5 Key Definitions in Health Plans

How many of the terms in this example below do your employees understand? If you’re getting blank stares over words like “co-insurance” and “out-of-pocket limit,” it’s time to educate your staff before open enrollment starts for the next plan year.

definitions health plans

Source: Centers for Medicaid & Medicare Services

 

Five Key Terms

Only 12% of American adults have a basic understanding of the terms used in their health plans.[i] As more health plans are transitioning to some type of Consumer-Driven Health Plan (CDHP), it is more vital than ever for employees to understand basic terms that identify their responsibilities for payment.

Here are five easy definitions for HR professionals to use when explaining your company health plan:

  1. Deductible

The amount an employee owes for health care services before the health indefinitions health planssurance or plan begins to pay. For example, if a deductible is $1,500 as in Jane’s example above, the plan won’t pay anything until a $1,500 deductible for covered health care services is met. The deductible may not apply to all services.[ii]

2. Co-payment

A fixed amount (e.g., $25) that an employee pays for a covered health care service, usually when service is received. The amount can vary by the type of covered health care service. Co-payments are more familiar in traditional plans such as Preferred Provider Organizations (PPOs).

3. Network

The facilities, providers and suppliers your health plan has contracted with to provide health care services. So in-network services or providers have already negotiated a billing rate that would be applied.

Out-of-network charges are usually more expensive, because no rate has been contracted with that doctor’s office or provider.

4. Out-of-Pocket Limitemployee deductibles

The most an employee pays during a policy period (usually a year). This limit usually includes deductibles, copays and/or co-insurance. Premiums, balance-billed charges or health care not specified in the plan would not be included.

5. Co-insurance

An employee’s share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.

In the example above, after Jane met her deductible ($1,500), her plan began to pay 80% of qualified health expenses. Jane’s part of the payment (co-insurance) was 20%, paid until Jane’s total expenses for the year hit her $5,000 out-of-pocket limit.

After Jane had paid a total of $5,000, her plan paid all other expenses for the rest of the plan year.

 

Equip Your Employeesdefinitions health plans

As HR departments approach a new year, health plan terms may still sound like a language most employees don’t know. Equip your employees to make decisions they will feel good about so they can better manage those vital health care dollars.MedCost

 

 

[i] Quick Guide to Health Literacy Fact Sheet,http://health.gov/communication/literacy/quickguide/factsbasic.htm (accessed September 13, 2016)

[ii] Centers for Medicare & Medicaid Services https://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf (accessed September 13, 2016)

 

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Employee Deductibles Rise Faster Than Wages

ks110111-medEmployer health insurance expenses continued to rise by relatively low amounts this year, aided by moderate increases in total medical spending but also by workers taking a greater share of the costs, new research shows.

Average premiums for employer-sponsored family coverage rose 3.4% for 2016, down from annual increases of nearly twice that much before 2011 and double digits in the early 2000s, according to a survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

But 3.4% is still faster than recent economic growth, which determines the country’s long-run ability to afford health care.

And the tame premium increases obscure out-of-pocket costs that are being loaded on employees in the form of higher deductibles and copayments. Another new study suggests those shifts have prompted workers and their families to use substantially fewer medical services.

For the first time in Kaiser’s annual survey, more than half the workers in plans covering a single person face a deductible of at least $1,000. Deductibles for family plans are typically even higher.

Deductibles are what consumers pay out of pocket before the insurance kicks in. Employers sometimes contribute to pre-tax accounts to help workers pay such costs.

Employers have been flocking to high-deductible plans in recent years, arguing that exposure to medical costs makes consumers better shoppers.wingeddollar-sm

It also saves employers money. Having workers pay more out of pocket shaved half a percentage point off premium increases of employer-sponsored plans in each of the past two years, Kaiser researchers calculated.

Since 2011, the average deductible for single coverage has soared 63%, according to the survey, while workers’ earnings have gone up by only 11%.

Microsoft PowerPoint - 20160825 Cumulative Slides [Read-Only]

 

 

(Kaiser Health News, Jay Hancock and Shefali Luthra, September 14, 2016)

 

Is Your Health Plan Affected by the Cadillac Tax?

One-Fourth of Employers Now Offering CDHPs to Avoid Tax

Employers continue to take action to avoid the looming excise or “Cadillac” tax on more expensive health insurance for their employees. This Affordable Care Act tax of 40% annually is currently set to take effect in 2020, but it is already having a major impact.

A 2015 Mercer study found that total health benefits cost averaged $11,635 per employee.[i] Cadillac taxThis average amount exceeds the Cadillac tax’s threshold of $10,200 for individuals, and would trigger the 40% tax on benefits above the threshold. And small employers are seeing higher increases in medical, dental and other health benefits than large employers.

Employers Turn to
Consumer Plans                                             

For the first time, 25% of covered employees are now enrolled in Consumer-Driven Health Plans (CDHP). Large employers of 20,000 or more employees have added CDHPs the fastest (73%). A projected 34% of employers with 50+ employees will be subject to the excise tax in 2020 if they make no changes to their current health plans.

 Cadillac tax

 

High-Deductible Health Plans (HDHP) are a type of Consumer-Driven Health Plans. Employers are saving an average of 18% with an HSA-eligible HDHP instead of a traditional Preferred Provider Organization (PPO) plan.[ii]

One key reason that employees are researching medical costs in advance for services such as maternity care, joint replacements and Emergency Room visits. A 2015 Consumer Health Insights’ survey showed that 22% always talked to others about costs or searched websites for information.[iii]

Employees who have a telemedicine option in their health plans can choose a more appropriate level of Cadillac taxcare for certain respiratory infections, fevers and nausea (see “Treatment Alternatives to the Emergency Room”). Choosing the right level of care reduces time away from work, boosting productivity. And employees save unnecessary dollars from their own pockets.

