by admin | Apr 26, 2017 | ACA, Benefit Management
A Summary of Benefits and Coverage (SBC) is four page (double-sided) communication required by the federal government. It must contain specific information, in a specific order, and with a minimum size type, about a group health benefit’s coverage and limitations. If an employer providing an SBC is a covered entity under the Section 1557 of the Patient Protection and Affordable Care Act (ACA), additional requirements apply.
On April 6, 2016, the Centers for Medicare and Medicaid Services (CMS), the Department of Labor (DOL), and the Department of the Treasury issued the final 2017 summary of benefits and coverage (SBC) template, group and individual market SBC instructions, uniform glossary of coverage and medical terms, a coverage example calculator, and calculator instructions.
The SBC is to be used by all health plans, including individual, small group, and large group; insured and self-funded; grandfathered, transitional, and ACA compliant. The new SBC must be used for plan years with open enrollment periods beginning after April 1, 2017. It will not be used for marketplace plans for the 2017 coverage year.
For fully insured plans, the insurer is responsible for providing the SBC to the plan administrator (usually this is the employer). The plan administrator and the insurer are both responsible for providing the SBC to participants, although only one of them actually has to do this.
For self-funded plans, the plan administrator is responsible for providing the SBC to participants. Assistance may be available from the plan administrator’s TPA, advisor, etc., but the plan administrator is ultimately responsible. (The plan administrator is generally the employer, not the claims administrator.)
Changes
The template includes a new “important question” that asks “Are there services covered before you meet your deductible?” and requires family plans to disclose whether or not the plan has embedded deductibles or out-of-pocket limits. This is reported in the “Why This Matters” column in relation to the question “what is the overall deductible?” and plans must list “If you have other family members on the policy, they have to meet their own individual deductible until the overall family deductible has been met” or alternatively, “If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.”
Tiered networks must be disclosed and the question “Will you pay less if you use a network provider?” is now included. The SBC also includes language that warns participants that they could receive out-of-network providers while they are in an in-network facility. The SBC also indicates that a consumer could receive a “balance bill” from an out-of-network provider.
The “explanatory coverage page” was dropped from the template.
The coverage examples provided clarify the “having a baby” example and the “managing type 2 diabetes” example, in addition to providing a third example of “dealing with a simple fracture.” The coverage example must be calculated assuming that a participant does not earn wellness credits or participate in an employer’s wellness program. If the employer has a wellness program that could reduce the employee’s costs, the employer must include the following language: “These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: [insert].”
The column for “Limitations, Exceptions, & Other Important Information” must contain core limitations, which include:
- When a service category or a substantial portion of a service category is excluded from coverage (that is, the column should indicate “brand name drugs excluded” in health benefit plans that only cover generic drugs);
- When cost sharing for covered in-network services does not count toward the out-of-pocket limit;
- Limits on the number of visits or on specific dollar amounts payable under the health benefit plan; and
- When prior authorization is required for services.
The template and instructions indicate that qualified health plans (those certified and sold on the Marketplace) that cover excepted abortions (such as those in cases of rape or incest, or when a mother’s life is at stake) and plans that cover non-excepted abortion services must list “abortion” in the covered services box. Plans that exclude abortion must list it in the “excluded services” box, and plans that cover only excepted abortions must list in the “excluded services” box as “abortion (except in cases of rape, incest, or when the life of the mother is endangered).” Health plans that are not qualified health plans are not required to disclose abortion coverage, but they may do so if they wish.
By Danielle Capilla, Originally Published By United Benefits Advisors
by admin | Apr 19, 2017 | Health & Wellness, Human Resources
I am proud to say that I have been involved in corporate wellness since the mid-1980s. Helping employees live healthier and happier lives, as well as supporting employers with best-in-class tools to improve their cultures, have been my passion and purpose. I have witnessed and worked on corporate wellness since the time when physical health was the most important aspect of workers’ health. I cannot say I have worked with wellness since its inception, though. Corporate wellness has been around longer than many people think. To predict the future of wellness, we must understand its past.
