The Patient Protection and Affordable Care Act (ACA) introduced many changes to the individual health insurance market beginning in calendar year (CY) 2014, including new rating rules and federal financial assistance to purchase health insurance through the insurance marketplaces. It is important to understand the condition and stability of the individual health insurance market and how the ACA has affected its health insurance consumers.
To support this understanding, actuaries Paul Houchens, Jason Clarkson, and Zachary Fohl prepared Milliman’s second annual profile of the individual health insurance market for each state along with the District of Columbia (DC). The profile summarizes insurer financials, marketplace enrollment, and federal assistance provided to households purchasing insurance coverage through the insurance marketplaces, incorporating recently released data from the 2018 open enrollment period and early 2018 effectuated enrollment snapshot.
This information is vital for stakeholders for a number of reasons, including:
1. Future legislation or administrative actions. While the pace of new healthcare reform legislation will likely slow in 2018 with the upcoming mid-term elections, data from the individual marketplace can be useful in informing future policy decisions both at the federal and state level.
2. 1332 State Innovation Waiver (1332 Waiver). The information in our state profile reports can enable a state to better understand the funding and coverage requirements that must be adhered to under Section 1332 of the ACA.
3. Marketplace enrollment trends. One important measure of risk pool stability is enrollment.
4. Cost-sharing reduction (CSR) termination. From CY 2014 through the first nine months of CY 2017, insurers received direct federal payments for the cost of providing CSR variants. However, effective October 2017, CSR payments were terminated by the federal government.
To read the full article which summarizes 2018 individual market enrollment and ACA subsidies, click here.
In 2019, the Centers for Medicare and Medicaid Services (CMS) will begin partially calibrating the HHS-HCC commercial risk adjustment model using actual Patient Protection and Affordable Care Act (ACA) experience from the 2016 EDGE server data submissions. CMS has based the model solely on non-ACA data up to this point.
This article by Milliman’s Zach Davis, Phil Ellenberg, and Brian Sweatman contains four interactive exhibits that allow issuers to review coefficients from the 2019 model. They can also compare how the EDGE data incorporated into the 2019 model will affect risk scores, and the magnitude of the impact on an issuer’s risk adjustment transfer.
Multiemployer health and welfare funds face a difficult challenge—how do you maximize benefits provided to your members while operating under a collective bargaining arrangement where the contributions paid to the fund are generally predetermined? In other words, how do you get the biggest “bang for your buck”?
There are a few ways to maximize the dollars spent on benefits—including optimizing pricing terms from vendors and audits, and reducing administrative costs.
Creating a benefit program that operates efficiently traditionally depends on the size of the group. Many insurance carriers, third-party administrators (TPAs), and pharmacy benefit managers (PBMs) offer more favorable pricing to groups that are larger in size. TPAs may offer lower administrative services only (ASO) fees and PBMs may offer better administrative fees, discounts, and rebate guarantees. Larger groups may also be able to negotiate trend or maximum increase guarantees in their renewals.
An alternative way to achieve better pricing terms is to join a labor coalition. Labor coalitions are set up as a group of welfare funds that contract with a particular provider or providers in exchange for more attractive pricing. The coalition operates as a collective with a board that makes recommendations, but each individual fund is still responsible for its own claims experience. The benefit is that vendors (generally, PBMs and stop-loss providers) will offer better pricing or lower administrative costs because they have exclusive contracts with the larger coalition, so each individual fund receives pricing based on a population much larger than its own.
In addition to administrative expenses that are paid to insurance carriers and TPAs, funds should review operating expenses. Administrative expenses are necessary so that a fund can provide benefits to its members, but dollars that are devoted to administration are dollars that are not being used to provide benefits to members. Therefore, it is in the fund’s and the members’ best interests to keep administrative expenses as low as possible, by reducing duplicative operations or by consolidating certain efforts.
