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Preventive Care

Once an underused component of the health care world that benefits both employees’ health and employers’ health care spending, preventive care is now a mandatory part of any health benefits package. Preventive care consists of measures taken to prevent diseases, rather than curing them or treating their symptoms.

There is significant research demonstrating that increased use of effective preventive services will result in less suffering from ailments that could have been prevented had they been detected and treated early on. Preventive care is often more cost-effective than treating diseases once symptoms appear. Some preventive care services even save more money than it costs to implement them.

Under the Affordable Care Act (ACA), private insurers—except for plans that have been grandfathered—are required to cover certain preventive services without any cost to the patient. Medical services such as immunizations, screening tests, medications and any other services that would prevent disease, injury and premature death fall under the umbrella of preventive care.

Preventive care should be incorporated into employer-sponsored health plans to lessen the cost and number of future medical claims by helping employees and their families stay healthy, while also complying with the provisions of the ACA.

Preventive Care for Adults

The following types of preventive care are available to all adults within specified age ranges or risk groups.

    • Abdominal aortic aneurysm screening: A one‐time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 who have ever smoked.
    • Colorectal cancer screening: Screenings for colorectal cancer using fecal occult blood testing, sigmoidoscopy or colonoscopy, beginning at age 45 and continuing until age 75. The risks and benefits of these screening methods vary. About 19,000 diagnoses could be prevented annually if people get screened, yet only one-third of adults complete regular screenings.
    • Depression screenings: Screenings for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis and effective treatment and follow-up.
    • Diabetes screening: Screenings for adults 40 to 70 years who are overweight or obese.
    • Diet counseling: Intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet‐related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
    • HIV screenings: Screenings for everyone ages 15 to 65 and other ages at increased risk.
    • Obesity screening and counseling: Screening for all adults; clinicians should offer or refer patients with a body mass index (BMI) of 30 or higher to intensive, multi-component behavioral interventions.
    • Sexually transmitted infection (STI) prevention counseling: Counseling for adults at higher risk.
    • Syphilis screening: Screenings for adults at greater risk.
    • Tobacco use screening: Screenings for adults at higher risk; tobacco users may receive intervention and cessation support. A comprehensive, effective smoking cessation program usually costs less than 50 cents per member per month, or less than $6 per member per year. You can save an average of $210 on yearly health care costs for each smoker who quits.
    • Vaccinations: Shots for hepatitis A, hepatitis B, herpes zoster, human papillomavirus (HPV), influenza, measles, mumps, rubella, meningitis, pneumococcal disease, tetanus, diphtheria, pertussis and varicella; doses, recommended ages and populations vary.

In addition to mandated no-cost preventive care, there are other existing preventive services that may be included by an insurer as part of a health group plan. These include things like adult vision and hearing screenings and vitamin and mineral supplements. Check with your insurer to see if additional preventive services are available for your plan’s recipients.

Maximizing Your Health Plan

How can you take advantage of the cost-saving potential of some of these preventive care services? Here are some ways that you can maximize your health care investment :

    • Educate your employees on the preventive care services that your health plan offers, their potential risk factors and the benefits of preventive medicine.
    • Find ways to make preventive care more convenient for your employees by working with nearby clinics, developing an on-site clinic or hosting a mobile van for vaccinations and screenings
    • Educate your employees on preventable health conditions. Your Consociate Health representative can provide you with payroll stuffers, flyers and posters to help educate your employees.
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Medical Care Choices

Health care costs are rising significantly, greatly impacting the price you and your employer pay for your health benefits. Consociate Health takes its responsibility to provide you with quality, affordable benefits seriously. You, too, must think carefully about how you use those benefits. Managing your personal health care expenses is one way you can help to keep costs down.

The role you play in managing health care costs is simple: Spend your health care dollars wisely. Each time you go to a medical provider or receive medical services you generate a claim that must be paid for through your employee health benefits. Essentially, the costs of your claims, and all your coworkers’ claims, determine the price you and your employer pay for your health benefits. In the end, decisions you make directly affect the year-to-year increases in your health benefits cost.

Making Wise Choices

When you have an illness or suffer a minor injury, you want to feel better—fast. Your health plan provides coverage for treatment that can be received in a variety of settings, such as your doctor’s office, a hospital or an urgent care center. However, every setting is not appropriate for every kind of care. Your responsibility is to know which setting provides the best, most cost-effective care for your condition.

