ACA compliance still important as lawmakers continue repeal push

Regardless of possible outcomes in Washington, employers still need to look at current operating strategies to make sure they’re compliant with looming ACA requirements that are still law of the land.

For example, the deadline for using the new summary of benefits and coverage template is fast approaching, Christine Pothm, a partner with the firm Vorys, Sater, Seymour and Pease, said Monday at EBN’s Benefits Forum & Expo in Boca Raton, Fla. Issued April of last year, the DOL shortened the SBC to five pages, and added important questions regarding deductibles, out-of- pocket limits and network providers.

“Make sure you’re making a quick comparison and you’re using the new one,” she advised. “There is a penalty associated with not using the correct template that is coming up.”

Pothm also noted changes brought about by the 2016 21st Century Cures Act that’s important for employers. First, it allows for what’s called a qualified small employers health reimbursement rearrangement. The IRS and DOL came out and said stand-alone HRAs are no longer permissible because they violated provisions in the ACA.

[Image: Bloomberg]

[Image: Bloomberg]


The second change was it provided additional marching orders to the IRS, DOL and HHS regarding mental health parity. The result of that regulation is “a lot of guidance issued from the tri-agencies,” she noted, adding that on the DOL’s site, under mental health parity, there are a number of 1-4 page summaries.

“I would encourage employers, if you haven’t seen the info, they’re great short little documents to see whether your plan is compliant,” Pothm added. “This is one of their top areas they’re looking at for enforcement.”

Employers also need to be aware of the DOL’s audits of group health plans, she said.

“They are cross training all agents to handle both retirement and group health plans,” she warned. “Typically if a retirement plan is pulled for audit, most likely they’ll add your group health plans to what they’re looking at.”

“Regardless of what Congress does, we still have a very active administration,” added John Hickman, partner at the international law firm Alston and Bird.

The current hot-ticket item is the Graham-Cassidy bill, a proposal crafted by Sens. Bill Cassidy (R-La.), Lindsey O. Graham (R-S.C.) and Dean Heller (R-Nev.) that essentially turns control of the healthcare markets over to the states.
Although the sticking points aren’t in the employer benefits arena, the bill does nix the employer mandate and includes HSA expansions, Hickman noted.

Reporting issues still wouldn’t be taken away in this bill, he warned, and employers will still have to comply with the ACA’s reporting requirements this year.

But, assuming the bill fails, there are still a number of potential stand-alone fixes, Hickman said.

For example, there is the bipartisan support of repealing the excise tax that we may see come down the line. “It’ll be an interesting time going forward,” he noted.

  • September 18 2017, 11:08pm EDT

How to help employees better understand Health Savings Accounts

Thirteen years into this HSA experiment, health savings accounts are still wildly misunderstood. Are they employer-sponsored health plans, spending accounts, checking accounts, savings accounts, investment accounts, or is it now most appropriate to refer to them as a retirement savings vehicle?

Here’s what HSAs are not: employer-sponsored health plans, despite the fact that many employers assist in establishing them for employees and contribute to the accounts. HSAs are best thought of as individually owned tax-exempt trust or custodial accounts available to individuals covered by what the IRS considers to be an HSA-eligible health plan. That’s pretty cut and dry, however it’s easy to see why there is still so much confusion. After all, an HSA shares many of the characteristics of the accounts listed above, and it’s up to the individual to decide how best to use the account.


Most consumers so far have yet to fully understand the opportunities and securities presented by an HSA — often misusing it as a checking account — but technology is helping to change that, engaging them on platforms that allow them to see the value of saving rather than spending. These emerging technologies also are helping employers and individuals pick and choose between the many HSA offerings.

Think of the HSA as having two components all under one tax-sheltered umbrella: A cash component for spend and an investment component for long term savings. If the cash component of an HSA is merely a spending account, what’s the benefit to having consumer engagement tools embedded into what otherwise looks like a checking account? The answer is it’s an opportunity to change behavior in how employees are using their HSA.

In an effort to demystify the HSA, let’s segment HSA owners into three buckets: The Spenders, The Savers and The In-Betweens. The Spenders are those HSA owners who use employee and employer contributions to pay for all qualified medical expenses as they roll in. The In-Betweens use employee and employer contributions to pay for some, but not all, medical expenses and are able to roll over a balance in the HSA from year to year. The Savers are a minority subset of the HSA market in that these folks are able to fully fund the HSA each year and pay for all qualified medical expenses through other means.

