per covered life
  • For plan years** ending on or after October 1, 2016, and before October 1, 2017: $2.26 per covered life

If you have already filed and used the form posted prior to the most recent update, please contact a tax professional on whether refiling is necessary.MedCost

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*If you downloaded the Form 720 (Rev. April 2017) before July 3, 2017, please note that
on page 2, under IRS No. 33, the rate is corrected to 12% of the sales price, not 12%
of the sales tax.)

*’*Plan year’ is generally the 12-month period stated in the Summary Plan Description, or for plans filing a Form 5500, the plan year stated in that filing. NOTE: The plan year may be different from the benefit year or the renewal period.

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This blog post should not be considered as legal advice.

3 Compliance Areas for Self-Funded Employers (Video)

self-funded employer compliance

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“There are three primary areas that employers should keep in mind when thinking about compliance for their health plan,” said Brad Roehrenbeck, General Counsel and VP of Legal Services and Compliance at MedCost.

1. Employment Retirement Income Security Act 

“The first of those is the Employee Retirement Income Security Act of 1974 (ERISA), which governs employer-sponsored benefit plans. ERISA was a law created in the early 1970s that has been applied to basically set the rules for how an employer that creates their own health plan should do that.”

Michael Berwanger, Director of Quality Management and Compliance, agreed. “ERISA requires several things of plan sponsors and plan administrators. One of those things is to provide notices of what benefits are available to employees. The types of notices that you might expect with the summary plan document are any tax filing notices you might need to be aware of.

self-funded employer compliance“This is to make employees aware of the rights available to them under ERISA. And with the right service provider, employers can feel confident knowing they’re distributing the right notices in the right formats.

2. HIPAA Compliance

“The second area of compliance for self-funded employers is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA requires that you safeguard patient data. Employers might find themselves subject to certain HIPAA rules; and with the right service provider, it could be relatively easy to navigate those waters.”

Keeping track of privacy obligations with documents that contain patient information is very important, said Brad Roehrenbeck. “Another thing that HIPAA requires is that anyone who handles that information, particularly if it’s electronic, must keep it secure. That basically means that you have to have systems in place that control who has access to that type of information, if you’re keeping it on your systems.

“HR directors want to make sure that they work with their IT departments to look at what kind of controls are in place, who has access to any folders where patient data is maintained, or anything else in relation to running the health plan. The HR department keeps that sensitive member information for the plan.

3. Internal Revenue Service Compliance

“The third primary area of the law that impacts health plans is tax laws. Like other types of benefit plans, health plans come with a tax benefit to both employees and employers. As dollars go in to support the plan, those dollars are provided on a tax-free basis.”

self-funded employer compliance“There are certainly tax advantages when you’re considering self-funding your health plan,” Michael Berwanger said. “To take advantage of those, you need to be aware of your compliance obligations -things like making sure you’re not discriminating unfairly in favor of your highly compensated employees.”

“There’s one other area of the tax laws that actually provides some additional benefit to employers and employees, and that is this concept of a Health Savings Account (HSA). Health savings accounts are a great vehicle under the tax laws where employees can set aside dollars and employers can contribute dollars on a tax-free basis. Those monies can be used toward deductibles and the payment of claims. Employees can keep that money for the rest of their lives or until such time as they need to use that for their medical expenses.

HSAs are a great asset for employees and a great savings vehicle. More importantly, it’s a great avenue for employers to engage with participants in the health plans to be conscious of where their health plan dollars are spent and to use them in a way that not only promotes their own health, but also the financial stability and viability and strength of both their dollars and the health plan dollars,” Mr. Roehrenbeck said.

self-funded employer compliance“As the markets continue to move towards a consumer-driven economy, it’s important for employees to be mindful of their options and how to best take advantage of the benefits available through their employers,” Mr. Berwanger noted.

“We find ourselves in a challenging environment. It’s important to be able to offer great incentives and great packages to employees. A self-funded health plan is a great opportunity to be able to do that.

“The risk can be worth the reward. Managing those compliance obligations isn’t as complicated as you might think, once you have a good trusted advisor to help you navigate that.”MedCost

(This post is a transcript from the video, “3 Compliance Areas for Self-Funded Employers.”)

 

 

Controlling Specialty Drug Costs (Video)

Specialty Drug Costs Can Be Managed with These Strategies
specialty drug costs

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“It’s interesting that a lot of these specialty drugs are designed for a very small percentage of the population that have a certain disease state,” said Michael Cornwell, MedCost Director of Sales and Underwriting.

“There may be less than 200,000-300,000 people in the country that need that particular drug. That’s one of the reasons specialty drugs are so expensive.”

