Navigating health insurance renewals can feel like walking through a minefield, especially given recent regulatory changes and market trends.
However, asking the right questions can help you clear a path to a plan that supports your employees without compromising your budget.
These key questions will help you and your team make informed decisions and protect your organization.
Key Questions for All Employers
- What Are the Primary Drivers of This Year's Premium Increase? Recent years have seen rate increases ranging from 7% to a staggering 37%. Identifying the factors behind these increases—like high-cost claims or prescription drug prices—allows you to target these areas specifically. Follow-up question: "What was done to control the cost of significant claims?" Often, the answer is nothing... or you might even get a blank stare. But it's essential to ask. The response will help you plan your next moves.
- How Does the Network Impact Employee Access to Quality Care? Ensure the network provides ample access to quality providers for your employees. Ask whether direct access to primary care with no out-of-pocket costs for employees is, or can be, included. There are ways to eliminate out-of-pocket costs altogether, leading to better health outcomes and employee satisfaction. This applies to both fully insured and self-funded plans. If you aren’t being presented with these options, ask for them!
- What Cost-Containment Strategies Are Included to Control Long-Term Expenses? It's not enough to control costs just for the coming year. Ask about tools for long-term savings, like genuine utilization management, care navigation, specialty drug cost controls, or direct primary care models. A prime example is Applied Behavior Analysis (ABA) therapy claims, which are becoming a significant cost driver. In fully insured or traditional self-funded plans, these claims can cost $600,000 to $800,000 annually, often with no attempt at cost control. Creative solutions exist to manage these expenses while ensuring quality care.
Additional Questions for Employers with Over 100 Employees
- What Level of Data Transparency and Reporting Is Provided? Data is crucial for employers. Insist on regular, detailed reporting on claims, utilization, and cost trends. This enables mid-year plan adjustments and proactive decisions for future renewals. Remember, it's your obligation as an employer to ensure due diligence. Employee complaints are fueling DOL and class-action lawsuits. Don't get caught unprepared!
- What Are the Stop-Loss Insurance Options, and How Are They Structured? For self-insured plans, understand the specifics of stop-loss coverage, like attachment points and aggregate limits. Contrary to common belief, self-insurance isn't necessarily riskier. With the right setup, you can control costs on large claims. For instance, we have a client paying $180,000 for an ABA therapy claim this year and next. Without cost-containment strategies, that claim would be closer to the $600,000 - $800,000 mentioned above.
Compliance Check: Are You Covered?
ERISA requirements have evolved significantly over the last three years. 401(k) requirements now apply to Health and Welfare plans. Ask questions about this! The risk to employers is real if ignored. And if you engage with the new requirements, you will find that your health insurance will decrease!
Here's an updated compliance checklist:
- ACA (Affordable Care Act) compliance
- Form 5500 filing
- Wrap documents
- Gag clause attestation
- PCORI fee
- RxDC (Prescription Drug Data Collection) reporting
- Broker compensation disclosure
- Mandatory notices (HIPAA, COBRA, Medicare Part D)
Many employers believe that insurance renewals can't be negotiated or that there are no creative solutions to control costs while improving care access. This is a myth. There are always options, from alternative plan designs to innovative cost-containment strategies. Don't accept the status quo without exploring all possibilities.
By asking these essential questions, ensuring compliance, and challenging common misconceptions, you can approach your renewal negotiations with confidence. Find the right plan that serves both your employees and your organization's bottom line, even in the face of complex regulatory changes and market pressures.
Remember, renewal time doesn't have to be overwhelming or excessively expensive. There's always room for negotiation and creative problem-solving. By being proactive and informed, you can navigate this process successfully and find solutions that work for everyone involved.
President @ Healthcare Management Sector | Specializes in healthcare management and wellness
1 个月You are spot on Allison. If there are no pro active measures in place to incentivize the employee to comply with health management and wellness directives, the cost will continue to escalate. There should be an arithmetic point that compares normal claims to high cost claims (I.e. 70% of claims volume are for normal claims and 30% are high risk claims or 65% of total dollars spent are for standard claims and 35% are for high risk claims) needs to be set as a standard) If the employer has implemented a health management and wellness plan, there should be a separate set of standards. If there is no or minimal difference between the first two standards and the healthcare management program data, then you need to change health management vendors.