All three segments of HSA owners receive the triple tax advantage: Contributions to an HSA are not taxed, interest paid and earnings on investments are not taxed, and distributions for qualified medical expenses taken today — or at any point in the future — are not taxed. Since all three segments are afforded the same tax benefits, one of the most important things for employers and individuals to consider when evaluating an HSA offering are the consumer engagement tools and functionality embedded into the cash component of an HSA.

To select a holistic HSA offering that empowers consumers in this way, look for an HSA offering that has the ability to link healthcare claims and receipts to payment capabilities, as well as dashboards with interactive charts that help individuals better understand healthcare spending and savings trends. Access to these types of enhanced functionalities will be key to shifting consumers’ mindset on how to use their HSA, enabling them to make better decisions when managing their money in these accounts.

Better HSA cash management leads to more savings, and more savings leads to greater healthcare purchasing power, not only for today, but in retirement as well. It goes without saying that employees need more savings for retirement. According to Fidelity, a couple retiring in 2017 will need an estimated $275,000 to cover healthcare costs in retirement. Paying for those qualified medical expenses with HSA dollars, instead of from other retirement accounts, increases healthcare purchasing power because HSA distributions for qualified medical expenses today and in the future are not included as income and thus never taxed.

While it may be somewhat ignorant to assume all employees have the ability to save $275,000 in an HSA for retirement, it’s equally as ignorant to assume employees in only the highest tax brackets have the ability to save long term for future medical expenses. With that said, the vast majority of today’s HSA assets are held in cash and the majority of employees are considered Spenders or In-Betweens. The best way to change behaviors from a spending mentality to a saving mentality is by meeting employees where they are interacting in their HSA with easy-to-use and engaging technology. Employees that don’t have these added benefits will continue to use the HSA as a checking account and will spend down balances just as fast as contributions roll in.

Jason Cook

Jason Cook is vice president of healthcare emerging market sales at WEX Health.

Single payer ‘dream’ would be a nightmare for Americans

Image result for emergency room

The Affordable Care Act’s exchanges are collapsing. In 40 percent of counties, consumers will have access to just one insurer on the exchange next year. In 47 counties, there will be no insurers on the exchange at all.


More insurers may pull out in the coming weeks. The ones that don’t may hike premiums by 40 percent or more.


Americans are frustrated with the exchanges’ high costs and limited options. That frustration is manifesting itself in growing support for a government-run, single-payer healthcare system. Forty-four percent of Americans now favor this approach, according to a recent Morning Consult poll.

Supporters of single-payer claim that it would eliminate wasteful spending and improve the quality of care. The reality is far different. Single-payer systems ration health care, slow the development of life-saving drugs and medical devices, and hamstring economic growth.


Single-payer systems control costs primarily by limiting access to health care.


In the United Kingdom’s National Health Service, 5 million patients will languish on waiting lists for non-emergency surgeries, such as hip replacements, by 2019.  In Canada, patients wait more than nine weeks between referral from a general practitioner and consultation with a specialist.


By comparison, American patients wait less than four weeks, on average.


In many cases, single-payer systems force patients to wait indefinitely for lifesaving medicines. For instance, Britain’s NHS only permits 10,000 people per year to receive highly advanced drugs that cure hepatitis C, a deadly infectious disease that afflicts 215,000 Britons. As of late 2015, the NHS covered just 38 percent of cancer medicines approved for sale in 2014 and 2015.


Those medicines that are available are subject to government price controls. Patients may feel like they’re getting a good deal. But such controls discourage investment in medical research — and thus slow the pace of medical innovation.


In the 1970s, four European countries developed more than half of the world’s medicines. But since they imposed price controls, those countries now invent only one-third of medicines.


The United States, by contrast, developed nearly 60 percent of the world’s new drugs between 2001 and 2010.


Single-payer systems don’t just cap spending on drugs. They also insist upon artificially low reimbursement rates for hospitals and doctors. In many cases, these payments don’t even cover the cost of providing certain treatments and procedures.

Despite these rigid limits on spending, single-payer systems are still enormously expensive. Lawmakers in New York and California are considering bills that would abolish private insurance and enroll all state residents in a single-payer system. Those systems would cost $226 billion and $400 billion, respectively. That’s more than double both states’ budgets.


To fund such systems, governments would need to impose crippling taxes. The tax hikes needed to pay for a nationwide “Medicare for All” system would eliminate more than 11 million jobs, according to a recent study.


In 2014, Vermont dropped its plans for a statewide single-payer system after calculating that it would have required a new payroll tax of 11.5 percent. And in 2016, voters in Colorado overwhelmingly voted against Amendment 69, a single-payer referendum that would have required a 10 percent payroll tax.