Writings about the effects of work exposure on workers and how to improve workers’ health and well-being can be found as early as the 1700s1. Later, the industrial revolution brought many health issues to workers such as working 14 to 16 hours a day, low wages, and very poor working conditions2. The World Health Organization’s (WHO) definition of health in the 1940s as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” opened our eyes to the concept of health and wellness as a more complex one3. In addition, the work of Halbert Dunn in 1959 helped the word “wellness” circulate more widely in the public health field, but it was the CBS 60 Minutes program with Dan Rather in 1979 titled, “Wellness, there’s a word you don’t hear every day,” that created curiosity about what corporate wellness was at that time – emphasis on physical health4. Corporate wellness has evolved since then and many studies have been published leading to a wealth of knowledge on best practices, return on investment (ROI), value of investment, risk reduction, health improvement, and more. The March 2017 edition of Health Affairs was dedicated exclusively on the relationship of work and health, and health and work highlighting important recent studies on wellness. Wellness has moved from physical health to thriving in other dimensions such as emotional, financial, spiritual, social, and intellectual health. In addition, many theories on behavior change and behavior economics have been adopted in wellness programs and its incentive designs. Wellness has changed from a “nice to have” to a “must have” benefit, but it must be done right and implemented consistently in order to provide positive results that align with your company’s goals.
I don’t have a crystal ball or special powers, but I believe the future of wellness lies in the following:
- Millennials in the workforce will demand more sophisticated technology.
- The traditional health risk assessment will be replaced by a more holistic kind – check out the True Vitality Test from The Blue Zones. (The UBA Health Plan Survey finds that although 72.5 percent of wellness programs include health risk assessments, their use has been declining, dropping 10.5 percent in three years.)
- Wellness will be part of all successful companies’ business objectives – the Chief Wellness & Well-being Officer’s ultimate goal will be to build a culture of health, self-responsibility, and emotional balance. Wellness will be an important piece of this. For great examples of companies ahead of our time, check out Dr. Ron Goetzel’s work at the Institute of Health and Productivity Studies at John Hopkins School of Public Health.
- Non-traditional workplace environments will replace the health-damaging sitting and sedentary work environment of today.
- Wellness will be more integrated with benefits in general, but more specifically with high-deductible health plans (HDHPs) as a way to help employees fund them.
- ROI will no longer be the focus, and instead it will be part of a long-term business strategy.
- Wellness will have a wider impact overall where employees will thrive in the workplace and bring their health improvement skills to their families and communities.
We now know how to deliver wellness that positively affects cultures and population health. We don’t need any additional studies. All we need are brave and open-minded companies to embark on the journey of optimal wellness and well-being. This journey is full of trials and errors, but also full of self-discovery and growth that can build very profitable companies filled with employees who truly engage at work and thrive every day. Who is with me in this journey?
By Valeria S. Tivnan, Originally Published By United Benefit Advisors
by admin | Apr 14, 2017 | Benefit Management, Group Benefit Plans
Many employers understand the value of having an Employee Assistance Program (EAP) since the heart and soul of organizations are employees. Employees who are physically and mentally healthy, highly productive, engaged in their work, and loyal to their employer contribute positively to their employer’s bottom line. Fortunately, most employees are positive contributors, yet even the best of employees can occasionally have issues or circumstances arise that may inadvertently impact their jobs in a negative way. Having an EAP in place that can address these issues early may mitigate any negative impact to the workplace. This is a win-win for both employees and employers.
A key component of EAP services lies in “catching things early” by assisting employees and helping them address and resolve issues before they impact the workplace. Most employees will use EAP services on a voluntary, self-referred basis that is completely confidential. Some employers may wonder if services are even being used by employees because it won’t be all that apparent, but most EAPs provide a utilization or usage report that will show the number of people served, and possibly the types of reasons services were requested.
If employee issues do begin to appear in the workplace—related to performance, attendance, behavior, or safety—it is important for managers, supervisors, and human resources to also have access to EAP services. They may wish to consult with an employee assistance professional that can provide guidance and direction leading to problem identification and resolution. These issues have the potential to become very costly for the organization—and again, the earlier they can be addressed, the greater chance of success for both employee and employer, with minimal negative impact to the company’s bottom line.
The key to getting the most out of an EAP is to make it easily accessible to employees, safe to use, and visible enough they remember to use it. It is important that employees understand using the EAP is confidential and their identity will not be disclosed to anyone in their organization. Promoting the EAP services with materials such as flyers, posters, or website information with EAP contact information will also increase the likelihood of employees accessing services.