MedCost Pharmacist Zafeira Sarrimanolis agrees. “It’s an exciting time in the drug manufacturing world, because all of these new medications have been coming out over the past ten years or so for medical conditions that really weren’t treatable before.

“For example, hepatitis C medications previously were not very effective and really hard for patients to tolerate. Now we have new medications on the market that are practically a 100% cure rate for patients.

specialty drug costsThese drugs are also a lot easier for them to take and tolerate. Part of the problem with that is the price tag on some of those new medications.”

“One of the largest reasons people are readmitted to the hospital is because they don’t adhere to the medication,” said Michael Cornwell. “Programs like step therapy ask you to try a clinically appropriate drug before you try a similar but more expensive one.

Prior authorizations probe a physician’s reasoning behind prescription choices. A lot of these specialty drugs are really for a pretty small percentage of the population. So when you look at a population as a whole, the people taking those drugs are usually between 1%-1½% of your population. That’s the good news.

“The bad news is they’re very expensive. Probably the biggest growth area in the specialty arenas are the cancer drugs. There’s a whole pipeline of new cancer treatments hitting the marketplace. But in that pipeline, member education and aid in helping and consulting is a good thing too. It allows us to have some personal outreach try to help these people manage their disease state.MedCost

(This post is a transcript from the video, CONTROLLING SPECIALTY DRUG COSTS.”)

 

PCORI Fee for Self-Funded Employers: Due July 2017

By Michael Berwanger, JD, Director, Quality Management & Compliance

 PCORI Required by ACA

PCORI due datesThe Affordable Care Act (ACA) includes provisions to promote research by the Patient-Centered Outcomes Research Institute (PCORI) that will provide information on the relative strengths and weaknesses of various medical interventions. This initiative is being funded by a tax that must be paid by insurers and plan sponsors of self-funded health plans. Per IRS Guidance, for self-insured and/or self-funded plans ending in 2016, filing and payment must be submitted to the IRS by July 31, 2017. The fees owed in 2017 are as follows:

  • For plan years* ending on or after October 1, 2015, and before October 1, 2016: $2.17 per covered life
  • For plan years* ending on or after October 1, 2016, and before October 1, 2017: $2.26 per covered life

*’Plan year’ is generally the 12-month period stated in the Summary Plan Description, or for plans filing a Form 5500, the plan year stated in that filing. NOTE: The plan year may be different from the benefit year or the renewal period.

 PCORI Fee Payments

PCORI due dateUnder the Internal Revenue Service (IRS) final rule, plan sponsors are responsible for paying the fee, which is treated as an excise tax by the IRS. A Quarterly Federal Excise Tax Return (Form 720) must be used when reporting liability for the fee. The form can be accessed at http://www.irs.gov/pub/irs-pdf/f720.pdf. Instructions for completing and filing the form can be accessed at http://www.irs.gov/pub/irs-pdf/i720.pdf. Completion of the form is relatively simple.  As described here, only the relevant parts of the form need to be completed, which include:

  • Identifying information at the beginning of the form
  • Part II, line 133 (“Applicable self-insured plans” line)
  • Part III, items 3 and 10
  • The signature section
  • The voucher form, if the form is mailed
  • The form may be filed electronically or mailed to:

Department of the Treasury
Internal Revenue Service
Cincinnati, OH 45999-0009

Additional Tips

The following information may be helpful in determining your tax obligation under the PCORI provision:

  • The plan sponsor must apply a single calculation method in determining the average number of lives covered under the plan for the entire plan year. However, the plan sponsor is not required to use the same method from one plan year to the next.
  • HRA and Self-Insured Plans: A self-insured Health Reimbursement Account (HRA) is not subject to a separate fee if the HRA is integrated with another applicable self-insured health plan that provides major medical coverage. The HRA and the other plan must be established or maintained by the same plan sponsor with the same plan year.
    • However, if a self-insured HRA is integrated with an insured group health plan, then the fee must be paid for both the self-insured product and the insured product.
  • Excepted Benefits: Excepted benefits (as defined under section 9832c of the U.S. Code) are exempt from the fee, as is a health Flexible Spending Account (FSA) that satisfies the requirements of an excepted benefit.
  • All plans that provide medical coverage to employees owe this fee. The insurer/carrier for fully-insured plans will pay the fee (typically, the fee is passed on to the plan). The plan sponsor for self-funded plans will pay the fee. Note, there is no exception for small employers, government, church or not-for-profit plans, nor for grandfathered plans or union plans. The fee is tax-deductible.
  • For more information, see: IRS FAQ or IRS chart that shows which plans owe the fee.

