The Chamber’s claim that stop-loss coverage “is typically not an ERISA-covered benefit” (emphasis added) should not be overlooked. Where employee contributions go toward the purchase of stop-loss coverage, i.e., where working premium rates for contributory, self-funded group health plan coverage include stop-loss premiums, the Department of Labor’s long-standing position is that the stop-loss coverage is a “plan asset” that is subject to regulation under ERISA. Conversely, where the stop-loss coverage is purchased by the plan sponsor with its own funds outside the plan, a fair reading of the DOL’s position in the matter (based on a 1992 guidance item that was recently supplemented) is that that stop-loss policy is not a plan asset and, as a result, not subject to ERISA. We assume that distinction is what the Chamber is referring to when it added the “typically” qualifier. The problem is that, at least in our experience, the … [Read more...] about Future of Affordable Care Act Week 4: Ryan Plan, “A Better Way”
Aged care costs explained
Recapture of excess advance payments of premium tax creditsThe ACA generally requires individuals to contribute toward premium payments based on household income. The balance of the premium is paid by a government-funded premium tax credit. If an individual’s household income increases during the tax year, the individual may receive an overpayment of the premium tax credit premium to which he or she is otherwise entitled. The ACA includes a special rule that limits the repayment obligation in this case. The bill repeals this special rule for tax years 2018 and 2019. (Elsewhere the bill repeals the ACA premium tax credit outright beginning in 2020.) The provision requires any individual who was overpaid in premium tax credits to repay the entire excess amount, regardless of income. … [Read more...] about The Future of the Affordable Care Act Week 7: The American Health Care Act
The individual mandateThe ACA included an “individual mandate” that requires most U.S. citizens to buy health insurance. The purpose was to ensure broad participation in the individual markets so that there would be enough healthy individuals in the risk pool to subsidize the cost of covering those who are less healthy. Most agree that the ACA penalty for not maintaining coverage was insufficient to induce enough healthy people into the pool. The result has been steep underwriting losses which have prompted major carriers to exit the public exchanges. The AHCA would eliminate the penalty retroactively, to the beginning of 2016. In its place, the bill would impose a “continuous coverage” requirement to induce people to buy coverage and stay covered rather than buying it only when they need it, which drives up costs in the exchanges. Health carriers could assess a 30 percent penalty on individuals who have a gap in coverage of more than 63 days in the prior 12 … [Read more...] about Can Congress Get to “Yes” on Replacing the Affordable Care Act?
Modified community rating—consequences and tradeoffsThe ACA’s modified community rating rules have come under harsh criticism by Republican lawmakers and conservative think tanks and policy shops. These are the rules that cap premiums paid by older individuals relative to the premiums paid by younger people. The ACA set the ratio at 3:1. ACA critics say this has the effect of shifting a large portion of health care costs to younger, healthier individuals who consequently exit the market leaving behind older and sicker individuals. The replacement proposals uniformly expand the community rating range to 5:1, which is closer to the actual spread. While this approach may well reduce costs and lure younger individuals back into the market, costs for older adults will rise. The paper explains the net impact and tradeoffs in the following example: … [Read more...] about The Future of the Affordable Care Act Week 6: Focus on the Individual Health Insurance Market
A: It has everything to do with helping to improve the health of our members, which is ultimately what states and the federal government are paying us to do. For our population, one of the more significant barriers to them gaining the very best health for themselves and often for their families are ... what we call these social determinants. It's food insecurities. It's lack of access to stable housing, stable utilities, transportation. … [Read more...] about WellCare Health Plans CEO Q&A: Insurers look beyond medical bills, cut costs