Disenchanted with the ACA marketplaces, tens of millions of Americans now dream of government-funded single-payer healthcare. If politicians actually grant their wish, patients and taxpayers would experience nightmares of rationed care, reduced innovation, and economic devastation.


Dave Mordo is the Legislative Council Chair of the National Association of Health Underwriters.

How benefits can help employees suffering in Irma’s wake

As employees seriously impacted by hurricanes Harvey and Irma begin to come to grips with the devastation, they might be wise to take advantage of several existing benefits, industry experts say. In addition, HR and benefits managers may need to create some new ones immediately to help employees get back on their feet.

Here is an overview of some benefits that can be used to help employees.

Supplemental PTO

“Some employees will need extra time, possibly several days, to deal with the aftermath of a natural disaster,” says Zack Pace, senior vice president of the benefits consulting unit of insurance firm CBIZ. “Documented programs could prove useful in catastrophic storm-related situations,” he adds. The can include unpaid as well as paid leave programs.

It is not unreasonable to require employees to exhaust accrued PTO before granting them extra paid days off. A careful balancing act will be needed, however. It’s important to avoid, in effect, favoring employees who had already exhausted their PTO before the storm, against those employees that had not yet tapped theirs.

That might be accomplished by granting extra emergency PTO after a specified numbers of days away from work have been taken. That way, employees who had already used up vacation days would not appear to enjoy a windfall relative to employees who had not yet done so.


Another important benefit under these circumstances is telecommuting, notes Pace.

“If you don’t currently allow it, now might be a good time to start one, and if you already allow telecommuting on a restrictive basis, you might want to liberalize it,” he says.



Employees with school-aged children whose schools have been closed might be scrambling to make emergency child-care arrangements. A temporary liberalization of telecommuting benefits may be required to accommodate such employees, as well as employees who need to stay home (assuming their homes are habitable) to supervise contractors making repairs.

Employees whose homes were severely damaged might have had to take up residence with relatives beyond commuting distance to the workplace could also benefit from a liberalized telecommuting policy.

Financial counseling

Even well-insured storm damage victims will take a big financial hit with home repairs and replacing destroyed property. Homeowner insurance deductibles can be high. In addition, many employees may discover their insurance policies don’t provide the protection that thought they did.

Often this can lead to employees’ seeking a hardship distribution from their 401(k). Although the IRS has indicated that a major hurricane like Harvey or Irma do satisfy permissible hardship withdrawal criteria, that isn’t always the best course of action for employee. “If an employee requests a hardship withdrawal, in my mind that’s an immediate referral to the EAP for financial counseling,” says Robert Lawton of Lawton Retirement Plan Consultants.

“Employees need to understand the implications, such as the fact that after all the taxes they’ll have to pay, between the penalties, state and federal income taxes, they’ll probably only wind up being able to keep about half of what they take out,” he says. “And that money can never go back into the plan.”

A plan loan might be a better option for the employee — or not. “It’s a slippery slope toward giving advice when employers try to explain these decisions to employees, and that’s not the employer’s role,” Lawton warns. “That’s why it’s important for the employee to be referred to a financial counselor.”

Emotional health support services

Experiencing a severe natural disaster — even when direct personal loss is limited — can take an emotional toll on employees. That can range from very mild symptoms to those akin to post-traumatic stress disorder (PTSD). It behooves employers to promote their employee assistance plan benefits to encourage those who might benefit from counseling to take advantage of the opportunity, experts say.

“It is to both the employees’ and employer’s benefit to help workers manage the impact of natural disasters and critical incidents,” says Ann Clark, founder and CEO of benefits firm ACI Specialty Benefits. “Research indicates that when employees are exposed to a critical incident that is dealt with inappropriately, these employees are more likely to experience an increase in personal and health-related problems, and are at greater risk of using more sick days, having lower productivity or leaving their employment following the critical incident.”

Group legal and disability insurance

Employees that have taken advantage of group legal benefits might be able to tap that resource to learn about their legal rights if they run into issues with their insurance company, or landlord if they are being required to pay rent for a home that’s uninhabitable due to storm damage.

Finally, employees who sustained personal injuries in the storm severe enough to keep them from being able to work for an extended period might be able to take advantage of disability income benefits.

  • September 12 2017, 7:42pm EDT

5 common COBRA compliance pitfalls to avoid

Staying on top of health insurance regulations may feel like an uphill battle for brokers and their small business clients, but the costs and penalties for being out of compliance can be disastrous.

So what are some of the everyday compliance pitfalls to watch out for? This is the first in a series of articles that will explore common compliance challenges and how to avoid them.

