Selecting the best specialty coverage for your health plan

When evaluating which specialty coverage — vision, dental, life or disability — to include in their employee health plan, employers may benefit from going back to the basics.

“Employers should remind themselves that while the marketplace always evolves, some aspects may remain the same. They should continually evaluate the latest, greatest differentiators between specialty line carriers to ensure they are getting the best coverage,” says Lee Bowers, specialty sales executive at Anthem, Inc.

Smart Business spoke with Bowers about what employers need to weigh when adding specialty coverage to their health plan.

What should employers pay attention to in regards to network access?

When selecting a specialty carrier, employers should look for a strong local and national dental and vision network. They should also look for a vision carrier that has a blended network of independent practitioners — opticians, optometrists and ophthalmologists, the leading retail providers in the marketplace, such as Sears or Lenscrafters, and more regional vendors like Crown Vision Centers and Clarkson EyeCare Centers. A strong mix is important as employees may choose to see an independent practitioner for their eye exams, but prefer the convenience and access that a retail provider offers.

How do contracts need to be set up?

When it comes to contracts for specialty coverage, there is more than meets the eye. For example, many employers tend to focus only on the copayments associated with exams and materials (lenses or eyeglasses), but they may be overlooking additional services that are not covered, but are often preferred, such as polycarbonate lenses or scratch coating. Contracts for dental coverage are evolving, too.

Many carriers are changing the way they cover certain services. For example, crowns and bridges may be covered only every seven to 10 years instead of every five years as it has been in the past. These sorts of changes may seem slight, but they could have a significant impact on employees’ out-of-pocket costs. That’s why it is important for employers to assess the contract associated with their current specialty coverage and then shop and compare other available contracts.

What’s important to know about integrating benefits?

Many leading insurance experts believe there is real value in integrating benefits to provide extra diagnostic and preventive care. For example, regular dental cleanings may detect symptoms that trigger or require further intervention on behalf of that member. By having an integrated benefit solution, a more proactive approach may help get the employee the resources and assistance he or she needs to get on the right treatment track, rather than being passive and waiting for the medical condition to deteriorate. The result is better health for the employee as well as the group, which can lower the costs of the overall health plan.

How do voluntary plans fit into specialty coverage trends?

As medical and other personnel costs continue to increase, many employers are moving away from an employer-sponsored dental, vision, life or disability plan. As an alternative, employers may offer an ancillary program where the employee pays for the benefit. This sort of voluntary plan allows employees to elect the additional coverage that suits their personal needs.

When deciding which carrier is best for their specialty coverage needs, employers should still pay close attention to network strength, contractual provisions and competitive rates. However, it is also important that the selected carrier has enrollment procedures, communication materials and other support they can provide for employees. Whether it is via hard copy informational kits, electronic communications or even phone-based webinars, the carrier should have a process in place to get the plan set up and encourage employees to participate in the voluntary coverage options.

When selecting a carrier to provide employee benefits, employers should feel confident that there is a solid plan in place to ensure the best possible outcomes for employees.

HealthLink is a fully owned subsidiary of Anthem, Inc., one of the nation’s leading health benefits companies.

Insights Health Care is brought to you by HealthLink

How to use customer service to reduce your costs

Most people call customer service when they have a problem or a complaint. But proactively using customer service to get information or ask questions could help employers, and their employees, save on their health care costs.

“While some large group employers may have a customer service line dedicated to their account, small and midsize employers also can benefit from educating their employees about the customer service department,” says Karen Gotsch, manager of Customer Care at HealthLink, Inc.

Smart Business spoke with Gotsch about best practices for customer service in your health plan.

In an ideal world, how should customer service function for a health plan?

Ideally, customer service should function as a go-to resource for employees looking to get the most from their benefit coverage. Customer service can find providers that meet employees’ needs and participate in their health plan, ensuring they receive the highest level of benefits on medical services.

Customer service can also help employees determine what services are covered and whether or not they need pre-certification. Otherwise, employees could end up paying more out-of-pocket if they receive care that isn’t covered.

What’s the reality for many companies?

Many employees are still not well educated about their health plan and the best practices for maximizing their benefits. Employees often assume they’ll receive their full level of benefits, no matter which doctor or facility they choose, which isn’t necessarily true. They don’t always understand or take into consideration that there may be exclusions or limits associated with their health plan.