NOTE: MedCost is not a tax preparation company, and you may have additional tax obligations for other benefit plans that you offer to your employees. Please consult with your tax advisor for guidance. This blog post should not be considered as tax or legal advice.MedCost

 

Listening to the Voice of the Customer (Video)

Health care is complex. It always has been — even more so today in a continually changing industry and environment. MedCost strives to be the kind of partner that helps our customers navigate, translate and adapt to those changes.

When MedCost started as a small company, we were still using some of the principles we use today. We were sitting down and listening to the unique needs of the customer. We were using data even before there were sophisticated mechanisms to use data. To understand what was driving their costs, what providers they were utilizing, how we can essentially customize some sort of solution, whether it be a product, a program or a service to essentially help them better manage or to achieve what they were trying to achieve with their health plan.

In this time, in this industry, collaboration is more important than ever. We have a legal team, a communications team, a pharmacist, an underwriting team — all designed to essentially help support the employers, and bring some of the best new ideas to the employer to help them engage in new or better health and wellness programs. And also to drive lower costs for their population.

We essentially try to be one single source for an employer to come and partner with them — to not only design but to administer their health plans.

We’re interested in your unique needs. Contact Jason at jclarke@medcost.com or call 336.774.4283.MedCost

(This post is a transcript from the video, “Listening to the Voice of the Customer.” )

2018 HSA and HDHP Dollar Limits Released by IRS

By Michael Berwanger, JD, Director, Quality Management & Compliance

The IRS has released Revenue Procedure 2017-37, setting the 2018 dollar limitations for health savings accounts (HSAs) and high-deductible health plans (HDHPs).

The contribution, deductible and out-of-pocket limitations for 2018 are shown in the table below. All of these amounts are scheduled to increase from 2017. (The 2017 limits are included for reference.)

2018 HSA HDHP

For guidance on HSAs, please review the IRS frequently asked questions’ page at https://www.irs.gov/publications/p969/ar02.html.MedCost

This blog post should not be considered as legal advice.

 

Prescription Insurance: Why Are Costs Rising?

MedCost pharmacistBy Zafeira Sarrimanolis, PharmD, MedCost Clinical Consultant

Prescription insurance has become an increasingly major cost for employers. New drug approvals by the US Food and Drug Administration (FDA) are expected to escalate this year with multiple innovative drugs already being approved for cancer, multiple sclerosis and other conditions.

As researchers discover more treatments, costs will continue to climb. For this reason, smart management of pharmacy plans will be even more vital for employer health plans.

2017 Drug Pipeline

2016 saw a below average number of drug approvals. 2017 is expected to bounce back with 30+ new specialty drugs.

Specialty medications are high-cost prescription drugs used to treat complex conditions. The blue bar (below) shows specialty medication drug approvals. The green bar represents traditional brand and generic drugs. Technology, innovation and new scientific discoveries have caused specialty medication drug approvals to rapidly increase over the last few years.

prescription insurance

Growth of Novel Drugs in Prescription Insurance

In 2016, 22 novel drugs were approved, which was the lowest number since 2010. A novel drug is an innovative product with a unique chemical structure that has never been approved by the FDA before.  Typically novel drugs meet an unmet medical need.

prescription insurance As of May 5th, 20 novel drugs have already been approved this year. It’s an exciting time for healthcare as we treat more complex conditions and improve member health and quality of life.

But it comes at a cost – literally.

 

Summary

When 1% of prescriptions drive 40-45% of an employer’s pharmacy spend, avoiding wise management is no longer optional. Part of my role as a MedCost Pharmacist is to emphasize the importance of cost-management strategies to our employers and consultants.

prescription insurance

I also work closely with our clients to help employers understand the importance of educating their employees about these changes and why they are needed.

It’s all about making sure each employee gets the right drug for the right medical condition at the right time. That’s how we control pharmacy costs.MedCost


Sources

 

 

 

 

 

 

5 Factors in Employer Prescription Drug Costs

Why are employer prescription drug costs spiraling higher every year?

“There are a combination of factors,” said Zafeira Sarrimanolis, PharmD, MedCost Pharmacist and Clinical Consultant. “This is a major problem for employers who do not want to make employees unhappy by instituting clinical pharmacy programs in their health plans.”

employer prescription drug costs


What Are the Factors in Employer Prescription Drug Costs?

  1. Manufacturer Price Hikes.

    Costs for drugs like EpiPen® and Humira® have been widely publicized.[i] Prices are escalating 16-17% per year. Manufacturers are also promoting new uses for existing high-cost drugs, even though there are already FDA-approved, lower-priced drugs for the same conditions already on the market.

