Tag Archives: group health insurance

Evolving landscape of preventive services

The introduction of the Patient Protection and Affordable Care Act (ACA) brought about many legislative changes intended to improve the health of people in the United States. One such change was the introduction of mandatory coverage with no cost sharing for services determined to be “preventive.” Some examples of the services included on the A and B Recommendations lists of the U.S. Preventive Services Task Force (USPSTF) are blood pressure screening for adults, depression screening for adolescents and adults, intimate partner violence screening for women of reproductive age, and skin cancer behavioral counseling.

The USPSTF regularly updates its recommendations and the ACA preventive services list has been modified many times since the introduction of the ACA in 2014. In this paper, Milliman’s Barbara Collier and Michelle Klein examine the evolution of preventive services. They also discuss how these services have been impacted by the COVID-19 pandemic.

COVID-19 benefit changes: Action required for employer health insurance plans

This article reflects guidance issued through July 31, 2020; additional changes are possible in the future as the national emergency continues to unfold.

Recently enacted COVID-19 legislation and related federal guidance require some mandatory group health plan benefit changes and offer other voluntary changes you can elect to provide temporary relief to employees. Be aware that some of the changes require that you notify participants via a summary of material modification (SMM) or an updated summary plan description (SPD).

Now you have some work to do: Deciding which relief options to offer and notifying participants about the changes with an SMM or updated SPD. Communication is crucial, especially during this current crisis. With so many uncertainties these days, notifying participants about relief offered through their benefit plans can bring comfort and appreciation for their benefits.

Mandatory group health plan benefit changes

COVID-19 testing coverage

All group health plans (including high-deductible health plans) must cover COVID-19 testing and the doctor’s visit at 100% of the cost (with no cost sharing required of the employee). The plan must pay 100% of the incurred cost of a visit during which a COVID-19 test is administered or ordered, regardless of whether the provider is in- or out-of-network. This includes the cost of items and services related to the administration of a COVID-19 test in a variety of settings: office visits, urgent care, emergency room, drive-through, and telehealth.

When it comes to treatment of COVID-19, however, a recent publication by the U.S. Department of Labor affirms that employers have no mandatory responsibility to waive cost sharing for treatment of COVID-19 symptoms, and the plan’s normal deductibles, copays, and coinsurance may apply.

Suspension of deadlines during the “outbreak period”

The outbreak period for the COVID-19 crisis has been defined as beginning March 1, 2020, and ending 60 days after the national emergency period ends. As of mid-August (the publication of this article), the national emergency period has not ended. Certain group health plan compliance deadlines that would fall during this time have been paused until the national emergency ends. These changes apply to ERISA plans (both health and retirement plans).

What deadlines are affected?

  • HIPAA special enrollment, such as the 30-day election period following marriage, birth, or adoption of a child or loss of other coverage. As an example, if a participant was married on February 14, typically that person would have until March 15 to enroll a new spouse. That deadline is suspended during the outbreak period, and the participant will have until 15 days (time remaining in the original special enrollment period) after the end of the outbreak period to make changes. If, for example, the outbreak period ended on October 1, the participant would have until October 15 to enroll the new spouse.
  • Most participant COBRA deadlines, such as the 60-day period to elect COBRA and all COBRA payment deadlines. This delay gives qualified individuals and beneficiaries significantly more time to evaluate whether COBRA coverage is desirable or affordable, because they can wait until the end of the outbreak period and elect to pay for coverage retroactively.
  • Health flexible spending account (FSA) claim filing deadline. If the original deadline was March 31, 2020, for example, the new deadline will be 31 days after the end of the outbreak period. (Because they are non-ERISA plans, dependent care FSAs are not subject to this rule.)
  • ERISA claims and appeals deadlines for benefit claims, appeals of adverse decisions, and requests for external reviews of decisions are also delayed; claims are not required to be filed until the end of the outbreak period.

Keep in mind: Participants don’t have to wait until the end of the outbreak period to enroll or submit claims.

Voluntary group health plan benefit changes

In addition to these mandatory updates, recent federal guidance allows other voluntary changes to group health plans. If you choose to implement any voluntary provisions, they should also be included in your communication to participants.

For group health plans, you might be considering:

  • Relaxing deadlines for cafeteria plan elections
  • Allowing employees to make certain midyear changes to health plan and FSA elections
  • Extending the 2019 FSA grace period for incurring claims to December 31, 2020
  • Increasing the health FSA carryover from $500 to $550

Show support for your employees

Employees need to hear from you during these challenging times—especially with some good news. Take a close look at what you can do with your benefits program to ease the pressure on employees and support them in some very practical ways.

Report highlights commercial health insurance financial results and emerging trends

Medical loss ratio data published by the Centers for Medicare and Medicaid Services (CMS) provides a detailed picture of insurer financial results from the fourth full year of Patient Protection and Affordable Care Act (ACA) implementation. This data, supplemented with CMS marketplace and statutory financial data through calendar year 2018, illustrates continued stability in group insurance markets in terms of both enrollment and insurer financial results. However, the individual market is experiencing declining enrollment outside the insurance marketplaces and yet significantly improved financial results for the insurers relative to 2014 through 2016.