Image result for consolidated omnibus budget reconciliation act

Let’s begin with one of the more commonplace issues: Federal COBRA administration.

As many agents know, COBRA mandates that employers offering insurance must extend coverage to former employees and dependents following the loss of that coverage for up to 18 months. But COBRA requirements can be difficult to follow, and compliance mistakes can cost a broker and their client big money in statutory fines, excise tax penalties, civil lawsuits, regulatory audits and more.

Top errors
Unfortunately, when it comes to COBRA, it is very simple to misstep. Here are the five most common pitfalls to watch for:

1) Miscalculating employee counts: This may seem deceptively easy, but too often companies incorrectly count their employees. For example, COBRA rules count part-time as a “fraction of an employee” equal to the number of hours that employee works divided by full-time hours. An example would be two part-time employees working 20 hours getting counted as one full-time employee. Accurate counts are important especially for businesses in farming, construction, real estate, retail and other industries that often rely on part-time and seasonal workers. Brokers must help ensure counts are accurate, which includes making clients aware of the requirement and working closely with trusted tax advisers and/or compliance experts to assure alignment with mandates.

2) Types of plans subject to COBRA: The mindset that COBRA only applies to medical, dental and vision can be an expensive one, so change it. The regulation covers any plan maintained by an employer to provide healthcare benefits to employees. This means that certain wellness programs, flexible spending accounts, health retirement accounts, executive reimbursement plans and more also fall within COBRA. So make sure to review and address the full spectrum of the proffered benefits plans to assure compliance.

3) Failure to notify of qualifying events: The fines for notification failure are steep, and the potential exposure to costly legal claims from former employees even steeper. Liability can even exist if an individual is not harmed. Qualifying events, such as an employee termination, require specific notices with mandated content and specific time frames. Agents who are unsure about details are wise to turn to COBRA experts to guide them through the notification process. This will protect them and their clients.

4) Employer notification requirements: Non-compliance with general notices is the No. 1 most frequent civil penalty with COBRA. For instance, a group health plan must provide a general notice describing COBRA rights to an employee and adult dependents covered under the plan within the first 90 days of coverage. It must be sent at the appropriate time — new employee becomes covered under a plan, employee adds dependents to plan upon marriage or open enrollment, etc. — and clearly spell out basic information about COBRA, as well as employer and employee/dependent responsibilities, rights and obligations. Additionally, general notices such as this must be archived. Not following procedures could put a plan out of compliance, result in significant penalties and might expose a business (and its consultants) to legal liabilities. Make certain to follow procedures, and then document, document, document.

5) Rate determination period: COBRA requires plan premiums to be set and then fixed for a 12-month period. This provides qualified beneficiaries with some assurance not only of the COBRA premium amount but also that it will not be subject to frequent fluctuations. However, this period can cause hardship for employers that have mid-year plans and/or a premium change occurs. If the premium goes up outside of the determination period, then the employer is on the hook to cover the increase. These costs can add up significantly, so make sure to be aware of them.

Remember to be vigilant and focused when it comes to COBRA directives and obligations, and turn to trusted compliance advisers and experts when needed. Because even an unintentional error can cost an employer a bundle, and a broker their client.

Next time, the focus will be on pitfalls to avoid around ERISA plan documentation. Stay tuned.

Marc McGinnis

McGinnis is vice president of national sales for The Word & Brown General Agency.

Deadline Looms for Insurers to File Rate Proposals

Regulators grapple with uncertainty in the health-care system as they embark on the review process

Anthem Inc. has said it wouldn’t offer exchange plans in Maine next year if the federal government stops cost-sharing reduction subsidies.
Anthem Inc. has said it wouldn’t offer exchange plans in Maine next year if the federal government stops cost-sharing reduction subsidies. PHOTO: ASSOCIATED PRESS

A deadline for insurers to file 2018 prices for health insurance sold through Affordable Care Act exchanges arrives Tuesday, but state regulators are still struggling to make decisions about pricing and coverage amid uncertainty in federal health policy.

The upshot is confusion in what is typically an orderly, regimented regulatory process for reviewing insurance offerings that will go on sale to consumers on Nov. 1.

States are taking different approaches, based on their best guesses about what Congress and President Donald Trump’s administration might do regarding the health-law marketplaces, though several state regulators said in interviews that they are leaning toward approving hefty rate increases.

According to actuarial firm Milliman Inc., at least 32 states have requested that insurers prepare alternative premiums for different scenarios, Most of those states are still holding off on a final decision on which rates to choose.