Some employers offer pricing transparency tools such as HealtheReports™ which compares costs for a complete procedure. Employees can review local facilities that offer mammograms, colonoscopies, X-rays and other services. HealtheReports also lists comments from members about their recommendations for health care organizations.

A New Era in Health Care

CDHP plans require a shift in thinking about medical spending. In traditional plans, employees are used to handing over their insurance card and paying a small copay.

PiggyBankIt can come as a jolt to employees to realize that CDHP coverage begins with paying expenses up to a higher deductible before insurance kicks in. For this reason, employers must proactively educate employees when introducing CDHP options.

Our next blog will detail key steps for employers to take in providing tools for smart decision-making. Employers who can manage staff expectations with a balanced understanding of the changing health care industry will build a productive partnership with your team.MedCost

 

[i] “With the Excise Tax in Their Sights, Employers Hold Health Benefits Cost Growth to 3.8% in 2015,” Mercer Global, November 19, 2015, http://www.mercer.com/newsroom/national-survey-of-employer-sponsored-health-plans-2015.html (accessed August 8, 2016)

[ii] Ibid.

[iii] “Debunking Common Myths about Healthcare Consumerism,” McKinsey & Company, December 2015, http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/debunking-common-myths-about-healthcare-consumerism (accessed August 11, 2016)

Health Costs Up 6% for Big Employers in 2017

Big employers expect health costs to continue rising by about 6 percent in 2017, a moderate increase compared with historical trends that nevertheless far outpaces growth in the economy, two new surveys show.

These cost increases, while stable, are both unsustainable and unacceptable,” said Brian Marcotte, CEO of the National Business Group on Health (NBGH), a coalition of very large employers that got responses from 133 companies.

Employers are changing tactics to address the trend, slowing the shift to worker cost sharing and instead offering video or telephone links to doctors, scrutinizing specialty-drug costs and steering patients to hospitals with records of lower costs and better results.

Most large-company employees should expect a 5 percent increase in their premiums next year and, in contrast to previous years, “minimal changes” to plan designs, NBGH said.

(Kaiser Health NewsJay Hancock, August 9, 2016)
Kaiser Health News

More Employers Are Choosing This Health Plan

Cost & Government Regulations Are Major Factors

If you’re like most employers, covering the costs of your employees’ health care is a major concern. Expenses for employee hospitalizations, chronic diseases and drug costs are threatening to swallow up annual profits for businesses.

Employer-sponsored health premiums rose 203% between 1999 and 2015.[i] This is why more employers are choosing high-deductible health plans (HDHP), as the graph below shows. Is it possible to manage health care costs and still do business?

HDHP

 

What Is an HDHP?

A high-deductible or consumer-driven health plan has lower premiums and higher deductibles than traditional insurance plans.[ii] Instead of copays, a covered employee would pay health costs until the deductible is met.

Many companies offer a Health Savings Account (HSA) or a Health Reimbursement Account (HRA) that offers significant tax advantages for both employers and employees. The HDHP combined with HSA or HRA contributions can shelter income from taxes while helping to keep premiums low.

HDHP

Benefits

How can your Human Resource department explain this shift in benefits, when only 12% of adults have a basic understanding of health terms?[iii] Here are some real benefits to tell employees when migrating to an HDHP:

  1. “Your income tax will be lower.” Employees contributing to an HSA will shelter that income from federal taxes. This can add up to 39.6% in savings, depending on the tax bracket. Can anyone say “free money”? Especially when companies add their contributions to an HSA if an employee participates in the program.

2. “You will have more control over how you spend your health dollars.” One reason HDHPs are also called “consumer-driven” is because employees have choices about where they shop services. If the same treatment for a respiratory infection can be obtained by a telemedicine call instead of the family doctor, out-of-pocket savings can really add up. And many employers offer price comparisons for services that allow smarter choices before getting treatment.

3.  “You will have an automatic nest egg for health expenses.” It’s not easy to save, but payroll deductions can ease planning for costs. And the beauty of HSAs is that employees take this account with them, even if they change jobs. HRAs reimburse qualified medical expenses up to a fixed amount each year — another tax-free savings funded by employers, which can be rolled over to be used in subsequent years.

Summary

Employer health benefits, health care, employee claimsIn this tumultuous era of health care, employees are gaining an increasing amount of financial responsibility. This gives smart employers the opportunity to treat your staff as partners in decision-making.

Educating your employees is a key foundation to bridging the transition to HDHPs as a benefits option. The next blogs will provide important steps to make that transition successfully, and how to manage expectations during the change.

 

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[i]  “Recent Trends in Employer-Sponsored Health Insurance Premiums,” Kaiser Family Foundation, January 5, 2016, http://kff.org/infographic/visualizing-health-policy-recent-trends-in-employer-sponsored-health-insurance-premiums/ (accessed June 16, 2016).

[ii] High Deductible Health Plan (HDHP), HeathCare.gov Glossary, https://www.healthcare.gov/glossary/high-deductible-health-plan/ (accessed June 29, 2016)

[iii] Quick Guide to Health Literacy Fact Sheet, http://health.gov/communication/literacy/quickguide/factsbasic.htm (accessed June 29, 2016)