Individual market enrollment declines prompted several state-based initiatives to improve affordability for nonsubsidized consumers. As of April 2018, seven states have received approval from CMS for a Section 1332 State Innovation Waiver for implementing a state-based reinsurance program to improve premium affordability. The impetus for these state-based initiatives, which primarily benefit consumers not qualifying for federal premium assistance, is supported by a number of national enrollment trends.

  • National off-marketplace enrollment for ACA-compliant coverage declined from 4.9 million in 2016 to 2.4 million in 2018.
  • Marketplace Advance Premium Tax Credit (APTC) consumers represented 56% of national ACA-compliant enrollment in 2016, increasing to approximately 70% in 2018.
  • Marketplace APTC enrollment has remained relatively stable from 2016 to 2018, varying from 8.2 million to 8.6 million across the three-year period.

While individual market enrollment continued to decline in 2018, underwriting margins reported in year-end financial statements indicate the health insurance industry’s margins improved. The individual market experienced a nearly 10% underwriting loss in 2015 compared to underwriting gains likely approaching 10% in 2018.

This report, written by Paul Houchens, Jason Clarkson, and Jason Melek, provides a detailed review of the commercial health insurance industry’s financial results in 2017 and evaluates changes in the market’s expense structure and enrollment relative to prior years. It also discusses emerging financial trends for the commercial health insurance markets.

Commercial health insurance: Overview of 2016 financial results and emerging enrollment and premium data

In this report, Milliman’s Paul Houchens, Jason Clarkson, and Jason Melek provide a detailed review of the commercial health insurance industry’s financial results in 2016 and evaluate changes in the market’s expense structure and enrollment prior to relative years. They also provide enrollment and Advanced Premium Tax Credits estimates for 2017.




Five ways the Amazon/Berkshire Hathaway/JPMorgan Chase deal could change healthcare in the U.S.


This week, Amazon, Berkshire Hathaway, and JPMorgan Chase announced plans to join forces in order to provide their U.S. employees with healthcare solutions that are “simplified, high-quality and transparent.” Large employers are growing increasingly frustrated with the challenge of providing their employees with affordable, high quality healthcare, and the announcement has many speculating that the partnership could disrupt the U.S. market.

Amazon, Berkshire Hathaway, and Chase bring a fascinating blend of perspectives to this area. And while we don’t know exactly how they will transform healthcare, we do have ideas of what could be possible (imagine a world where insurance claims might be a thing of the past). In this article, Milliman experts explore the ways in which healthcare could change as a result of this venture.




Commercial health insurance financial results provide insight into ACA program stability

Milliman has released its annual report on the commercial health insurance market’s financial results, which provides a clear picture of health insurers’ financial experience in a given year. The report, based on medical loss ratio data submitted to the Centers for Medicare and Medicaid Services (CMS) and released in the fall of 2016, provides a final accounting of insurers’ financial results after “3R” transfer payments have been completed. Today’s report details results for 2015, the second full year of implementation of the Patient Protection and Affordable Care Act (ACA). The report also summarizes estimated effectuated insurance marketplace enrollment through 2016 and corresponding federal expenditures on premium and cost-sharing assistance. As the United States approaches a potential new round of healthcare reform, Milliman’s report is a helpful tool in analyzing the effect of current ACA financial assistance components to consumers and the impact on the health insurance industry from the insurance marketplaces and “3R” programs.

Key takeaways from Milliman’s report include:

• Underwriting margins in the individual market deteriorated from a 6.0% earned premium loss in 2014 to a 9.6% loss in 2015. The 2015 underwriting losses were due in large part to the risk corridor program funding shortfall.
• With no funding currently scheduled, the cumulative risk corridor payment shortfall has reached $8.3 billion, with nearly 90% owed to insurers in the individual market.
• Since 2013, individual market enrollment has increased from 10.9 million to 17.5 million, driven by the introduction of the insurance marketplaces and associated premium assistance. Conversely, the fully insured small group enrollment has shrunk from 17.3 million to 14.7 million, which is attributable primarily to fewer small employers offering coverage.
• The insurance marketplaces continued to take on a greater role in the individual health insurance market, with 56% of estimated 2016 market-wide enrollment attributable to coverage purchased in the marketplaces, relative to only 36% in 2014.
• From 2014 to 2016, the percentage of individual market enrollees receiving premium assistance has increased from 31% to 47%. Similarly, enrollment in cost-sharing reduction plans is estimated to have increased from 21% to 32% of national individual market enrollment.

Milliman’s overview of financial results provides a comprehensive look at insurers’ financial experience as well as the number of Americans impacted by marketplace subsidies under the ACA. As new healthcare proposals are debated in Washington, we believe this report provides a valuable tool for policymakers and insurers looking to better understand how insurance markets may react to future regulatory and legislative changes.

To receive regular updates of Milliman’s healthcare reports, contact us at here.