“The uncertainty makes it very difficult to navigate, and it’s not going away,” said Eric A. Cioppa, superintendent of the Maine Bureau of Insurance.

Insurer Anthem Inc. has said it would stop offering exchange plans under Obamacare, as the law is known, in Maine next year if the federal government stops payments known as cost-sharing reduction subsidies.

Those payments, which Mr. Trump, a Republican, has threatened to halt, reimburse insurers for money they advance to reduce health-care costs for low-income ACA enrollees.

A White House spokesman said the president “is working with his staff and his cabinet to consider the issues raised by” these payments. Anthem, which has already announced retreats from several exchanges, declined to comment.

After federal officials pushed back an earlier deadline, insurers are supposed to submit their rate filings for 2018 exchange plans to state and federal regulators by Tuesday. Regulators then have until Sept. 20 to complete their reviews and approve rates. Insurers are due to sign final federal contracts to offer plans by Sept. 27.

Some insurers said they are moving forward with plans to participate in the 2018 marketplaces but holding off on final decisions until the late-September cutoff.

“We’re keeping our options open,” said David Holmberg, chief executive of Highmark Health, which sells exchange coverage in Pennsylvania, West Virginia and Delaware. “There has to be a clear set of rules for 2018 for us to participate.”

Other big insurers, including Molina Healthcare Inc., have said they are still considering leaving more exchanges. Health Care Service Corp., a major exchange insurer, said in a statement it has filed proposed rates in all of the states it is serving that account for the uncertainty around the cost-sharing payments, but it “will make final decisions in late September” about the scope of its offerings.

A Senate committee is set to begin hearings Wednesday on legislation intended to stabilize the exchanges created under the 2010 law, which will be tough to pass in time to affect the 2018 marketplaces. Any bill is likely to include funding for cost-sharing payments.

The Congressional Budget Office estimates that if the payments end, insurers would decline to offer exchange plans in regions representing around 5% of the U.S. population next year and would raise premiums on average about 20% on the middle-tier “silver” plans. The cost-sharing subsidies are tied to silver plans.

Maryland’s insurance commissioner, Al Redmer, Jr., recently approved steep rate increases. But the rates didn’t include an extra bump for the potential loss of the federal cost-sharing payments, Mr. Redmer said. “The law is the law, and we have to assume it won’t change,” he said.

That could leave insurers in a squeeze, said Chet Burrell, chief executive of the state’s largest exchange insurer, CareFirst BlueCross BlueShield. If the payments stop when insurers haven’t accounted for the extra expense in their rates, he said, “the losses become very, very serious” and “that then threatens the viability of the market.”

Mike Kreidler, Washington state’s insurance commissioner, said he hasn’t made a final decision on rates, but he anticipates the cost-sharing payments will continue.

“I feel like I’m being a pessimist if I go in there and assume they’re going to yank the rug out from under us,” said Mr. Kreidler, a Democrat, who is slated to testify in Wednesday’s Senate hearing. “I can’t believe anyone would do anything so incredibly dumb.”

But several state regulators said they were reluctantly moving toward allowing insurers to raise rates by an extra margin to make up for the potential loss of the cost-sharing payments, if the payments weren’t guaranteed by Congress in the next few weeks.

“I would be afraid if I didn’t [approve an extra rate margin], the insurers would decide not to participate in the market,” said Julie Mix McPeak, Tennessee’s insurance commissioner, who is also testifying in the Senate hearing.

In Mississippi, insurance commissioner Mike Chaney, a Republican, said he too was leaning toward approving the extra increases if the federal payments remained up in the air. If the state’s lone remaining exchange insurer were trapped with the extra costs, without an offsetting increase in rates, he said, he fears that “next year I would not have a carrier at all who would market in the state.”

One key question is whether states and insurers will be able to alter rates if circumstances change.

Maryland’s Mr. Redmer said he would consider allowing an extra rate increase if the cost-sharing payments stopped. Mississippi’s Mr. Chaney said if he allowed rate increases because of the risk of losing cost-sharing payments, he believed he should be able to approve a rate cut in his state if the federal money does come through.

But other state officials said they didn’t believe the ACA allowed for rates to change once coverage has taken effect in January.

Asked about the potential for rate changes in the fall or next year, a spokeswoman for the Centers for Medicare and Medicaid Services, a federal agency, said insurers can’t change their rates after the Sept. 5 submission unless a state, through its rate-review process, requires a revised filing.

Write to Anna Wilde Mathews at

Appeared in the September 5, 2017, print edition as ‘Insurers Face Deadline on Rates.’

