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MLR Rebate, What’s an employer to do?

Some employers will receive rebates from carriers that did not meet the medical loss ratio (MLR) requirements for the prior calendar year.

The MLR is the percentage of premium the carrier spent on medical expenses based on the experience of all of the carrier’s policies broken out by state and market (i.e., individual, small group, or large group). The MLR is not based on a group’s own claims experience. If the carrier spent less than 80% of premium dollars on medical expenses (or 85% for large groups with 51 or more employees), then the carrier must rebate to policyholders by August 1st after the end of the calendar year.

For employer, the carrier will generally pay the rebate to the employer who may then be responsible for sharing a portion with employees. If a portion of the rebate is considered an ERISA plan asset, employers are obligated to handle the rebate according to ERISA rules.

Note: The MLR rebate rules are slightly different for governmental and church plans that are exempt from ERISA, as well as for insured plans with a trust.

We have found a few documents throughout the years that we reference for guidance on this subject:

When Hospital Systems Lose Their Way

Many hospital systems are set up as not-for-profit systems or incorporate or charter themselves originally as a benefit to the community’s general good, later lose their way.  I remember living just outside of Winchester, Virginia many years ago coming home from work late one evening receiving a collection letter from Valley Health Systems regarding an unpaid medical bill. A health care episode I did not recall but would have been fine paying my bill and had the ability to pay, obviously some confusion that I would later straighten out. What I found most odd about that evening’s mail was while I had the hospital’s aggressive collection letter threatening to sue and use the full force of the law to collect on its self-interests  it was also accompanied within that same day’s mail delivery a letter from the same health care system asking me to donate to their hospital’s fund to help pay for things such as uncompensated care; most of us understand that to be accounts receivables.  All I could think about is how strange a system the nation’s health care had become.

I cannot help feel for individuals such as Heather Waldron and John Hawley who are losing their 4-bedroom home thanks to efforts by University of Virginia Health System.  Read: “UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”

Balance Billing, a.k.a. “Surprise Billing”

Bipartisanship is in the air in Washington, D.C. Well, at least on one issue that has frequently made the news over the past several years: surprise, or balance, billing. Driven by devastating stories in the popular press, a slew of proposals have been introduced in Congress over the past year. While diverse in their approaches, all of the proposals seek to increase consumer protections and shield patients from unexpected and often outsized bills. President Donald Trump has expressed his support for these efforts. Without a doubt, federal action on the issue is long overdue.

Yet, ultimate success seems far from certain, as jousting among competing stakeholders has replaced the usual partisan quarrels in D.C. Moreover, while surprise billing has unquestionably caused great individual harm, the current debate has largely missed two other important problems related to provider networks: inaccurate provider directories and inadequate provider networks. These problems are inherently complex, harder to turn into news stories, and defy simple solutions. Yet, they also affect a much larger number of Americans’ financial and physical well-being than does surprise billing.

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Application Programming Interfaces (APIs)

In 2015, ONC recognized the potential for APIs to revolutionize health care data sharing, as it has already revolutionized data sharing in other industries. ONC issued a regulation that included “certification criteria” for APIs. Using APIs as part of electronic health records systems, or EHRs, can make it easier for patients to get and share important health information. APIs can also help health care providers share patient information with other providers securely and efficiently.

APIs are messengers or translators that work behind the scenes to help software programs communicate with one another. If you have ever used a web-based application or a mobile “app” on your computer, smartphone, or tablet to purchase a flight or pay a bill, you’ve probably used an API.Today, APIs have become an integral part of both our personal and business worlds. ONC has adopted API certification criteria for electronic health records to help enable access to health information for clinical and patient-facing uses.

Let’s start with something you’re familiar with. Think about searching for a flight. Before APIs, people had to visit various airlines’ websites to compare prices. Now, there are travel search programs that centralize airline flight information. How do they do this? By using APIs.APIs in health care are already doing the same things. For example, mobile apps can use APIs to gather data from fitness trackers and add the data to a patient’s personal health record. In the near future, patients may even be able to use an API to electronically share diagnostic information with their doctor in real time – like blood pressure readings, blood sugar levels, and other health information patients generate themselves.Now that certified electronic health records are required to provide APIs, patients will be able to connect with these APIs to gather and share health information, like from health care providers’ patient portals.

Let’s take a look at a scenario in which a patient securely accesses her medical records with the help of APIs.1.) The patient downloads and logs into the app with her username and password.2.) The patient uses the application to link securely to an API for the health careprovider’s EHR.3.) The application sends a request to the patient’s health care provider EHR asking for access to her medical records.4.) The health care provider’s EHR validates the request coming through its API and sends back the patient’s data to the app.5.) The patient can now access health information from the app and can merge this information with other health information from other sources – for example, patient portals – to access all the data in one place.

Now that we understand the role that apps and Application Programming Interfaces play for interoperability, let’s look at how APIs work.APIs describe a specific set of technical instructions that allow one piece of software to interact with another piece of software.When we talk of APIs in health care, most of the APIs work in ways that are very similar to how modern websites work. In general, when an API-enabled app uses the API to make a call from the app to an EHR that has data, the EHR returns data in a compatible cross-application format such as JavaScript Object Notation, known as JSON, or Xtensible Markup Language – XML.Because the app only needs to know how to call the API, the app can then access data from various EHRs without having to know how the data is stored within each EHR. This makes it easy and quick for applications to combine data and provide new and interesting applications.APIs in health care typically use a secured version of Hypertext Transfer Protocol, called HTTPS, as the underlying transport technology. Many APIs provide additional levels of security and privacy by using well established industry standards for authentication and authorization, such as OpenID Connect and OAuth 2.0, which are used by some social media platforms such as Facebook and Twitter, to protect a user’s identity and their data.

We have learned that APIs act as a doorway to data that lets people with the right key get through. APIs work in exactly the same way on different types of devices, in various operating systems, and on a range of mobile devices. When using APIs, remember that the security safeguards required by the ONC certification rule establish a floor of security controls that all certified electronic health records must meet. However, even when using certified health IT resources and tools, there are risks whenever data are shared electronically. The HIPAA Security Rule can help providers manage these risks. The Security Rule requires providers that are covered by the rule to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting electronic personal health information, or e-PHI. Covered providers are required to perform risk analysis as part of their security management processes. When health care providers add APIs or other new technologies to facilitate information sharing, the best way to identify the risks is to conduct a revised security risk assessment. If the analysis identifies new risks, security measures will need to be put in place to reduce those risks.This process will help providers protect their practice from threats such as ransom ware, theft, or other types of hacking. ONC offers a Security Risk Assessment Tool online, free of charge, to help small and medium providers assess their risk so they can take the appropriate precautions.

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2020 H.S.A. Health Savings Accounts New I.R.S. Limits

Health savings account (HSA) contribution limits for 2020 are going up $50 for self-only coverage and $100 for family coverage.

The annual limit on HSA contributions will be $3,550 for self-only and $7,100 for family coverage. That’s about a 1.5 percent increase from this year.

In Revenue Procedure 2019-25, the IRS confirmed HSA contribution limits effective for calendar year 2020, along with minimum deductible and maximum out-of-pocket expenses for the HDHPs with which HSAs are paired.