Massachusetts employers with six or more employees are required to annually submit the new Health Insurance Responsibility Disclosure (“HIRD”) form, regardless of whether they offer health insurance to their employees or not. The Massachusetts Department of Revenue (DOR) recently issued guidance on the new HIRD reporting requirements. An individual is considered to be an employee if the employer has included such individual in the quarterly wage report to the Department of Unemployment Assistance during the past 12 months. The new HIRD form only consists of a single employer form, which only needs to be completed once annually. The old HIRD form consisted of an employer form and an employee form, which required separate forms completed and signed by each employee who declined to enroll in employer-sponsored insurance (“ESI”) or the Employer’s Section 125 Cafeteria Plan to pay for health insurance.

To file your HIRD form, login to your MassTaxConnect (“MTC”) withholding account and select the “File health insurance responsibility disclosure” hyperlink under the account alerts. The HIRD reporting period will be available to be filed starting November 1 of the filing year, and must be completed by November 30. Thereafter, HIRD reporting will be due on November 30 of each subsequent year.  Although HIRD may be completed by your payroll company, it is the employer’s responsibility to ensure compliance and timely filing.  The HIRD form collects employer-level information about your company’s health plan offerings and does not collect any personal information about employees.  The form will assist MassHealth in identifying its members with access to qualifying ESI who may be eligible for the MassHealth Premium Assistance Program.

In response to Republicans’ failure to repeal the Affordable Care Act (ACA), the Trump Administration is using administrative action to modify the ACA and health insurance options for Americans. On October 12, 2017, President Trump signed an executive order that instructs various departments to consider regulations related to association health plans and short-term insurance. Shortly after, the Administration announced that they would no longer make cost sharing reduction (CSR) payments to insurers on the Exchanges.  Section 1402 of the ACA requires insurance companies to reduce the amount that eligible low-income policyholders pay out of pocket for co-payments and deductibles.  Accordingly, the federal government must reimburse insurers for reductions when the Secretary of HHS is notified.

Without these payments, insurers will either increase premiums or pull out of the Exchanges altogether. In anticipation of the announcement, some insurers have already increased premiums for the 2018 enrollment period. In spite of this, policy makers can mitigate the harm that could be felt as a result of not funding CSR payments.

The Passage of the Murray-Alexander Stabilization Bill

Senator Lamar Alexander (R-TN), Chairman of the Senate Committee on Health, Education, Labor, and Pensions (HELP) and Ranking Member Senator Patty Murray (D-WA) revealed a bipartisan plan to help stabilize the insurance market. The Murray-Alexander Bill seeks to stabilize the insurance market by funding the CSR subsidies and increasing state flexibility in their administration of the Marketplace.

The bill proposes to fund CSR payments for the remainder of 2017, as well as 2018 and 2019. The bill also reduces the time for the Center for Medicare and Medicaid Services (CMS) review of 1332 waivers, from 180 days to 90 days and creates a new 45 day expedited review process for qualifying circumstances. Through Section 1332 waivers, states are allowed to implement insurance market innovations that provide coverage “comparable” in benefits and affordability.

The Congressional Budget Office (CBO) scored the Murray-Alexander Bill and found that it would cut the federal deficit by $3.8 billion in the next decade. The CBO notes that savings would come from states offering lower-cost policies, attracting younger and healthier individuals into the market.  Insurers would lower their premiums because of the influx of younger individuals and in the long-term, save the government more than $1.1 billion in premium tax credits. Despite the savings scored by CBO, the Murray-Alexander bill will not have an affect on 2018 plans. Further, the bill may not pass before open enrollment ends on December 15.  The bill has bipartisan support in the Senate, but will have difficulties in the House because of Speaker Paul Ryan’s opposition to the current version.

