Health Reimbursement Arrangement Regulations
Health Reimbursement Arrangements can only be processed by Responsible Reporting Entities as of October 2010.
Stringent reporting requirements, with daily fines for failure to comply, went into effect as of October of 2010. Only CMS (Center for Medicare & Medicaid Services) approved Responsible Reporting Entities can process Health Reimbursement Arrangement claims. Because of higher premiums, more and more employers are amending to higher deductible plans and “self funding” some or all of the higher co-pays/deductibles by means of an HRA. Many employers mistakenly believe that they can simply cut those reimbursement checks for their employees themselves. CMS requires that, when any HRA claim is paid, information must be obtained from the claimant as to whether they are Medicare-eligible. Any claim actually paid on someone who is Medicare-eligible must be electronically reported to CMS. BMC is a CMS-approved Responsible Reporting Entity.
Healthcare Reform Update
New restrictions are in place for terminating employees from your plan.
The brief background is that the Patient Protection and Affordable Care Act of 2010 (PPACA) prohibits health insurance carriers and group health plans from rescinding coverage except for cases involving fraud. You CANNOT retroactively terminate coverage if the employee paid premium (contributed to the cost). If the employee was paying premium, you can only terminate the coverage with a FUTURE termination date (e.g. end of the current month). You MAY still terminate retroactively as part of your reconciliation of eligibility if the member did not contribute toward the cost of the premium past the termination date you are requesting. The most common scenario for a retroactive termination is when an employee is no longer employed and you are, therefore, not taking premium contributions. In that case, the retro termination is still permitted. When you submit a retroactive termination, the insurance company (and BMC) will regard the request as your verification that no premium/contribution was paid by the employee/dependent for that period.
Healthcare Consumer Tips
Encourage your employees to be vigilant consumers when it comes to their health care.
I’m going to share two recent examples from my personal experience:
Prescription Costs: A year ago my eye doctor prescribed Pataday, a once a day eye-drop for allergies. I learned that my insurer would not cover the expensive, cutting-edge Pataday without lengthy pre-certification, but they would allow Patanol, the same medication in a twice a day formulation. I had my provider switch my RX to Patanol and have used it for a year. At my last refill I was charged the highest level of co-pay as a non-formulary RX. I just saw my eye doctor and was given a new RX for another year of Patanol. By checking the insurer’s website and looking at the formulary, I learned that Patanol is non-formulary, however, Pataday is now on the lower co-pay 2nd tier (a brand name on the formulary). For me, that’s $15 a month in co-pay savings AND the convenience of using the eye-drops only once a day. This is a good reminder to all of us: formularies can change monthly or quarterly. Monitor your prescriptions over the course of a year. It only takes a few minutes and can save you time and money. And don’t assume that either your doctor or your pharmacist is going to monitor it for you! While you’re at it, remember that most medications you take continuously can be mail-ordered, saving an additional co-pay. My doctor authorized the Pataday to be dispensed in a 90 day supply. By mail order, I’ll only pay two co-pays for a three month supply.
Provider Over-Charging: Like many of our clients, BMC has amended our health care plan to include higher co-payments for office visits. After several visits to the eye doctor for those allergies, I happened to log into the personal on-line account I have with my insurer (ibxpress for Keystone/Personal Choice, Aetna Navigator for Aetna or myUHC for UnitedHealthcare) and viewed the explanation of benefits for my recent claims. I was startled to learn that my insurer had actually allowed LESS for my follow-up visits than my co-pay. All network providers agree to be bound by the discounted fees. I contacted my provider’s billing office and they acknowledged that I had overpaid and arranged for a refund.