The first step is to become familiar with your benefits—don’t wait until you are sick or injured. Review your benefits and know your copayments and coinsurance amounts for an office visit, urgent care facility or a hospital emergency room. And, remember to learn about what is required of you if you need to seek medical care when you are out of town.

Office Visits

For most illnesses or injuries, the best choice for medical care may be a visit to your general practitioner or primary care physician. Your regular doctor knows you best, has your medical history, and has the expertise to diagnose and treat most conditions. For most illnesses and injuries, and for regular checkups and preventive care, your doctor can provide the most cost-effective care.

Urgent Care

Many situations require immediate care that you might not be able to receive in your doctor’s office, yet these situations might not be serious enough to require the services of a hospital emergency room. In these situations, a walk-in clinic or urgent care center may be an appropriate choice.

Below are some guidelines for determining when going to an urgent care center is appropriate.

  • You have telephoned your doctor or nurse practitioner and he or she recommends that you go to an urgent care center.
  • Your symptoms or injury have occurred outside of your physician’s regular office hours and are too severe to wait until the next regular office hours, yet they are not severe enough to warrant a visit to the emergency room.
  • You do not have a regular doctor or primary care physician.
  • You are out of town.
  • You are unable to reach your doctor or nurse practitioner by phone.

Remember, care received in an urgent care facility is costly, yet it is much less expensive than an emergency room. Your best choice for non-urgent situations, however, is always a scheduled appointment with your doctor.

Emergency Room Care

A visit to the hospital emergency room is the most expensive type of outpatient care. Emergency rooms should only be used for true emergencies, as they are staffed, equipped and best suited for medical emergencies. Going to an emergency room for non-emergency care is a poor use of your health benefits and can be very costly. Some examples of situations where emergency room care is appropriate are as follows:

  • A major injury, such as a broken bone
  • A wound that continues to bleed vigorously despite application of pressure
  • Decreased mental activity or awareness, or disorientation
  • Shortness of breath
  • A cold sweat accompanied by chest pain, abdominal pain or lightheadedness
  • Severe pain

The next time you are faced with deciding where to go to receive medical care, be sure to evaluate all your options and choose the setting that best suits your illness or injury. Of course, in a true emergency, seek the appropriate care without delay. Choosing the most cost-effective options will go a long way toward ensuring that your employer can continue to provide you and your family with the quality, affordable health benefits you rely on.

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The Differences Between Short- and Long-term Disability Insurance and COBRA

Voluntary benefits are becoming increasingly important to employees as they focus on their physical, mental, social and financial health. As a result, many employers have expanded their voluntary benefits offerings to address employees’ needs and improve their attraction and retention efforts.

Among these offerings are disability benefits, which can provide guaranteed income or job protection to employees who are unable to work due to serious illness or injury. The most common disability benefits are short-term disability (STD) and long-term disability (LTD) insurance. However, understanding the differences between STD and LTD benefits and other laws, such as the Consolidated Omnibus Reconciliation Act (COBRA), can be complicated and difficult for employers to navigate.

This article provides a general overview of STD, LTD and COBRA and explores how both types of disability insurance differ from COBRA.

What Are STD and LTD?

STD and LTD insurance are the most common forms of disability benefits.

Short-term Disability Insurance

STD insurance replaces all or a portion of an employee’s income due to a temporary disability. Under STD plans, employees receive a percentage of their income, typically 40% to 70% of their base pay, but employers can allow employees to supplement their STD benefits with paid sick leave or other benefits. An STD insurance policy is paid either fully or partially by the employer, and the median length of STD insurance coverage is 26 weeks, according to the U.S. Bureau of Labor Statistics.

To qualify for STD insurance, an employee files a claim under their insurance policy. The employee must prove their illness or injury qualifies as a disability under the plan’s terms. STD insurance generally requires employees to wait for a short period—on average, seven days—before they start receiving benefits to discourage abuse and because many employers’ paid-time-off benefits cover shorter absences than those covered by STD insurance. While STD insurance plans do not guarantee job protection, employees may be entitled to it through their employers’ policies or under state and federal laws, such as the Family and Medical Leave Act.

Employers offer STD insurance because it helps employees remain financially stable while recovering from an illness or injury, allowing them to stay productive and focused when they’re physically able to return to work. Since the income employees receive under STD insurance is paid by insurance companies, employers have the financial resources and flexibility to hire temporary or contract workers to fill workforce gaps without experiencing high labor costs. In states that don’t require employers to participate in disability income plans, employers can offer full, partial or noncontributor STD insurance plans.