Senate panel to begin bipartisan hearings on stabilizing health insurance market

WASHINGTON – Senators looking for ways to stabilize the individual health insurance market will hear from governors and state health insurance commissioners at their first bipartisan hearings next month.

The hearings, set for Sept. 6-7, will focus on stabilizing premiums and helping people in the individual market in light of Congress’ failure to repeal and replace the Affordable Care Act, or Obamacare.

“Eighteen million Americans, including 350,000 Tennesseans – songwriters, farmers, and the self-employed – do not get their health insurance from the government or on the job, which means they must buy insurance in the individual market,” said Sen. Lamar Alexander, the Tennessee Republican who chairs the Senate Health, Education, Labor and Pensions Committee.

“My goal by the end of September is to give them peace of mind that they will be able to buy insurance at a reasonable price for the year 2018,” Alexander said.

Sen. Patty Murray, D-Wash.

(Photo: H. Darr Beiser, USA TODAY)

Washington Sen. Patty Murray, the committee’s top Democrat, said the path to making health care work better for patients and families “isn’t through partisanship or backroom deals.”

“It is through working across the aisle, transparency, and coming together to find common ground where we can,” she said.

The attempts at a bipartisan approach to fixing health care mark a change in strategy after the failure last month of Republican efforts to repeal and replace Obamacare. The GOP bill was pieced together behind closed doors by a small group of Republican senators, with no input from Democrats and no public hearings.

Alexander has said lawmakers must find a way to stabilize the individual insurance market because millions of Americans will be unable to buy insurance unless Congress acts.

At the hearings, the committee will hear from state insurance commissioners and governors because they are closest to the problem and can suggest steps that Congress can take to help make insurance available at affordable prices, Alexander said.

“Any solution that Congress passes for a 2018 stabilization package will have to be small, bipartisan and balanced,” he said.

It also should give states more flexibility in approving insurance policies and fund the cost-sharing reduction payments to help stabilize premiums for 2018, he said.

Murray said it’s important for the committee to hear from state leaders because they “understand full well the challenges facing health care today, and many have been outspoken about how the uncertainty caused by this administration has impacted the individual insurance market and therefore families’ premiums for 2018.”

, USA TODAYPublished 11:29 a.m. ET Aug. 22, 2017

Simplifying the healthcare payment system

With employers and employees expected to carry a rapidly increasing portion of out-of-pocket healthcare spend, enterprises and employees alike are in need of new tools that reduce the complexities of healthcare billing, help navigate rising cost and make more educated plan and benefit choices.

To help their clients in this endeavor, brokers may want to take a look at a new product that attempts to simplify the healthcare payment and saving system. By utilizing a collaboration of healthcare, benefits and financial networks, Medxoom has initiated the first wave of its app to deliver mobile-first bill payment and financing for users.

Tito Milla, co-founder of Medxoom, says the app is meant to give price awareness to employees who might not know that their health plan, doctor’s office or their prescriptions are not the cheapest choice within the options provided to them.

Bloomberg/file photo

“When you look at the market today, the growth of out-of-pocket spending has grown to over 250% since 2006,” Milla says. “The average is well above $1,000 across the country and for employers with under 200 employees, the number jumps to $2,000.”

Milla adds that when it comes to billing systems for provider networks, traditionally their payout comes from insurance companies with a 95% to 96% success rate. However, for patient responsibility 30% to 50% of network billing comes from the employee, rather than the insurance carrier, depending on the practice.

“The more the cost shifts to the patient, the more it becomes a billing issue for the doctors,” Milla says. “We are a mobile first platform and we are about making healthcare payments simple.”

With the freedom to not be tied down to one specific doctor and their electronic or paper format of payment, Medxoom provides users with the ability to make payments to any provider with any type of health plan, including PPOs, HMOs and HDHPs — with access to HSAs should the employee have one available.

Jordan Hackmeier, managing partner at Jeff D. Hackmeier & Associates INC. out of Miami, is one of the brokers who has partnered with Milla and the Medxoom team to share the app with his clients. Hackmeier says his firm is piloting the app with a small physicians group and plans to pilot the app with a second client with a 50 to 90 employee base.

“The employers are finding value in this product by the way it provides clarity by explaining what their deductible is, what’s left to be paid, why the employee is still paying out-of-pocket. What is most exciting is how they can still add on more and more features,” Hackmeier says. “It appears to me that this product is going to be something that is going to solve a lot of problems in the healthcare industry.”

One feature Hackmeier says is appealing to him is Medxoom’s ability to offer a loan option to users who lack the funds to pay their medical bills immediately. “If you can’t pay $5,000 to satisfy your deductible at your hospital, Medxoom partners with lenders who will loan you the money,” Hackmeier says.

