The Trump Administration is pushing ahead
with rules requiring hospitals to disclose their contracted rates with
insurance carriers and Preferred Provider Organizations (PPOs) for 300 “common”
services, effective January 1, 2021.
The administration’s push for transparency
in healthcare pricing will also require insurance carriers to disclose the
rates they negotiate with hospitals and physicians.
It is expected that some hospitals will
challenge the transparency rule in court, and many insurance carriers are also
likely to object to the new regulations.
Will Transparency Decrease Costs?
If the disclosure rules go into effect,
what is the likely prognosis for the cost of healthcare? Will the disclosure of
contracted rates spur competition and cause hospitals to reduce prices to
maintain business? Recall years ago, when Lasik providers began to advertise and
actively compete with each other – the result was reduced fees for laser eye
Or, conversely, will the new disclosure
rules lead lower-cost hospitals to increase prices for services, so that they
are more aligned with their pricier competitors?
A desire for transparency in healthcare
pricing has been an ongoing issue – and numerous experts believe it is one of
the reasons true “consumerism” is difficult to achieve. It remains to be seen
if competition in healthcare can truly drive down costs.
Potential Effect on Reimbursement
In recent years, there has been a change in
reimbursement methods from volume-based methods to those based on quality and
value. The new rules may drive the creation of even newer algorithms that blend
allowed charges with quality scores in an effort to come up with the “best
Proponents of “Fair Market Pricing” may experience
a boost, too, as they are able to illustrate a maximum allowed cost for a
variety of procedures in a given geographic area. It is unknown, however, if
employers will embrace such a change in how charges are derived and subsequently,
expose their employees to balance billing and/or collections.
As additional details about the disclosure rules for contracted rates become available, we will provide updates. Questions? Contact the Findley consultant you normally work with, or contact Bruce Davis at 419.327.4133 or email@example.com.
January 1, 2020, employers can establish two new Health Reimbursement Accounts
(HRAs) — an Individual Coverage HRA (ICHRA) and an Excepted Benefit HRA (EBHRA).
This could be a significant development for employers sponsoring employee
health benefit plans — both insured and self-funded.
Questions Employers Should Ask
consider the following questions regarding the impact of the new rules.
new HRA rules change how your organization delivers health benefits? If
believe these new rules will facilitate more job mobility? If so, how will that
trend impact your ability to retain talent, or attract new associates?
How Did We Get to this Point?
You may recall that
in October 2018, proposed regulations were released by the Departments of
Health and Human Services, Labor, and Treasury to enable employers of all sizes
to use a Health Reimbursement Arrangement (HRA) to finance individually-purchased
health insurance on a tax-preferred basis.
Comments on the
proposed regulations were due by December 28, 2018. In June 2019, final
regulations were released and generally apply for plan years beginning on or
after January 1, 2020.
currently purchase health insurance from either the ACA Marketplace (i.e. the
public “exchange”) or directly from an insurer.
Employers with less than 50 full-time employees can currently reimburse an employee for individual health insurance premiums using a Qualified Small Employer HRA (QSEHRA). In 2019, the amounts an employer can contribute to a QSEHRA are limited to $5,150 for Single coverage or $10,450 for Family coverage.
Effective January 1,
2020, two new HRAs can be established.
Individual Coverage HRA (ICHRA)
As long as the individual purchases ACA-compliant health
coverage, the employer (of any size) can reimburse the employee for those
premiums subject to these rules:
The employer cannot also offer a traditional group health plan in addition to the ICHRA
Offering an ICHRA will satisfy the ACA employer mandate under Section 4980H so long as a) the affordability threshold is met; and b) the employer makes the ICHRA available to entire classes of employees, such as FTEs, or PTEs. However, there are minimum class sizes:
For those employers with less than 100 employees: minimum class of 10 employees
For employers with 100-200 employees: the minimum class is 10% of total employees
For employers with more than 200 employees: the minimum class is 20 employees
A notice of the availability of an ICHRA must be provided at least 90 days prior to the beginning of the plan year (a model notice accompanied the final regulations)
When an employee or their dependent gains access to an ICHRA, a Special Enrollment Period applies
The amounts contributed to the HRA must not favor highly compensated individuals—there are only two instances in which the employer’s HRA contributions can vary: a) older employees may receive higher amounts (but not to exceed a 3:1 age band); or b) employees with greater numbers of covered dependents may receive a higher amount
no limit on the amount the employer can contribute to the ICHRA and
amount of the ICHRA reimbursement is not taxable to the employee
Excepted Benefit HRA (EBHRA)
wishing to continue offering traditional health benefits (including PPOs, HMOs,
or qualified high deductible health plan/HSA plans) can offer an EBHRA to pay:
reimbursements are also tax-exempt, the amount that can be contributed by the
employer is limited to $1,800 per year. This amount will be indexed for
inflation after 2020.
An employee could
opt-out of his/her employer-sponsored health plan and still be eligible for the
EBHRA. However, an employee cannot have both an ICHRA and
contribution (DC) approach to employee health benefits is not new. A few
years ago, private health insurance exchanges were a hot topic. However,
they did not catch on for active employees, primarily because the insured
models were inefficient due to state premium taxes, ACA market share fees and
broker commissions. In addition, they had an unsatisfactory record in
providing long-term rate stability.
The ICHRA promises
to be more viable, assuming the individual health insurance market remains
healthy. Remember, the ACA still applies to the individual market in that
a person can’t be denied coverage due to pre-existing condition, or have his/her
premiums increased because of health status.
When HIPAA was
enacted in 1996, a key objective was to facilitate portability of health
insurance and end “job lock”. However, that goal was not fulfilled in an
employer-sponsored health benefits environment. But with individually-purchased
health insurance, portability is achieved. As a result, will employees be more
apt to change jobs and either look for employers with ICHRAs or negotiate
additional compensation to pay their health insurance premiums? If so, how
does this impact an employer’s employment value proposition, or their ability
to retain qualified talent?
Although the Trump
Administration believes these HRA rules will appeal mostly to small-to-medium
employers, it is likely larger employers looking for an effective DC approach
to health benefits will take a serious look at ICHRAs. Although health
care cost trends have moderated somewhat in recent years, they are still accelerating
at three times inflation. Any opportunity to budget health benefit
expenses on the same basis as wage and salary increases is very important to
continue to follow HRA developments. To learn more about how these rules impact
your future health care strategy, appropriate employee communications, or
suitable HRA administrative arrangements, contact your Findley consultant or
Bruce Davis at firstname.lastname@example.org or 419. 327.4133.