GPAHU Pulse – December 2022

GPAHU - Monthly State and Legislative Updates

Here’s something to talk about when discussing plan design options and employer contribution strategy with group clients in the New Year.

Over one-third of consumers find the stress of figuring out what is covered under their employer’s health plan to be more stressful than their current job. As a recent survey by the Wakefield Group and Gravie of over 1000 employees with group coverage reveals that 86% of consumers are concerned that their health benefits will not cover a portion or all of their exams, treatments, or procedures for this year. Additionally, 71% of consumers stated that their health plan does not cover mental health, and two-thirds of consumers are concerned that their current mental health coverage does not address the needs of themselves and their families.

Source: https://www.prnewswire.com/news-releases/new-study-shows-consumer-concern-for-rising-healthcare-costs-this-open-enrollment-season-301639999.html

The Big Three

Each month GPAHU identifies three top public policy or legal developments that could impact our members and clients.  Here are this month’s big three!

New Jersey Moves to Mandate Coverage of Abortion Services in All Fully Insured Plans

The New Jersey Department of Banking and Insurance (NJDOBI) is taking steps to mandate that all fully-insured policies sold in the state cover access to abortion services as part of the implementation of the Freedom of Reproductive Choice Act signed by Governor Phil Murphy earlier this year. The NJDOBI recently released a study on access to comprehensive reproductive healthcare in the state which found a need for regulatory action to require coverage for abortion services under fully-insured health benefits plans, so they have started the formal rulemaking process to implement the requirement.

The NJDOBI is seeking advance comment on its proposal prior to its publication in the New Jersey Register, which provides for a 60-day public comment period. Simultaneously, the Individual Health Coverage and Small Employer Health Benefits Program boards are moving forward with implementing the requirement for the individual and small employer markets, effective January 1, 2023. The requirement would take effect in the large employer market after the rules process under the Administrative Procedure Act is completed in 2023.

Control of PA House In Dispute

While Democrats won control of the Pennsylvania House of Representatives by one vote during the November elections for the 2023-2024 legislative session, control of the House is under dispute.  Since Pennsylvania needs to hold three special elections to replace Democratic members who have moved on to higher offices or are recently deceased, which party will have enough votes to fully control the lower chamber when the House members are sworn in and elections for House Leader are held in January is still up in the air. 

To make sure they have full control, House Democrats had a Delaware County judge swear their leader, Representative Joanna McClinton (D-Philadelphia), in as the presiding officer of the House during an unpublicized ceremony. McClinton then scheduled special elections for February for all three seats, which are districts where a Democrat is expected to win easily. House Democrats cite precedence for this move because is 2004, the House Republican leader had himself sworn in early to schedule a special election.  However, in that instance the Republicans were the majority party for both the prior and new legislative sessions, and there was no issue with party control due to the need for the special election.

In response, Pennsylvania House Republicans filed a lawsuit to block the three special elections from taking place in February, citing lack of authority on the part of Representative McClinton. The suit contends that Bryan Cutler (R-Lancaster), as Leader of the Republican Caucus of the House of Representatives is the one with the authority to schedule the elections, at least until January 3, 2023, when all the new House members are sworn in and will elect their new leader.

The House GOP lawsuit seeks to delay the special elections to later in the Spring of 2023, which creates a scenario where House Republicans could claim control of the lower chamber for at least a few months. Currently, to win the Majority Leader’s race, both parties will need votes from the other party.  Previously, Cutler indicated he did not plan to run for Leader again, but it is not clear if Republicans will attempt to field another candidate.  GPAHU and PAHU will be keeping an eye on this situation, since it could impact House Committee assignments, the legislative calendar, and the goals of the incoming Shapiro administration for 2023.

Key Federal Compliance Deadlines on the Horizon

There are two significant federal compliance obligations for group health benefit plans that brokers need to be on top of before year-end.  One is the new federal reporting obligation that’s been labelled the RxDC (Prescription Drug Data Collection) report . All group health plans, of all sizes and funding structures, must make sure their 2020 and 2021 reporting is complete on or before December 27, 2022.  Then, on January 1, 2023, all group plans must make a participant-specific price transparency tool available to all participants for 500 commonly covered services.  While carrier or third-party administrator and PBM assistance is needed for groups to be able to meet their obligations, ultimately employer group plan sponsors do have liability to ensure reporting submissions and transparency tool creation and maintenance.

The RX DC reporting must detail plan spending on both prescription drug and traditional medical care. Report sections include both data-based segments and narrative responses about plan spending and must be submitted through an online portal to be managed by the federal Centers for Medicare and Medicaid Services (CMS). Reports on 2020 and 2021 calendar year spending are due on or before December 27, 2022. After that, calendar-year reports are due by June 1 annually. So, all employer group plans will need to submit 2022 calendar year data by June 1, 2023.  Even though plan vendors will be primarily responsible for producing the data needed for these reports, the submissions do require information typically only known to the employer group plan sponsor.  Also, all employers are ultimately responsible for ensuring that the appropriate data is reported to CMS.

Concerning the price transparency tool requirements, health insurance carriers and group health insurance plan sponsors must ensure people can see price data and obtain an estimate of their own cost-sharing responsibility for 500 specific covered items and services. Plan participants also need to be able to compare expenses and price data across different providers and facilities, including those in and out-of-network. This information needs to be online and specific to all plan participants, but if a participant wants the information in writing, it must be made available to them upon request.  For groups with fully-insured coverage, they may transfer responsibility and liability for creating and maintaining this tool to their carrier, but they need to do so via a formal agreement, Employers who offer self-funded coverage, including level-funded coverage, may rely on their carrier or third-party administrator to perform these compliance functions for them with an agreement in place to do so. However, these types of plans always retain ultimate liability for any compliance mistakes.

To make sure group clients are prepared for RxDC reporting, brokers should confirm that each employer client has a plan to complete their RxDC filings, including providing CMS with the plan-specific sections of the report.  Regarding the price transparency tool, brokers should verify all group clients have written agreements in place with their health insurance carrier and/or third-party claims administrator or other applicable vendor. This agreement needs to specify that the carrier/TPA/other vendor will provide employee group plan participants with the online price transparency and cost-sharing data the law requires them to have access to and handle any written requests in a timely manner before January 1, 2023.  Fully insured plan agreements should include a transfer of liability. Finally, all brokers should monitor carrier and TPA response to this new requirement at the beginning of 2023, to stay on top of any compliance issues.

Check This Out!

If you want to expand your health policy knowledge beyond this newsletter, here is a resource to check out!

The National Health Interview Survey (NHIS) has monitored the health of the nation since 1957. NHIS data on a broad range of health topics are collected through personal household interviews. Survey results have been instrumental in providing data to track health status, health care access, and progress toward achieving national health objectives.  To check out their fast facts on health insurance coverage and other statistics, click here!


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