By Nancy Cannon, Originally Published By United Benefit Advisors
by admin | Mar 31, 2017 | Employee Benefits, Group Benefit Plans, Human Resources
The age-old adage, “you get what you pay for,” certainly holds true in the stop loss industry. I cannot stress enough how important it is to look at more than just the premium rates on a spreadsheet.
To understand the importance, let’s use the auto insurance industry as a comparable example. If you were purchasing car insurance for yourself, would you always accept the lowest price without doing a coverage comparison? How would you know if that insurance company might jack up your rates on renewal, or once you have an accident, or possibly delay your claims and find every reason or loophole not to pay them?
Apply that same thinking to stop loss coverage with larger dollar amounts at risk. Not every stop loss policy is alike and not every carrier is going to provide you with the coverage you are seeking. As an employer, you want to make sure the employee benefit plan you sponsor for your employees will not result in any significant liabilities for your company. You want the peace of mind of knowing there won’t be any surprises along the way.
All stop loss carrier policies are different. Over my 20-plus years in the industry, I have seen some very unique language and provisions in stop loss policies that most people would not notice without looking at the fine print. You must be aware of these potential provisions that could cause significant gaps in coverage between your employee benefit plan and your stop loss policy.
How can you best protect your company? You can start by working with your broker or administrator to narrow down the list of stop loss providers to those that best meet your needs. Brokers and administrators are best suited to understand the complexities of stop loss insurance and provide you with the best possible information regarding policies and choices.
By keeping this, and the following items, in mind during your selection process, you should be able to find a carrier to serve your needs.
The most important advice I can provide is to look beyond just price and at the actual stop loss policy. The lowest price doesn’t always mean the best value. So make sure to:
- Read the stop loss policy before you purchase your coverage
- Ask for a sample policy
- Understand ALL the provisions of the policy itself
- Ask your broker or administrator to review the policy if you don’t understand all the provisions
Additionally, there are a few other things you will want to look for, or ask about, when selecting a stop loss carrier. In part two of this blog, which will be posted the first week of April, I will discuss some of the most frequent items I have seen that cause issues or gaps in coverage.
By Steven Goethel, Originally Published By United Benefit Advisors
by admin | Mar 29, 2017 | Cybersecurity, Human Resources
I’ve looked at clouds from both sides now
From up and down and still somehow
It’s cloud illusions I recall
I really don’t know clouds at all
— Joni Mitchell, “Both Sides, Now”
And like that song from 1969, it appears that most employees really don’t know cloud computing at all. In an article on the Society for Human Resource Management’s website titled, “Public Enemy No. 1 for Employers? Careless Cloud Users, Study Says,” a North American IT solutions and managed services provider called Softchoice found that 1 in 3 users of cloud-based apps (e.g., Google Docs and Dropbox) download the app without letting their IT department know. Cloud computing became popular a few years ago because people could store all their documents, photos, and other information and then access that data from anywhere at any time and on any device.
What makes this such a bad situation is not the cloud computing itself, but that the vast majority of employees lack any sense of cybersecurity. That same study found that 1 in 5 employees:
- Keep their passwords in plain sight (e.g., on Post-it Notes on their desks).
- Have accessed work files from a device that was not password-protected.
- Have lost devices that weren’t password-protected.
Complicating this further is that the employees who actually do use passwords usually have weak passwords. That is, they are easy to guess (e.g., “1234,” “password,” or their username). Rather than leave a company and its network vulnerable to attack, some IT people suggest a ban on cloud accounts for work.
Security breaches involving a company’s intellectual property can be very costly. Sometimes referred to as “ransomware,” the important data of an organization will either be stolen or encrypted and will not be released until a fee is paid.
A better solution to a ban on cloud accounts would be to educate employees on the necessity for cyber security, train them to improve their online security habits, and remind them that IT rules are in place to make a company more secure, not make it more difficult for employees to be productive. Cyber thieves are clever and when they can’t break into a system using technology, they often rely on the flaws of human nature.
As we become more and more connected to the Internet, we leave ourselves and the companies where we work more accessible to cyber threats. It’s imperative that employees keep everything locked down.
By Tara Marshall, Originally Published By United Benefit Advisors