Long-term Disability Insurance

LTD insurance provides employees with income for long-term illnesses and injuries. Employees generally receive 60% to 80% of their base pay; however, some employers’ LTD plans offer more limited income replacement benefits. Similar to STD, employees receive income benefits until they are able to return to work or have exhausted policy limits. LTD benefits requirements tend to be more rigorous than STD because workers need to demonstrate they’re unable to perform any job, not just the job they were working before the illness or injury.

These plans often work together with STD, so when an employee exhausts their STD benefits, LTD benefits continue to provide the employee with income. As with STD benefits, LTD does not provide workers with job protection. Employees who become permanently disabled may continue to receive LTD benefits through their retirement date or until they’re eligible for Social Security disability benefits.

What Is COBRA?

COBRA allows individuals to continue their group health plan coverage in certain situations. This law requires group health plans maintained by private-sector employers with at least 20 employees to offer continuation coverage to covered employees and dependents when coverage would otherwise be lost due to certain specific events. These events include the following:

  • Death
  • Termination
  • Reduction in employment hours below the plan’s eligibility requirements
  • Divorce or legal separation
  • Medicare eligible
  • Child’s loss of dependent status under the plan’s rules

COBRA sets rules for how and when continuation coverage must be offered, how employees and their families may elect continuation coverage, and when continuation coverage may be terminated. Employers may require individuals to pay for COBRA coverage. Group health coverage for COBRA participants is usually more expensive than coverage for active employees because many employers pay a portion of the premium for active employees.

COBRA continuation applies to plans that qualify as group health plans as defined by the Employee Retirement Income Security Act (ERISA). Under ERISA, a group health plan must be a plan, fund or program that is established or maintained by an employer and has the purpose of providing medical care. Health insurance plans, self-funded health plans, health maintenance organizations and prescription drug plans generally meet ERISA’s criteria for a group health plan. Medical care is defined as care for the diagnosis, cure, mitigation, treatment or prevention of disease and any other undertaking affecting any structure or function of the body.

The Differences Between STD and LTD and COBRA

An employer is not required to offer COBRA continuation on a voluntary benefits plan if the plan does not qualify as a group health plan and the plan is considered completely voluntary. STD and LTD benefits generally provide income replacement for individuals who must take a leave of absence from work due to a qualifying condition instead of medical care. Because STD and LTD typically do not provide medical care, they’re not subject to COBRA and would not be required to continue under COBRA. However, although uncommon, if an STD or LTD insurance provided medical care, it may be considered a group health plan under COBRA and subject to continuation coverage.

While STD and TLD benefits are generally not subject to continuation coverage under COBRA, an employee’s disability can initiate COBRA requirements if it produces a qualifying event. For example, if an employee becomes disabled and doesn’t return to work at the end of their disability leave or notifies their employer of their intent not to return, the employer’s plan will determine whether this is a qualifying event. If this is determined a qualifying event, COBRA requires the employer to notify the employee of their COBRA rights and provide the employee with the option to continue group health insurance coverage.

Summary

STD and LTD benefits can provide sick and injured employees with financial stability and peace of mind when they’re unable to work. Understanding how these types of disability insurance differ from COBRA can help employers stay compliant and ensure employees have the benefits they need and desire.

This Benefits Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice. © 2023 Zywave, Inc. All rights reserved.

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A Primer on Medical Stop-loss Insurance

Catastrophic and unexpected health care claims are on the rise. This increase in catastrophic claims is, in part, the result of medical and pharmaceutical advances, such as specialty drugs and cell and gene therapies, as well as medical price inflation. As a result, many employers with self-funded health plans are actively looking for ways to minimize their financial exposures to potentially catastrophic claims. A common strategy these employers have leveraged is purchasing stop-loss insurance.

 

 What Is Stop-loss Insurance?

Generally speaking, stop-loss insurance helps self-funded employers protect themselves from higher-than-anticipated health claim payouts by limiting their exposure to employee medical claims that exceed a predetermined amount. In other words, such coverage can prevent abnormal claim frequency and severity from draining employers’ financial reserves.

Stop-loss insurance plays an important role in helping employers manage their health care costs and protecting against unexpected or catastrophic claims, as it sets a ceiling for the amount they pay in health claims. This coverage is not a form of medical insurance, but rather a policy employers can purchase to manage their financial risks.