Comprehensive option
Hunt Turner, co-managing director of Wood Gutmann & Bogart Insurance Brokers out of Tustin, Calif., is sharing Medxoom’s app with his clients on the West Coast, and says Medxoom is one of the more comprehensive options for healthcare apps on the market.

“I’ve seen platforms that are more transparency-driven through analytics, but not really tied specifically to HSAs,” Turner says. “My self-funded clients want to have the best information on the healthcare market and it has been a bit of a challenge to find a good comprehensive site.”

From both Hackmeier and Turner’s clients who are piloting the app at their companies, response has been mostly positive. “I think there is a learning curve just around understanding of what it does and doesn’t do because it is relatively new to consumers,” Turner says. “Those who immediately understand the technology are appreciative of the quick access to information.”

Milla says he and his partners are starting Medxoom in the smaller employer market and want to eventually ramp to the large employer market by the end of 2017, with the assistance of large regional brokers.

White House: Health-Insurer Payments Will Be Made in August

Move comes after Trump warned of halting monthly subsidies


The Trump administration said on Wednesday the federal government would make a set of payments to insurers for August, despite threats from the president that the funding would be halted following the failure of Senate Republicans to repeal most of the Affordable Care Act.

Governors and Democratic lawmakers have been urging President Donald Trump to continue the payments, known as cost-sharing reduction payments, because insurers have said they may pull out of the ACA’s insurance markets or raise premiums in 2018without the funding.

The nonpartisan Congressional Budget Office said in a report Tuesday that premiums for popular, midprice plans on the ACA exchanges would rise 20% next year without the payments.

The money compensates insurers for reducing out-of-pocket costs for some low-income consumers who sign up for plans on the exchanges. About seven million people qualified for the subsidies in 2017.

Some GOP lawmakers oppose the payments, saying the money was never appropriated by Congress and amounts to a bailout for insurers. Recent comments from Mr. Trump had led to questions about whether the next payment, expected around Aug. 22, would be made by the federal government.

“If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!” Mr. Trump tweeted on July 29 after Senate GOP lawmakers failed to pass a bill to repeal most of the ACA.

The future of the payments remains in question, spurring bipartisan efforts among some in Congress to ensure the funding is preserved.

Sens. Lamar Alexander (R., Tenn.) and Patty Murray (D., Wash.) are planning hearings on legislation to shore up the ACA markets. The legislation would likely continue the payments in 2018 while giving states greater flexibility on ACA implementation, a change that Republicans have sought.

“Congress owes struggling Americans who buy their insurance in the individual market a breakthrough in the health care stalemate,” Mr. Alexander said in a statement Wednesday after a White House spokesman said the insurer payments would be made in August.

Some Republicans panned the decision on payments and called again for the 2010 health law to be repealed.

“We cannot dig our hands into a hole $20 trillion deep to bail out insurance companies,” Rep. Mark Walker of North Carolina said Wednesday.

Write to Stephanie Armour at and Louise Radnofsky at

Appeared in the August 17, 2017, print edition as ‘Insurers to Receive Payments in August.’

Health Exchange Premiums Would Rise 20% in 2018 If Subsidies Ended, CBO Estimates

Deficit would increase by $194 billion through 2026 if subsidies halted because government would pay more in tax credits

A CBO report released Tuesday estimated that health law exchange premiums would rise 20% in 2018 if subsidies to insurers ended.
A CBO report released Tuesday estimated that health law exchange premiums would rise 20% in 2018 if subsidies to insurers ended.PHOTO: ASSOCIATED PRESS

Premiums for many insurance plans on the Affordable Care Act’s individual market would climb by 20% next year if the Trump administration halts billions of dollars in payments that go to insurers under the health law, the Congressional Budget Office estimated Tuesday.

The payments that help compensate insurers for reducing out-of-pocket costs have become the latest front in the battle over the health law, with President Donald Trump warning he could end the funding after Senate Republicans failed late last month to repeal the ACA.

Democrats, insurers and some governors have been urging Mr. Trump to preserve the payments in order to protect the stability of the individual insurance markets.

The report by the nonpartisan CBO and the Joint Committee on Taxation, a panel that includes House and Senate members, says the ACA markets wouldn’t implode without the funding, estimated at $7 billion this year. But it concludes that a decision by Mr. Trump to halt the payments would raise premiums for mid-priced plans and leave slightly more people without an insurer to choose from on the individual markets.