  2. Increased Use of Prescription Drugs.

    The number of people taking cholesterol drugs is up from 6.5% (1999-2002) to 13.1% (2009-2012). Similar increases are seen in other common chronic conditions, including depression which increased 6.4% to 9.0% over the same period.[ii]

employer prescription drug costs

 

3.Specialty Drugs.

New, expensive medications for diseases such as cancer and multiple sclerosis are constantly hitting the market. Specialty drugs account for about 1% of total prescriptions but 35-45% of pharmacy spend, averaging $3,400 per drug per month.[iii]

4. Patent Expirations.

In 2016, Crestor, Zetia and Benicar all had patent expirations. The increased competition from generic equivalent drugs is decreasing costs across the board. Unfortunately for high-cost injectable medications like Humira, the introduction of generic versions is not as simple.

5. Advertising.

An estimated 80 drug commercials per hour are shown across TV outlets.employer prescription drug costs[iv] Radio, magazines, newspapers and social media also contain prescription drug ads that prompt individuals to ask doctors about specific drugs.

It’s an exciting time in the drug industry with the influx of new drugs coming on the market,” said Michael Cornwell, MedCost Director of Sales and Underwriting. “But it also presents challenges for us in the industry since controlling these costs is not always user-friendly.”

 

Employer Strategies for Controlling Prescription Drug Costs

 

Pharmacy Benefit Managers

Working with a Pharmacy Benefit Manager (PBM) supports cost management for employers in the pharmacy portion of their health plans. A PBM negotiates discounts and rebates from drug manufacturers, which are then returned back to the employer. PBMs also contract with pharmacies and process pharmacy claims.

The PBM controls pharmacy costs for employers through development of a preferred drug list (or formulary) and clinical programs. MedCost as a benefits administrator works closely with PBM partners to get the best rates for employers, customizing a pharmacy plan for each client’s unique population.

Formulary Management

Preferred drug lists are arranged in tiers, or cost levels, of generic, preferred and non-preferred medications. A PBM Pharmacy & Therapeutics Committee of industry experts follows a clinically-driven formulary decision-making process to define the preferred drug list. Some drugs are excluded from coverage in favor of clinically-similar alternatives that treat the same disease.

Exclusions can save as much as 15% of prescription drug costs in an employer’s health plan.

Prior Authorization

Prior authorizations require a doctor to provide additional clinical information to determine whether the health plan covers that drug. Employees, providers and health plan administrators dislike the inconvenience of waiting for approval of drugs. But this strategy is key to ensure that members take safe, clinically-appropriate and cost-effective drugs.

“There’s a human factor,” said Michael Cornwell. “We do not want to be disrupted in using familiar medicines. But employers cannot save money without these strategies.”

Step Therapy

Step therapy requires initial use of a lower-cost, clinically-similar drug for a medical condition, before a higher-cost drug for the same condition is covered by a health plan.

Summary

When 1% of prescriptions drive 40-45% of an employer’s pharmacy spend, avoiding wise management is no longer optional”, said Zafeira Sarrimanolis. “Part of my role as a MedCost Pharmacist is to emphasize the importance of cost-management strategies to our employers and consultants.”

“I also work closely with our clients to help employers understand the importance of educating their employees about these changes and why they are needed.”

“It’s all about making sure each employee gets the right drug for the right medical condition at the right time. That’s how we control pharmacy costs.MedCost

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[i] Brad Tuttle, “21 Incredibly Disturbing Facts about High Prescription Drug Prices,” Money Magazine, June 22, 2016, http://time.com/money/4377304/high-prescription-drug-prices-facts/ (accessed April 26, 2017).

[ii] “Health, United States, 2015,” National Center for Health Statistics, Centers for Disease Control and Prevention,   https://www.cdc.gov/nchs/data/hus/hus15.pdf#079 (2009-2012), (accessed April 26, 2017).

[iii] “The Growing Cost of Specialty Pharmacy – Is It Sustainable?” American Journal of Managed Care, February 18, 2013, http://www.ajmc.com/payer-perspectives/0213/the-growing-cost-of-specialty-pharmacyis-it-sustainable (accessed April 26, 2017).

[iv] “Prescription Drug Costs Remain Atop the Public’s National Health Care Agenda,” Kaiser Family Foundation, October 28, 2015, http://kff.org/health-costs/press-release/prescription-drug-costs-remain-atop-the-publics-national-health-care-agenda-well-ahead-of-affordable-care-act-revisions-and-repeal/ (accessed April 26, 2017).