How should employers educate their employees about customer service?

Employers have a unique opportunity to educate their employees about their health plan benefits. Employers should focus on having the information readily available so it is easy to access when a question arises. Open enrollment is prime time to talk about benefits as most employees are engaged in the decision-making process at that time. It’s also important to use easy-to-understand layman terms and avoid terms that are highly technical when possible.

Employees need to be aware that customer service is available as a resource to help with any questions or concerns.

Do smaller companies concerned about resources and time need to take a different approach?

Employees should be educated about their health plan benefits no matter the size of the company or employee group — and it doesn’t have to take a lot of time and resources. Employers should utilize communication avenues they already have in place, such as their website, employee newsletters and other internal communications. Smaller companies that don’t have a corporate intranet or newsletter could try making benefit education a part of their next scheduled team meeting, or simply send an email out to their employees.

What are the benefits of being proactive?

Using customer service as a proactive resource can positively affect employees in a number of ways. Taking the time to find a provider that is a good fit and that participates in their health plan can lower out-of-pocket costs. They can also utilize customer service to determine what their out-of-pockets costs will be, whether or not certain procedures are covered and if there are pre-certification requirements.

This sort of education can ensure employees don’t receive a surprise bill, and it gives them the knowledge they need to review their Explanation of Benefits (EOB) for accuracy to avoid overpayment.

What else is important to know?

Employers should educate their employees about any self-service options, such as online bill pay or how to search for a doctor. These tools can save employees time and help them get the most from their health plan in a way that is easy and convenient.

Employees should always review their EOBs for accuracy before paying a bill. It is important for employees to understand that they may have different plans for different benefits so they know whom to call with questions. Keeping all of this important information together and easily accessible when calling customer service is also a great way to save time.

Insights Health Care is brought to you by HealthLink

How health care fraud has changed in the electronic age

In the electronic age, fraud is a major concern. As consumers become more engaged in making informed health care decisions, health care fraud has evolved. Your employees’ understanding and concerns about fraud needs to evolve as well.

“Nearly every aspect of life can be conducted online and is susceptible to hacking and theft. The health care industry is shifting toward more web-based services, such as telehealth. More online services provide more opportunities for criminals,” says Howard Levinson, DC, CFE, AHFI, clinical fraud director, Special Investigations Unit, at Anthem, Inc.

Smart Business spoke with Levinson about how employers can impact the risk of fraud.

What fraud are you seeing in health care?

The majority of health care providers submit their claims for payment electronically. More than 1 billion claims are submitted annually to Medicare. Private payers process hundreds of thousands of claims on a daily basis. For the most part, that volume is handled by sophisticated computer software, and in many cases a human eye never sees it.

Fraudsters can generate claims for fictitious patients just by entering data into billing software. They can submit claims for services that were never rendered. Unscrupulous providers, who know a service wouldn’t be covered, may purposefully enter incorrect data. For example, a large sports medicine practice was aware a certain joint injection wasn’t covered by a health plan. In order to have the treatment paid by the plan, however, the provider submitted an alternate code for a service that was covered. The plan’s investigators discovered the scheme during an audit. The overpayment for the miscoded service was nearly $1 million.

In addition, the Affordable Care Act (ACA) mandated electronic medical records (EMR) as the standard. EMRs have proven effective and efficient in documenting patient care but have also created opportunities for fraud. An unscrupulous provider can cut and paste patient visit information that isn’t timely or accurate, or create an entirely fictitious EMR to submit as a claim for payment.

Investigators are challenged by the time it takes to identify fraudulent records. They must review individual records to compare visit information and look for potential duplicates or cloned information. If suspicious information is detected, the investigator then must interview patients, physicians and their staff.

Also, the audit function of most EMR systems keeps track of all patient visit entries, entry changes and every time someone accesses that EMR. While this function helps identify potentially cloned or copied patient visits, lab findings or symptom descriptions, some programs don’t have an audit function or the provider can turn it off.

How can employers help minimize the risks?

Employers should educate their employees about health care fraud, waste and abuse. Federal and state agencies offer educational materials and services, so tap into these and make them readily available to employees.

Employers should ensure their network and systems are secure and adhere to the latest security guidelines. Require company-wide education on computer and mobile security standards and advocate for the use of strong, regularly updated passwords.