In an ironic twist, stopping the subsidies would also wind up costing the federal government more in the end, the report said. Higher premiums for mid-priced plans would require the government to pay larger tax credits to consumers to help offset coverage costs. The federal deficit would increase by $194 billion through 2026, the report said.

The assessment reflects the negotiating struggles still ahead over the ACA in Congress, where Republicans have already spent months on failed attempts to repeal and refashion former President Barack Obama’s 2010 health law. The demise of the repeal effort means the ACA will remain in place for the foreseeable future, but its markets remain fragile, with insurers promising to raise premiums or stop participating without the federal money, known as cost-sharing payments.

Now, Republicans must decide whether to work with Democrats to stabilize a law they have pledged for more than seven years to dismantle.

Already, some GOP senators are working with Democrats on a possible bill to preserve the payments to insurers. But some House Republicans opposed to the assistance, which they call a bailout for insurers, are digging in with another push for repeal.

The CBO and tax-panel report also highlights the power the Trump administration now holds over the law. Questions are mounting about whether the federal government will devote resources to the fall open-enrollment period for ACA insurance plans. And Mr. Trump has sounded intent on halting the payments, despite calls from some within his own party who fear a political backlash in the midterm elections if the premium costs rise.

“Regardless of what this flawed report says, Obamacare will continue to fail, with or without a federal bailout,’’ Ninio Fetalvo, a White House spokesman, said in a statement. He added: “No final decisions have been made about the CSR payments. We continue to evaluate the issues.”

Rep. Tom Reed (R., N.Y.,) co-chairman of a bipartisan House group that has advocated for authorizing the cost-sharing payments, called Tuesday’s CBO report “another log on the pile of pressure” on Congress to act. He said the adverse effects that CBO highlighted would disproportionately hit rural counties in GOP-held districts. “Politically and substantively, I just don’t understand how you could stand in front of a town hall and say, ‘I’m sorry I didn’t do anything, because ideologically I wanted to go a different route,’ ” he said.

Democrats seized on the report to assert that Republicans and the Trump administration were threatening to sabotage health insurance.

Sen. Brian Schatz (D., Hawaii) wrote on Twitter on Tuesday afternoon that “the president of the United States is causing health care premiums to go up because he’s mad. Let that sink in.”

The CBO report said that rising premiums would mean that more people would qualify for cost-sharing subsidies. Also, the larger premium tax credits would make buying coverage on the individual market more attractive: While the number of people uninsured would be about 1 million higher in 2018 than in an earlier estimate, it would then be 1 million lower in each year starting in 2020, the CBO estimated.

Premiums for the mid-priced plans on the exchange would be 25% higher by 2020, the CBO projected.

Sens. Lamar Alexander (R., Tenn.) and Patty Murray (D., Wash.) are planning hearings on legislation to shore up the ACA markets following failed GOP efforts to replace most of the health law. The legislation would likely continue the payments in 2018 while giving states greater flexibility in how to implement the ACA, a change that Republicans have sought.

The federal payments compensate insurers for reducing out-of-pocket costs for some low-income consumers who sign up for plans on the exchanges. About seven million people qualified for the subsidies in 2017.

Mr. Trump could choose to end the payments on his own. The cost-sharing subsidies also face a legal threat. House Republicans sought in a 2014 lawsuit to block the payments. A federal district judge in May 2016 ruled that the payments were improper. The Obama administration appealed, and payments to insurers have continued in the meantime.

In another sign the Trump administration may pare back parts of the health law, the Centers for Medicare and Medicaid Services has proposed canceling two Obama administration programs aimed at attaching a fixed price to medical services rather than allowing providers to bill for each individual service.

The payment model, known as bundled payments, were a pilot program under the ACA aimed at reducing medical spending by emphasizing results of care rather than volume.

CMS published a rule last week indicating it planned to cancel bundled payments for heart attacks and bypass surgeries along with an expansion of a joint-replacement payment program that would have included hip surgeries. Both payment programs were scheduled to take effect on Jan. 1.

Separately, the ACA’s markets are on increasingly stronger footing. Centene will offer health coverage on the ACA exchange in 2018 to all Nevada counties, Gov. Brian Sandoval said on Tuesday. The state had been facing the prospect of 14 bare counties.

The announcement means only two counties in the U.S. are at risk of having no insurers participating next year, according to the Kaiser Family Foundation. That’s a sharp drop from more than 40 counties that risked having no participating insurers on the exchanges a few months ago.

Write to Stephanie Armour at

Appeared in the August 16, 2017, print edition as ‘CBO Sees a Jump In Health Premiums.’

Updated Aug. 15, 2017 8:37 p.m. ET

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