The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

Informed Health Care Decisions Cut Costs & Saves Lives

All too often, employees are forced to make important choices that can affect their family’s health and health-related financial security. Making these decisions can be stressful and confusing; especially when a family member is ill or when considerable medical expenses are involved.

That’s why many insurance companies now provide treatment cost estimators which provide an easy way to see how much certain procedures and services will cost before a visit to a provider. Armed with this information, employees can make cost effective choices and more informed decisions.

Knowing the costs upfront is important due to their responsibility for paying a portion of their health care costs. And it’s helpful for budgeting aspects of their health benefits and health insurance plans, such as health savings accounts and flexible spending accounts, or for seeing how quickly they may reach their deductible and coinsurance limits.

Employees will need to create a login to their insurance company plan to access these tools. Also, it is important to note that some carriers’ sites display rates billed by the providers and others display the contracted, negotiated rates for in-network providers.

As of this posting, Medical Mutual, Aetna, and United HealthCare use the negotiated rates in their illustrations. However, Anthem uses only the rates billed by the provider, which may not provide an accurate picture to employees about their actual costs.

PPACA: What Will the Supreme Court Decide?

In late March the Supreme Court took the somewhat unusual step of setting aside three days on its calendar just to hear the various aspects of the Constitutional challenge to the Patient Protection And Affordable Care Act. The schedule affirms the universal expectation that the court will issue a ruling on the healthcare law in June, at the height of the 2012 campaign. The Supreme Court sessions began with one hour of arguments on whether it can reach a decision on the reform law before 2014.

There is a possibility that a separate federal law will prevent the courts from ruling until the law’s individual mandate has taken effect. The justices then heard two hours of arguments on the core question of whether the mandate is unconstitutional. And, finally, the court heard two and half hours of arguments on two issues: how much, if any, of the law’s other provisions can be upheld if the mandate is unconstitutional, and whether the health law’s Medicaid expansion is constitutional. There hasn’t been another case in recent memory that’s been argued on this kind of schedule. It no doubt reflects the Court’s own recognition of the complexity and importance of the issues involved.

SBC: Summary of Benefits and Coverage

The Departments of Health and Human Services, Labor, and Treasury, have issued the final regulations for the Summary of Benefits and Coverage. To help consumers better understand and compare health plans, insurers and group health plans are required to provide a new, uniform way to show benefits and define health care industry terms. The effective date for providing the SBC begins on September 23, 2012. Of course, the Supreme Court decision could affect this requirement.

The Signed Waiver: Important Protection

Most employers have some people in their workforce that do not need or want benefits for various reasons. Much of the time it is because they are covered by their spouse’s health insurance plan; although, other reasons do exist.

If your company has employees that are eligible to participate in the health insurance plan but have chosen not to for any reason, we suggest that you have them sign a “waiver of participation” form. This form is generally provided by your insurance carrier and normally is required to be completed by non-participating employees.

The signed waiver is your only protection against allegations that you did not offer coverage to an employee. The question of whether or not you allowed the employee to participate can easily be proven if you have a waiver that has been signed by the employee. Of course, this is not an allegation that comes up often. When it does, it is usually because there are outstanding claims and no insurance to cover them. This is a liability that most employers are not interested in self-insuring. A properly signed waiver is the best protection against this happening to your company.

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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