Also, educate employees on potential scams such as phishing emails, online pop-up ads or links that seem legitimate but have attachments that shouldn’t be opened.

What are other best practices?

Employees should take the same safety measures they would with their financial information. Also, they should be suspicious of anyone offering anything in exchange for personal and health care information, such as free medical equipment, whether via an unsolicited phone call or what appears to be a legitimate television ad.

They should review all medical bills, Medicare summary notices and explanation of benefits to make sure the medical services listed were received and are being accurately billed. If unusual or questionable charges appear, they should contact their health care provider or health benefits plan.

Criminals are targeting health care and their methods are getting more sophisticated and complex. Make sure you educate your employees on the potential tactics used by criminals and the high cost of fraud, waste and abuse in the health care industry.

Insights Health Care is brought to you by HealthLink, Inc. HealthLink is a fully owned subsidiary of Anthem, Inc., one of the nation’s leading health benefits companies.

How using a three-tier network strategy can contain health care costs

Traditionally, health insurance employee benefits have two tiers — in-network and out-of-network. But in self-funded solutions, in particular, you may have the ability to set up a three-tier benefit design.

This network strategy can help you contain cost by incentivizing and channeling your employees to lower cost facilities and doctors, says Abbe Mitze, account executive II at HealthLink.

“By influencing your employees’ behavior in a non-disruptive way, you’re using the carrot approach versus some type of punitive measure,” Mitze says. “And I’ve seen an example where a 30 percent shift occurred while employees were seeking care when this type of arrangement was introduced to them over the course of a year.”

Smart Business spoke with Mitze about setting up a three-tier benefit design.

Why is it so important to try to contain health care costs?

Health care premiums continue to increase for the 55 percent of firms that offer health benefits to at least some of their employees. The annual survey of employers by the Kaiser Family Foundation found that annual premiums for employer-sponsored family health coverage reached $16,834 in 2014, which is up 3 percent from the year prior. Of that amount, workers paid $4,823 on average toward that cost.

If employers want to continue to offer health plans — which can be used as a recruiting tool — they must find ways to better manage their costs.

How does a three-tier benefit design work?

A three-tier option introduces in a third tier of benefits that is based upon the cost of care with the facility or provider. A facility and provider is placed into tier I if it is a lower cost option, tier II if it costs a little bit more and then tier III is out-of-network.

Then you take the benefit design and pair that with the cost. The richest benefit option — where the employee is going to pay the least out of their pocket — is applied to tier I.

If you want to introduce this type of design typically you’re coming from a two-tier benefit network design, so tier I becomes a better benefit than employees currently have today. Tier II is the current in-network benefit level, and tier III remains out-of-network.

People can be attached to their doctors, so that’s why you let them keep their current benefit. Employees still have a choice and have access to the full network, but you reward them for going to the most cost effective providers.

In what situations does this kind of benefit design work best?

A three-tier design is important in a self-funded solution because the dollars that are being paid out for claims are the employer’s dollars. Your third-party administrator or carrier needs to be able to administer a three-tier benefit design, and not all claims payment systems can accommodate that.

This also works better in an area where you have at least two hospitals and multiple health care providers. If you live a rural town with only one hospital, there won’t be as much engagement because people don’t have as many choices.

What best practices would you recommend health plan sponsors follow when implementing a three-tier benefit design?

Quality and cost are not correlated in the health care industry, and your employees need to be educated about that. Overall, you want to be very clear in the employee communication and education. It’s all about the education of who falls into what tier, and making sure employees are aware of that.

You can even add an online tool, like a treatment cost calculator, so they can make a more educated decision. The tier is calculating some of the cost for them already, but the right technology can further enhance their selection.

In 2014, 19 percent of employers offering health benefit had tiered networks in their largest health plan, according to Kaiser’s survey. Tiered networks continue to be a compelling tool to channel your employees’ choices, which you should take time to research and consider implementing.

Insights Health Care is brought to you by HealthLink.

How to utilize captive self-funded arrangements to reduce risk

The worlds of health insurance and financial wealth investment are merging together with captive self-funded arrangements.

These captives also are giving small and midsize employers a way to operate a self-funded group health plan for less risk.

Traditionally, midsized firms, those with 100 to 1,000 lives, have been reluctant to self-fund. While 93 percent of firms with 5,000 or more employees have self-funded health care, only 58 percent of midsize firms chose this option, according to a 2010 report by the Kaiser Family Foundation.