You can also ensure that the dollars spent on claims are consistent with the intent of the plan with a claims audit and / or a dependent eligibility audit. A claims audit is generally performed by an outside vendor, who reviews a sample or a certain subset of self-insured claims that the fund’s TPA pays on behalf of the fund. Claims audits typically need to be written into the TPA contract. Dependent eligibility audits are also generally conducted by an outside firm that sends mailings to all members with dependents. Members must provide proof of eligibility (e.g., birth certificates, marriage certificates) for each of their dependents so that their dependents continue to be eligible for the plan. A dependent eligibility audit can remove spouses who are divorced or children who aged off of the plan, ensuring that the dollars spent on members and dependents are only for those who actually should be on the plan.
Finally, it is good practice to do market checks or requests for proposals (RFPs) on a regular basis. A market check is a pricing comparison and analysis to compare competitive pricing for substantially similar-sized customers and for substantially similar PBM services. The market check is measured on the basis of a total, aggregate comparison of the pricing terms offered by a single vendor to a single plan, and not on the basis of individual pricing components or best price points available from multiple vendors. Aggregate PBM pricing comparison includes the sum of the cost of medications, including dispensing fees and claims administrative fees, less rebates received by the plan. This type of analysis creates leverage in negotiations with current PBMs, as well as informing trustees when it may be time to renegotiate and / or consider a more competitive PBM contract. On the other hand, an RFP process asks for quotes from other providers (in addition to your current provider) and allows you to determine whether another carrier or service provider can provide a better or more cost-effective product. For prescription drugs, it is a good idea to do a market check on a regular basis, although PBM contracts often establish market check parameters that limit the ability of plans to perform this important benchmarking. It is also a good idea to perform an RFP once the contract is set to expire, allowing yourself enough time (at least three – six months) to implement a new carrier as smoothly as possible if you decide to switch after analyzing the RFP results. For other vendors, it is a good idea to do an RFP on a regular basis.
Milliman is pleased to announce the recipients of this year’s Opportunity Scholarship program. This scholarship program, now in its second year, was created to assist students from ethnic groups and races that are under-represented in the fields of actuarial science, data science, computer science, economics, programming, mathematics, statistics, data analytics, or finance.
This year, the Opportunity Scholarship recipients include 16 students from colleges and universities across the United States, Australia, South Africa, and the United Kingdom who have demonstrated academic excellence and plan to pursue a career in actuarial science or related fields. Last year, which was the inaugural year of the scholarship, 12 scholarships were presented.
“Milliman is proud to assist students from diverse backgrounds in achieving their educational goals in fields like actuarial science, mathematics, computer science, and finance,” said Milliman Chief Executive Officer Steve White. “This year’s group of recipients comes from a wide array of backgrounds and has shown that they excel academically, with the drive and knowledge to succeed.”
Below is the list of this year’s Scholarship recipients:
Buried within the new amendment to the tax code, the Tax Cuts and Jobs Act, is a provision to allow employers to take a tax credit for providing paid family and medical leave for their employees. The United States is the only developed nation that does not offer paid leave for employees to care for family members. This new provision is a small step to try to fill that gap.
Starting in 2018, employers can now take an additional tax credit for part of the wages that are paid to employees taking qualified leaves. However, the provision is currently set to terminate at the end of 2019, which may make some employers think twice about whether this is the right time to begin offering paid leave. This article will lay out the provisions of the new credit and provide thoughts on how employers can offer this benefit to their employees. Milliman does not provide tax advice, and the commentary provided in this article should not be construed as such. Companies are encouraged to seek tax or legal counsel before pursuing any particular tax strategy.
Who is covered?
An employer is eligible for a tax credit for eligible paid family and medical leave benefits paid to an employee who has been employed by the employer for one year or more and who earned less than 60% of the “highly compensated employee” limit under § 414(q)(1)(B) in the prior year. That means, for 2018, this credit will only apply to employees who made less than $72,000 in 2017. That doesn’t mean that an employer should exclude its higher-paid employees from this benefit, just that the benefits paid to higher-paid employees will not be eligible for the tax credit.
What types of leaves are covered?