State Efforts

States can play a role in telling insurers where to apply their premium increases. For example, states could tell insurers to apply premiums to only Silver marketplace plans, all metal level plans inside and outside the marketplace, or all Silver plans inside and outside the marketplace. About 30 states assumed that CSR payments would not be disseminated and either encouraged or required states to increase premiums onto marketplace silver plans only. States that choose this option allows consumers in the marketplace to receive premium tax credits and consumers outside the marketplace to not experience any increase in premiums. Additionally, some legal scholars and health policy experts argue that states could pay for the premium themselves and then bill the federal government.

Legal Challenges

Eighteen states and the District of Columbia sued the Trump Administration seeking an immediate injunction to block President Trump from ending CSR payments to insurers. California federal judge, U.S. District Judge Vince Chhabria, denied the motion for an injunction.  Judge Chhabria argued that states had enough time to plan for the end of the cost-sharing payments and adjusted accordingly. Although Judge Chhabria has denied the injunction, California Attorney, General Xavier Becerra, will still proceed with the lawsuit.

Despite the Trump Administration’s attempt to unravel parts of the ACA, states and Congress are working to anticipate more downstream impacts and must act to find solutions or ways to mitigate the issues that will arise for low-income policy holders.

Stakeholders should anticipate a continuation of unstable markets as insurers will have to adjust their rates or leave the Exchanges if there are no changes made to fund CSR payments. State regulators will have to use creativity and flexible ways to help their constituents.

Everyone is talking about Ebola, including the risk of contracting it, treatment for those who do contract it, and protection for those who treat patients who have it.  There has been very little discussion, though, about how to pay for the costs of treating Ebola patients, including whether health insurance will cover the treatment and pay the providers.

Most health insurance coverage that complies with the ACA minimum essential coverage standards will cover the costs of medically necessary hospitalization and physician services.  However, many of those policies have significant out of pocket expenses that must be paid by the patient, including deductibles and coinsurance amounts.  There is likely to be an annual cap on the out of pocket expenses (at least in ACA compliant plans), so that may limit the overall amount the patient has to pay.  Also, many policies do not cover, or provide very limited coverage, for care provided outside the country, or for evacuation expenses if you become ill while in another country- so if you are traveling you should check with your insurer and purchase travel health insurance if those expenses would not be covered.

Additionally, given that there is no actual treatment for Ebola itself, other than addressing the symptoms by providing intravenous fluids, balancing electrolytes, and maintaining oxygen and blood pressure, insurers could take the position that the inpatient level of service is not medically necessary (although none have stated this position.)

Furthermore, most insurers  use networks of providers, and either do not cover care out of the network or cover it at a lower rate of reimbursement- and the out of pocket annual limitations are not required to apply to out of network services.  In the event the patient is sent to a non-network facility for treatment, the insurer could classify the services as out of network, and either not cover them at all, or provide coverage that is subject to significantly higher coinsurance, deductibles and potentially limits based on “usual customary and reasonable costs,”  leaving the patient with a very large bill.

Finally, for providers that participate in an insurer’s network, there is generally a contracted rate for services provided.  If a facility has set up a specialized area for treatment of Ebola patients, and needs to provide more than the usual level of staffing for safety reasons, and purchases and uses expensive safety related gear and equipment, it is not clear whether those expenses would be reimbursed by the insurer.  Similarly, the cost of safety equipment for family members would also likely not be covered.

A number of insurers have posted information on their websites about the disease itself and when to get treated.  See, for example, Aetna. Similarly, Kaiser Permanente has lots of information about Ebola and treatment, but the materials mostly address obtaining care and being treated at Kaiser facilities.

Some insurers recommend that covered persons review their policies for coverage information.  See, e.g. Cigna. This may be useful with respect to coverage overseas and for evacuation services, but the policy is not likely to address the other questions discussed above.

The Blue Cross Blue Shield Plans affiliated with Health Care Service Corporation, including Texas, Illinois, Montana, New Mexico and Oklahoma, have information on their websites about Ebola, and indicates that treatment will be covered, including the hospital stay and other treatment, although some of the other issues are not addressed.

Given the fear and concern about this very deadly disease, it would be helpful if more insurers would clearly state their position regarding coverage.