“These arrangements have been around for a while, but they are gaining more ground as small groups look for ways to self-fund with reduced risk,” says Abbe Mitze, account executive II at HealthLink.

Smart Business spoke with Mitze about the benefits of captive self-funded arrangements.

What are captive self-funded arrangements?

They pull together a group of employers — who are either close to each other regionally or have some common thread of industry such as farm implement stores — and put them in the same pool when they buy their stop-loss insurance.

Stop loss insurance is what protects the employer’s plan assets once the claims reach a certain predetermined amount. These policies protect you against an unexpectedly large claims when you self-fund your health insurance.

Each group stop-loss captive has its own unique structure, but they all entail the employers buying individual stop loss policies. The critical mass and structure of these programs provide economies of scale for each employer by providing greater purchasing power.

Due to the risk sharing opportunity that the captive provides, it is also a more efficient model from an insurance purchasing standpoint

By spreading the risk across many companies, employers can find a piece of mind that is priceless. They don’t have to be as concerned about large swings in cost, which is one of the biggest deterrents to smaller group self-funding.

In addition, the captive or insurance broker who manages the captive will take some of those stop-loss premiums and invest them.

If the investment does well, the employer groups in the captive would receive a dividend. You could use that dividend to reinvest in wellness or other health measures that would benefit your self-funded solution.

How does the captive group typically find each other, in order to come together?

The insurance or captives broker would get a concept pulled together, secure the vendor they want to use or who they want to manage the captive, and then go out and find the collective group of employers. They are the ones who explain the concept and what all is involved.

Doesn’t an association or trust plan do the same thing?

It’s very similar. An association or trust comes together to leverage their volume to have more purchasing power in the market. And the same is true for a captive, but then there is this financial component of an additional reward based upon the investments that are made.

What else do employers need to know?

You still manage your health benefits and plan independently, just as you do today as a standalone employer group. The only thing it affects is your stop-loss.

There’s not a lot of administration on the part of the employer group, but you do need to make a small initial investment that provides the starter capital for the wealth management piece. It’s typically a percent of the stop-loss premium.

Who would be a good candidate for a self-funded captive arrangement?

The employer group would need to have a tolerance for self-funding, and also have the capital necessary to make that minimal investment upfront.

Insights Health Care is brought to you by HealthLink

How managing care can improve health care and cut costs

Too often, patients aren’t properly taking medications, following up on care after release from the hospital or correctly managing chronic diseases.

With medical management, utilization management nurses and medical case managers work with members to ensure they get the most out of their health care benefits, says Dr. Robert Sorrenti, medical director at HealthLink.

“Medical management includes utilization management, in which we look at services to make sure they are medically necessary so inappropriate medical services can be eliminated,” Sorrenti says. “It also includes disease management, putting a focus on people who have high-risk conditions, such as cardiac disease or diabetes, better managing drivers of the cost of care.”

Smart Business spoke with Sorrenti about medical management and how to encourage employees to use the available services.

What is medical management?

In a broad sense, medical management addresses the use of services and their appropriateness according to medical standards, the quality of members’ experiences as they receive health care and ultimately the cost of the care. For example, if someone uses the emergency room multiple times in inappropriate ways, a case manager might approach that person about finding a primary care physician.

Medical management strives to make sure physicians are following accepted standards of care and doing appropriate tests. It’s not only about saving money; it helps members avoid being exposed to unnecessary services.

How would a utilization manager interact with someone with a chronic condition?

That patient might be impacted in a number of ways. If you’re admitted to the hospital, you or your provider would let the utilization management team know. The utilization management nurse would contact your physician and hospital to learn why you were admitted and what’s the plan of care.

As your hospital stay continues, the UM nurse makes sure you are in the right setting for your needs and that you aren’t staying in the hospital too long.

As your discharge approaches, the UM nurse considers what services you need after discharge. Do you need to go to a rehabilitation facility or skilled nursing facility? Do you need support services at home? Do you understand what your benefits are for these types of care?

The UM nurse helps arrange for those services within your benefits, making sure you use network providers and minimize out-of-pocket expenses.

After discharge, a case manager might look for gaps in your understanding of what you’re supposed to be doing and make sure you follow your doctor’s directions for medication and additional care.