In order to receive this tax credit, the program must cover the same types of leaves as those covered under the Family and Medical Leave Act of 1993. These leaves may be taken for the following reasons:
• Birth of a child
• Adoption or fostering of a child
• To care for a spouse, child, or parent with a serious health condition
• The employee’s own serious health condition
• A qualifying exigency arising out of the fact that a spouse, child, or parent is on (or called to be on) active duty in the armed forces
• To care for a member of the armed forces or a veteran (with service in the past five years) with a serious injury or illness who is the employee’s spouse, child, parent, or next of kin
However, if the leave is provided as vacation leave, personal leave, or medical or sick leave (other than for one of the reasons above), then the leave does not qualify for the paid family and medical leave tax credit.
What amount of benefit needs to be provided?
A benefit amount between 50% and 100% of wages must be provided for at least two weeks in order for the employer to receive the tax credit. The tax credit is only available on the first 12 weeks of benefit paid in a year. Appropriate
adjustments are made for part-time employees.
How to determine the amount of the credit?
The amount of the paid family and medical leave tax credit is a sliding scale that increases from 12.5% to 25% of the amount of benefits paid to qualifying employees. The amount varies based on the percentage of the wages that are being replaced. The applicable percentage used to determine the tax credit is 12.5% increased by 0.25% for each percentage point that the rate of payment exceeds 50%. The table in Figure 1 is an example of how the tax credit works for an employee earning $1,000 per week and various options for the percentage of wages being replaced while on leave.
Does this credit apply to employers in states that mandate paid family leave already?
This tax credit doesn’t apply to state-mandated leaves. The regulation says that any leave that is paid by a state or local government or mandated by a state or local government shall not be taken into account when determining the amount of paid family and medical leave provided by the employer. Currently California, New Jersey, New York, and Rhode Island have mandated paid family and medical leave programs in place. In addition, Massachusetts, Washington, and Washington D.C. have passed leave legislations and will have mandated programs in place in the next few years.
Considerations in deciding to offer a paid family and medical leave program
If an employer decides to begin offering paid family and medical leave to its employees, it has a few decisions to make. The first decision is whether to insure the plan with an insurance company or to self-insure the benefit. If it decides to self-insure, it then will also need to decide if it wants to administer the plan on its own or if it wants to use a third party administrator (TPA).
The decision of whether to insure or not depends on the employer’s risk tolerance and cash flow availability. Taking into account the employee demographics, an estimate of expected claims costs and expenses can help an employer make the right decision for itself.
Milliman has assisted numerous clients in evaluating whether or not to adopt a paid family and medical leave program for their employees. Claims costs, expenses, and other risk considerations are all important items to review before implementing a new program. The interaction of the new plan with an existing leave program is often an important consideration as well. For example, the way that employees transition from a short-term disability maternity claim to a new child family leave should be carefully thought through from both the employee and the employer perspectives. In our experience, it is not only the cost of the program but also the employee’s experience, which are both important considerations.
More healthcare-related regulatory news for plan sponsors, including links to detailed information.
Agencies release final rule on short-rerm, limited duration health insurance
The Department of Labor’s (DOL) Employee Benefits Security Administration (EBSA), the Department of Treasury, and the Department of Health and Human Services (HHS) issued a final rule amending the definition of short-term, limited-duration health insurance that individuals may purchase. The final rule permits insurers to sell policies that cover periods longer than the three-month maximum permitted under the Patient Protection and Affordable Care Act (ACA), allowing for an initial period of 364 days and for renewals of up to 36 months.
Medicare Part D premiums continue to decline in 2019
The Centers for Medicare & Medicaid Services (CMS) announced that the average basic premium for a 2019 Medicare Part D prescription drug plan is projected to decline for the second year in a row. Earlier this year, CMS announced several changes in the Part D program aimed at further empowering Part D plans to drive a hard bargain with drug manufacturers and lower the cost of prescription drugs. CMS has been working to ensure that Medicare Part D plans can leverage all of the tools that are available to commercial plans in negotiations.
CBO publishes report on the cost related to employer mandate repeal and Cadillac tax delay
The Congressional Budget Office (CBO) released estimates related to the cost of the “Employer Relief Act” (H.R.4616), which would suspend the collection of penalties on large employers that decline to offer qualifying health insurance coverage for plan years 2015-2018 and delay implementation of the excise (“Cadillac”) tax on high-premium insurance plans by one year. The report assessed the costs based on the legislative text approved by the House Ways and Means Committee on July 11.