PPO medical plans offer direct in-network access to a large variety of healthcare providers in most geographic areas. On a PPO plan, usually you can call around and get an appointment with a provider who has availability within 7 - 10 days or sooner for urgent health issues. You can take matters in to your own hands to find a provider who will see you.
HMO plans are more restrictive and require members to see your designated primary care primary care physician and get referrals for specialists, diagnostic tests, physical therapists, etc. As a consumer protection, the State of California has legal guidelines that HMO plans must follow. If your HMO is not providing timely access, this is a helpful document to reference.
Big news in North County San Diego. UCSD Health has announced a partnership with Tri-City Medical Center. UCSD will absorb Tri-City’s property, outstanding debt and staff, and will form a new governing board. It's unclear if an when the facility will be rebranded and become an in-network option for insurance plans which provide access to UCSD Health.
Since the early days of the internet, physicians have used online resources to help guide effective care by providing information from clinical trials, medical specific websites like WebMD, and other webpages indexed by search engines. With the emergence of AI technology from Google and ChatGPT, access to the best information will continue to improve:
As the Writers Guild and UAW strikes are dominating the headlines, healthcare workers are facing similar challenges in dealing with cost of living increases. Wage increases may be needed to maintain adequately staffed medical facilities, but will certainly increase health insurance premiums in the future.
Below is some more information on these 2 related topics:
The CA legislature has approved a $25 minimum wage law for healthcare workers which is awaiting signature from the governor.
Kaiser workers in CA and nationwide are preparing for a strike.
As a trend, benefits administration systems with an Amazon-like benefits election experience are becoming more prevalent than human interactions like live open enrollment meetings and one-on-one conversations. While leveraging innovating technology is important, it is important for employers to consider the complexity of insurance benefits(and other important HR topics) and have a comprehensive strategy which provides access to deeper resources to help employees.
Interesting data on what drives health insurance premiums for 2023:
1. Inflation Driving Increased Provider Rates
2. Shift in COVID-19 Vaccine and Testing Costs to Health Plans
3. Uncertainty Surrounding Medi-Cal Redetermination
4. Emergence of Expensive Weight-Loss and Specialty Drugs
5. Misusing the Special Enrollment Period
1 in 4 of today’s 20-year-olds will become disabled before they retire. Long term disability insurance is very important. If employees become unable to work, LTD provides cash payments(usually around 60% of income) to cover non-medical living expenses: housing, food, etc.
This chart provides a breakdown of US employees who have LTD coverage, broker down by income quartiles.
A few interesting stats from the California Association of Health Plans :
-health plans spent 87 cents out of every health plan dollar, on medical care
-health plans picked up 92.6% of the tab of the 25 most costly prescription drugs
-Hospital care accounts for 31% of overall health care spending
This is interesting: the NHS has tapped private industry managed care provider Centene(owner of Health Net and administrator for US Government programs medicare, medicaid, and TriCare) to administer medical practices in the UK, seemingly to gain operational and financial efficiencies:
Health-related benefits continue to top the list in terms of importance in the 2022 SHRM Survey:
Great vid from WSJ on how healthcare pricing functions and how the marketplace is changing:
July 1, 2022 was a major milestone for healthcare pricing transparency. As of July 1, health insurers and self-insured employers must post on websites just about every price they’ve negotiated with providers for health care services, item by item. This is an important step for the free market healthcare system to thrive.
Bezos, Cuban, and now Newsom?
The State of California is exploring becoming a drug manufacturer. If enacted, Newsom's program will join Mark Cuban's Cost Plus and Amazon Pharmacy as big money entrants into drug manufacturing and distribution markets. More competition usually drives down prices.
Should Employers Force Workers to Take Time Off?
Here's a good article with arguments for both perspectives:
Unlimited PTO has become a popular option for companies due to easy administration, end of employment cost efficiency, and attractiveness to potential new hires. Balancing effective use and preventing overuse are important concepts to consider:
Pre-tax student loan repayments are becoming a larger part of the total benefits discussion. "Employers can provide up to $5,250 in student loan repayment benefits tax-free through 2025".
Starting Saturday, private health insurers will be required to cover up to eight home Covid-19 tests per month for people on their plans. Americans will be able to either purchase home testing kits for free under their insurance or submit receipts for the tests for reimbursement, up to the monthly per-person limit.
Some great ideas for a 2022 New Years Resolution:
I often get asked if dental insurance is worth it. I recommend that most employers offer dental insurance. Unlike medical, life, and disability insurances which provide financial protection to cover catastrophic health issues, dental provides a different type of benefit. In some ways it can be thought of as an employee perk to:
1. incentivize good oral health
2. streamline the tedious process of finding and utilizing dental care
3. provide good financial protection against the cost of dental care
Here's a solid video from CNBC on the topic:
The IRS has released 2022 limits for HSA, HSA, etc.:
Big changes in the realm of healthcare pricing transparency coming to consumers effective January 1, 2022.
For healthcare services scheduled at least three business days in advance, providers must give the participant’s plan a good faith estimate of anticipated charges.
The era of "buy now, we'll tell you how much it will cost later" is hopefully coming to an end.
Some employers may consider a health premium surcharge for unvaccinated employees:
All Individuals, Insured Groups, and Self-Funded Accounts insured through a Blue Cross Blue Shield affiliate from February 7, 2008, through October 16, 2020 will be receiving a settlement notice with option to file a claim and participate in the pending class action lawsuit related to antitrust law violations.
The American Rescue Plan Act of 2021 (“ARPA”) includes a 100% COBRA premium subsidy for periods of coverage occurring between April 1 and September 30, 2021, for certain eligible individuals. Details on how this will be administered have recently been published:
The American Rescue Act included a provision where the US taxpayers will pay 100% of the premium for COBRA participants from April 2021 through September 2021. This applies to employees who were laid off or hours were reduced so they lost health coverage. Exactly how the reimbursement will work for employers and COBRA administrators is TBD.