How can medical management help prepare a patient for surgery?

UM nurses might call members who are having elective surgery, before they go into the hospital and after they leave. They’ll ask, ‘Are you clear on what’s going to happen with your surgery? Do you have your care lined up when you go home? Do you have someone to take care of you?’

After the surgery, the UM nurse would follow up and ask, ‘Are you clear on the doctor’s instructions? Have you gotten the tests that you were supposed to get? Do you have an appointment to see the doctor?’

Readmission rates have been reported to run from 7 percent to as high as 20 percent in the Medicare population. The key to reducing those rates is making sure members follow up with their physicians after discharge.

It’s not about saying no and denying services; it’s about helping members do the right thing.

How can employers encourage employees to take advantage of medical management?

Employers can stress the importance of engagement with the medical management staff. In the past, people have wanted to keep medical management at arm’s length. If employers can encourage employees to cooperate, it can go a long way to benefiting both the member and the plan.

Employers also should stress the value of members actively participating in medical case management, which often targets those with complicated and extensive care needs. As the case managers help build the care plan, the member is essential to its success.

Insights Health Care is brought to you by HealthLink

Improve the health of your employees with preventive health reminders

Are you and your employees taking all the right preventive steps to wellness? Unfortunately, you may not realize what you’re missing or how screenings can impact your overall health plan.

As an example, many problems identified at annual health screenings are chronic diseases, such as diabetes and cancer.

According to the U.S. Centers for Disease Control and Prevention, 75 percent of medical spending dollars in the nation go toward chronic disease management. In 2010 alone, cancer cost $157 billion, while heart disease and stroke cost $315.4 billion. In 2012, diagnosed cases of diabetes cost $245 billion, including $69 billion in lost productivity.

Although your health plan may not pay for all of the recommended services and treatments, adopting at least some can help lower your benefit costs.

Smart Business spoke with Toni Collingwood, account manager II at HealthLink, about some preventive health screenings.

What screenings should children be getting?

  • Infants who leave the hospital less than 48 hours after birth need to be seen by a doctor within two to four days. The baby may get vaccines or added screenings for tuberculin or sickle cell anemia, if appropriate.
  • A baby’s blood count should be checked once between nine and 12 months.
  • Lead testing performed at 12 and 24 months, unless you’re sure the child hasn’t been around lead.
  • Babies can be tested for autism at 18 and 24 months.
  • From age 2 to 10, children should have an annual check for height, weight, body mass index (BMI), development and behavior, vision and hearing. Screenings for tuberculin and urine testing can be administered, if appropriate.
  • Starting at age 3, oral and dental health needs to be added and blood pressure should be checked.
  • From ages 11 to 18, annual checkups remain similar.

With adult women, what are some key screenings?

  • Annual screenings should check height, weight, BMI and blood pressure.
  • Cholesterol should be checked every five years starting at age 20, with more screenings as necessary.
  • A breast exam should be conducted every one to three years until age 40, when an annual doctor’s exam needs to be supplemented with a mammogram.
  • For cervical cancer, women should be checked every three years from ages 21-29 and every five years have a Pap test plus HPV test from ages 30 to 65. If the last three Pap tests where normal within the previous 10 years, women can stop screening for cervical cancer at age 65.
  • Sexually active women ages 25 and younger need to be screened for chlamydia.
  • Colorectal cancer and osteoporosis can start to be tested for around age 50.
  • Women born between 1945 and 1965 need to be screened once for Hepatitis C.
  • Pregnant women should see their doctor of OB/GYN in their first three months. Some tests or screenings that could be administered during the pregnancy include diabetes during pregnancy, blood count, Hepatitis B, HIV, Rubella immunity, Rh(D) blood type and antibody testing, syphilis, urinalysis, amniocentesis, chorionic villus sampling, special blood tests and ultrasound tests. Pregnant women should be vaccinated with Tdap vaccine, as well as possibly an inactivated flu vaccine.

What are some important screenings for adult males?

  • Annual screenings should check height, weight, BMI and blood pressure.
  • Cholesterol should be checked every five years starting at age 20, with more screenings as necessary.
  • Colorectal cancer and prostate cancer can start to be tested for around age 50.
  • Men born between 1945 and 1965 need to be screened once for Hepatitis C.
  • Those ages 65 to 75 who have ever smoked should be checked once for abdominal aortic aneurysm.