 

How Does Stop-loss Insurance Work? 

Under a stop-loss insurance policy, an employer’s claims liability is limited to a certain amount (also called an attachment point), therefore ensuring abnormal employee health claims do not drain the employer’s financial reserves. An employer can add stop-loss insurance to an existing plan or purchase it independently.

If an employer’s health claims exceed a predetermined amount, their insurer will usually reimburse them for all additional claims. For example, if an employer has a stop-loss insurance policy with an attachment point of $500,000, their insurer will typically begin providing reimbursement after the plan’s claims exceed $500,000. It’s worth noting that since stop-loss coverage only reimburses an employer for claims that exceed their policy’s attachment point, the employer is initially responsible for paying employee claims before they reach the established cost ceiling.

 

Types of Stop-loss Insurance

There are two types of stop-loss insurance: individual (or specific) and aggregate (or total claims). Understanding the difference between individual and aggregate stop-loss insurance can help self-funded employers evaluate and determine which coverage best meets their needs and reduces their financial exposures. Because health plan usage can be unpredictable, some employers choose to purchase both individual and aggregate stop-loss insurance to provide their organizations with maximum financial protection.

 

Individual Stop-loss Insurance

Individual stop-loss insurance limits an employer’s liability when an individual employee’s medical claims exceed the attachment point. As such, this coverage can protect employers against unexpectedly high claims from individual employees.

 

Aggregate Stop-loss Insurance

Aggregate stop-loss insurance can help safeguard employers from the total sum of health claims for an entire group of employees rather than any one individual. Under this coverage, an employer is usually reimbursed when their expenses for all employees’ medical claims exceed the attachment point for the plan year.

 

Stop-loss Insurance Considerations

Each organization is unique. Deciding whether stop-loss insurance is necessary depends on an organization’s specific needs, workforce characteristics and risk tolerance. Reviewing all relevant factors (e.g., rates, policy terms and potential exposures) can help employers decide whether purchasing this coverage makes sense. Employers can consider the following factors when evaluating whether to purchase stop-loss insurance.

 

Understanding the Attachment Point

The attachment points for individual and aggregate stop-loss insurance differ. Generally, the attachment point for an individual stop-loss policy is a specific dollar amount. As a result, an employer is only responsible for an individual employee’s claims up to that amount.

 

For aggregate stop-loss insurance, the attachment point is usually a percentage of expected claims. The typical attachment point for aggregate stop-loss insurance tends to be between 120% and 125% of expected health claims. In any case, a stop-loss insurance policy’s attachment point can vary depending on factors such as the employer’s size, employee demographics and overall risk profile.

 

Evaluating Coverage Limitations

Stop-loss insurance plans are medically underwritten; therefore, an insurer may refuse to cover certain conditions or require higher claim thresholds for those conditions. For example, if a plan enrollee consistently has high-cost claims, a stop-loss insurer may refuse to continue to cover that enrollee or require a higher claim threshold for the enrollee. This practice is known as lasering.

Additionally, since stop-loss contracts typically last for one year, an employer’s high-cost claimants may only be covered for a few months before the insurer excludes them from the policy upon renewal. Thus, the employer will likely be financially exposed to those claims the following year.

 

Monitoring Increasing Costs

While stop-loss insurance can help employers reduce their financial exposures when health claims are higher than anticipated in a given year, the cost of such coverage can increase annually. Rising claims can also make it more difficult to obtain rates from other providers.

 

Ensuring Stop-loss Coverage Aligns With Health Plan Provisions

Some stop-loss policies may exclude certain medical treatments or classes of individuals covered by employers’ health plans. Consequently, employers may be on the hook for expensive claims that aren’t covered under their stop-loss policies. Therefore, employers should consider reviewing their stop-loss policies and health plan provisions to ensure they align to limit their potential financial exposures.

 

Summary 

Selecting the right insurance policies can have major financial repercussions for employers. Having sufficient coverage can lower employers’ insurance costs, reduce their risks and keep their workers healthy. Stop-loss insurance can make all the difference in helping employers mitigate their financial risks, especially as catastrophic health claims are increasing. Understanding stop-loss insurance will allow employers to make the best policy decisions for their respective organizations. 

This Benefits Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice. © 2023 Zywave, Inc. All rights reserved.

 

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