Backdoor Regulation of Self-Funding – Stop-Loss and the Affordable Care Act

When the Patient Protection and Affordable Care Act (“PPACA”), (now commonly referred to as the  Affordable Care Act, the ACA, or "Obamacare") was signed into law by President Barack Obama on March 23, 2010, both the health benefits and health care industries were abuzz with rumor, conjecture, and fear.  As the dust has settled, we who service these industries have begun to appreciate the real impact the law has had on both the provision of health care, as well as payment for that care. Continue Reading >

Managed Care Vendors are an Important Part of a Self-Funded Health Plan

Most self-funded plans utilize the services of a third party administrator (TPA) or an Administrative Services Only (ASO) carrier to act as the medical claim payer for their self-funded plans.   The services provided by these organizations typically include claims adjudication and benefit plan administration.  The services should also include management of service providers to help lower the cost of claims. Continue Reading >

The impact of mental health and substance abuse coverage on self-insured plans

The issue of mental health in the United State is significant.  An estimated 26.2% of Americans ages 18 and older suffer from a diagnosable mental disorder in a given year according to the National Institute of Mental Health.  So what should employers know about compliance and the cost associated with mental and substance abuse coverage? Continue Reading >

Knowing Experimental Drugs: In your Health Plan and Stop Loss Policy

Experimental drugs are a proposed treatment for an illness such as cancer that has been tested in a laboratory and has received approval from the FDA to begin treatment on people.[i]   They have many uses that are vital, and often times the circumstances are life and death.  Even so, they are not always covered under all insurance plans across the United States, due in part to the unknown efficacy and cost of the drugs.  If experimental drugs are covered under your plans it is essential to take note in what instances they are covered, specifically clinical trials or off label drug use.  Therefore, if you are choosing an underlying plan (HMO, PPO) or a stop loss policy (for self insured plans) for your employees it is important to know what is covered under each. Continue Reading >

Workplace Wellness Programs for Self-Funded Employers

Workplace Wellness Programs for Self-Funded Employers:  Effective program design to maximize  potential cost savings!  An increasingly popular means of reducing health care expenses for self-funded employers are workplace wellness programs.   Approximately half of U.S. employers utilize this cost management strategy.  In this article we will explore typical elements, ways to ensure success, and the potential cost savings of effective workplace wellness programs. Continue Reading >

Factors to Consider for Self Funding Your Health Plan

If you are considering a self-funded health plan for your company you are certainly not alone!    Many employers, both small and large are now exploring the option of self insuring their health plan for a variety of reasons with larger long term savings topping the list.   However, self funding isn’t right for everyone; therefore we will discuss some of the factors you’ll want to consider before making any changes to your health plan. Continue Reading >

The Attack on Self-Funding

The Patient Protection and Affordable Care Act (PPACA), better known as Obamacare, set to take effect January 1, 2014, will make sweeping policy changes to America’s health care and insurance industries.  The self-funding niche of the health insurance market, where employers forgo premium payments and fund their own medical costs, was on track to survive relatively unscathed by the new taxes, requirements and restrictions created by the PPACA. However, self-funding and stop-loss insurance are increasingly attracting the attention of lawmakers.  As a result of increasing regulation, the sanctuary that has been dubbed the “self-insurance loophole” is shrinking. Continue Reading >

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In 2011, the top 5 most expensive medical conditions treated in US hospitals were: Septicemia, Osteoarthritis, Complication of device, implant or graft, Liveborn, and Acute myocardial infarction

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From 2010 to 2013, the number of claims that were individually $1 million or above rose by 1,000%

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In 2017 approximately 18% of the American public will purchase insurance through exchanges, radically transforming the health insurance landscape.

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In 2014, 98% of large firms (= 200 Workers) offer 1+ wellness programs to their employees.

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The most costly 1% of patients account for 20% of national health expenditures – accruing average annual expenses of nearly $90,000 per person.

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6% of firms offering fully-insured plans report they intend to self-insure because of Obamacare.

Reference: “2013 Employer Health Benefits Survey”. The Henry J. Kaiser Family Foundation.

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In 2014, PPO plans remained the most common plan type, enrolling 58% of covered workers.

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In 2012, 93% of businesses with 5,000+ employees and 80% of companies with 1,000-4,999 employees were self-funded

Massachusetts has the third-highest prevalence of self-funded insurance in the small-group market (Fewer than 50 employees).

Reference: “Self-Insured Health Plans: State Variation and Recent Trends by Firm Size”. Employee Benefit Research Institute, Nov 2012, Vol. 33, No. 11.

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In 2013, the average deductible was $2,906 for individuals selecting plans from marketplaces. This compares with average deductibles of $1,135 for an individual with employer coverage.

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In 2013, the average annual premiums for employer-sponsored health insurance are $5,884 for single coverage and $16,351 for family coverage, up 5% and 4% respectively from 2012.

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From 2010 – 2013, cancer followed by chronic/end stage renal disease and leukemia accounted for the top 3 costliest illnesses.

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