Insights Health Care is brought to you by HealthLink

How to get on-board with the health care transparency trend

The health care system has reached a tipping point — with its lack of price and quality transparency.

Along with the pressure of constant cost increases, consumer expectations and behavior have started to change. Employees and employers are demanding more transparency.

“Health care is the only experience you have as a consumer where you go into it not knowing how much it’s going to cost,” says Abbe Mitze, account executive II at HealthLink. “If you buy anything as a consumer, you know all of the facts, especially in the world of the Internet today.

“But in the world of going and having a MRI, you just go where your doctor tells you to go,” she says. “You don’t research it to find out what the cost difference could be if you actually compared the facilities that you have available within your network.”

Smart Business spoke with Mitze about what more transparency within the health care system means and the new transparency tools that are being added.

What are some of the problems that stem from health care’s lack of transparency?

In-network prices can vary by 300 to 500 percent, or more, for many common procedures. Patients often don’t realize there are such high swings because they don’t see these costs, which are tied to the facility, not the physician.

They also think that higher prices mean you’ll be getting higher quality care, but cost doesn’t always equal quality.

How is this changing?

With higher deductible plans, and higher coinsurance that the member is responsible for, taking time to do research on costs can really pay off, for both the health plan providers and the patients.

Many carriers, third-party administrators (TPAs) and provider networks recognize this, and are creating tools to assist employees with making educated, cost-effective choices when receiving care.

For example, there are websites and apps that let health plan members search facilities and see the cost of the top 300 procedures at the facilities in their network. It’s not necessarily about trying to get patients to switch their doctor, which is a very personal choice. It’s more about using simple cost comparisons for scheduled outpatient procedures at hospitals, outpatient clinics or imaging centers.

Along with these kinds of tools, carriers, TPAs and provider networks will drive employee behavior with a three-tier network. So, members have the choice of tier one, tier two or out-of-network; if they go to a tier-one facility, they pay less out of pocket. The tools can work in conjunction with a multi-tier plan because it helps enable consumers to see costs upfront so they are able to budget for whatever co-pay, coinsurance and deductible they will have for a procedure.

You also can tie in programs with utilization, cash rewards or point programs.

Are health care facilities resisting this kind of transparency because they fear patients will only consider cost, and not outcomes?

There will be an education curve, but employees and employers are demanding this kind of information now. Quality of care is certainly a factor that needs to be included in the ratings or grades that these transparency tools provide.

What have been the results of having more transparency, so far?

Research has shown that transparency, year over year, steadily increases the migration to lower cost providers across all clinical categories. For instance, one study found 27 percent of the health plan’s members used lower cost providers at the start. That increased to 49 percent by year one, and then 66 percent by year two.

Knowledge is power and everyone needs to know what he or she is paying for upfront — just like with any other product. These kinds of transparency tools are expected to become more and more prevalent within the industry.

Insights Health Care is brought to you by HealthLink

Where does the Affordable Care Act stand now for employers?

2014 was a landmark year for the implementation for portions of the Affordable Care Act (ACA). Employers with 100 or more full-time equivalent employees are now subject to the employer mandate and have to start offering affordable, comprehensive coverage or face penalties.

Those employers are working through the complicated process of reporting back to the IRS, which will substantiate that they are meeting all of the requirements.

“That’s what they are struggling with. It’s not necessarily the insurance or the health care part of it, but rather the administrative side of reporting back to the government and ensuring the information is correct,” says Abbe Mitze, account executive II at HealthLink.

That’s why it’s important that your insurance consultant and tax consultant are working together on this, she says.

Smart Business spoke with Mitze about what employers need to know about the ACA legislation in its most current form, and how to stay up to date going forward.

What’s the latest on who has full-time employee status?

Under the ACA, those who work more than an average of 30 hours per week are considered full-time. Previously, an employer could determine what they considered to be a full-time employee, which most put at 40 hours.

Reducing it to 30 hours has expanded the population of full-time employees, therefore, putting additional expenses on large employers who are now required to provide coverage to these employees, when coverage is required. Legislation has been proposed to change that to either 35 or 40 hours. It passed the House in January, and although the Senate hasn’t voted yet, it’s expected to pass. The speculation, however, is that President Barack Obama will veto it.

This — along with some other proposed modifications — is something to continue to keep an eye on with the upcoming 2016 presidential election.

Everything you’ve talked about has to do with employers with 100-plus employees, what about smaller employers?

Employers with 51 to 99 employees were subject to the employer mandate regulations and subsequent fines for not complying, but were given a reprieve until 2016. Many of the eEmployers with less than 50 employees are taking advantage of transitional relief. They get to keep their non-ACA compliant benefit design, and thus continue to avoid community rating, meaning you can’t use health as a factor in determining premiums. Insurance companies will be able to only use age and tobacco use.

In 2016, both groups — those with two to 50 employees and 51 to 99 — will be considered small group and have community rating apply to them. Right now, it’s estimated that community rating could increase costs 30 to 50 percent for healthy employee groups. Because of this, they definitely need to start looking at all the solutions that are available in the market now to prepare. This includes small group self-funding solutions that don’t have to follow community rating.

So, no changes in 2015 are expected?

No, there’s no true expectation that things are going to change.

But there is one other thing looming on the horizon — 2018 is when the Cadillac Tax is slated to begin. That’s when, if your total premium exceeds a certain threshold — $10,200 for individual coverage and $27,500 for family coverage — a 40 percent excise tax is imposed.

How can employers make sure they continue to stay up to date and compliant with the law?

Make sure you have a very consultative insurance broker that will keep you up to date, in addition to using your own media resources. This can be your insurance carrier, your network, your third-party administrator or your broker. All of your partners who help provide the coverage to your employees really play a critical role in helping you navigate this.

You are so focused on your specific business and making sure that it’s successful, it’s critical to have a trusted adviser at your side.

Insights Health Care is brought to you by HealthLink

How to utilize the right tools when making health plan decisions

Determining whether it’s worth the disruption to move your employees to a different health plan with a new network of hospitals and doctors is never an easy decision. There are, however, several different health care tools that can help.

These resources also can give you an idea of how much money you may save by moving to a different health plan.

“These are important decisions employers make to keep their employees happy and keep money in the bank that they can use for other things,” says Ann Henry, proposal coordinator, senior, at HealthLink.

Smart Business spoke with Henry about what information GeoAccess reports, disruption analysis and requests for proposals (RFP) provide, and how you can use the data to make better decisions.

What’s the timing for using these tools? 

Timing is very important. Typically, employers request some type of analysis a year to six months ahead of their effective date, which is the date their health plan starts each year. Most employers like to sync this date with their annual budgets.

Some employers wait until the last minute. But to do a thorough analysis and allow time for good decision-making, it makes sense to start the process six to nine months prior to the plan effective date.

The larger the employer, the more time may be required.

What information do GeoAccess reports provide?

A GeoAccess report allows an employer to see if their employees have good access to the network of providers.

The report takes the zip codes of where the employees live and measures how far they will have to drive to get to a hospital or a physician that’s in the network. The report shows what percentage of employees has access to a given number of hospitals, primary care physicians or specialists.

Accessing providers that are in the network is important because it saves everyone money, and some health plans won’t pay claims for a provider outside the network. For example, if an employer requests a GeoAccess report and finds that 10 employees have to drive too far to see a provider that’s in the network, that’s a good indication to keep shopping.

What is a disruption analysis, and how does it specifically help?

A disruption analysis shows an employer how disruptive it will be for their employees to use a different network of providers because most people like their doctors and don’t want to change them.

By looking at the employer’s claims activity for six months to a year, the analysis can match providers used by the employees to the prospective network of providers. This determines what percentage of providers used is participating in this other network.

The analysis can be taken a step further. If the claims data includes the billed amounts of the claims, the analysis also can estimate how much those claims would have cost with the new network. This gives the employer an idea of what kind of discounts they would have received with a different network using the historic claims data. It helps determine if another network of providers will save employers more money.

How can companies get the most out of their RFP process? 

Employers need to think about what they like about their current health plan and make sure that any new plan still has those attributes. They also need to think about what is lacking or where there have been issues and see how a different health plan can lead to improvements.

What else should employers consider when making health care decisions? 

Employers and brokers need to be careful about network discount information. There are lots of ways to calculate a network discount and different definitions can show different results. An employer may think they are making an apple-to-apple comparison when they aren’t. When an employer or broker asks for network discounts, the second question should be, “How was this discount calculated?”

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