Stay Informed & Prepared

Health Plan Compliance

Sibson Consulting offers a range of compliance services and publications to help employers navigate the maze of federal, state and local laws and regulations related to benefit plans. Our services include:

  • Reviewing documents, policies and administrative processes to ensure that the plan is in compliance with HIPAA
  • Preparing the Summary of Material modification/Summary of Material reduction in Covered Services of Benefits
  • Preparing annual notices to employees and enabling electronic delivery of the notices and other plan communications
  • Reviewing claims and appeals policies and discussing any complaints from employees
  • Creating plan documents and COBRA policies for plans with and without HRAs
  • Reviewing subrogation and reimbursement policies, worker's compensation and third party liability recovery procedures
  • Reviewing plan design for compliance issues as well as reviewing benefit administration for health and welfare plans using Crosscheck
  • Reviewing Medicare and Medicare Secondary Payer policies and Coordination of Benefits (COB) in general
  • Ensuring that federally-required policies and procedures are complete and up-to-date, including the Uniformed Services Employment and Reemployment Rights Act (USERRA), the Qualified Medical Child Support Order (QMCSO) and the Family and Medical Leave Act (FMLA) notices and policies
  • Reviewing policies and procedures meant to safeguard the plan in the event of an Retiree Drug Subsidy (RDS) audit
  • Ensuring that reporting and disclosure notices are up-to-date and have been sent out as required
  • Addressing the various aspects of the ACA, from assistance in applying for reimbursements under the Early Retiree Reimbursement Program to modeling the potential impact of the Premium Assistance Tax Credit, and evaluating the Health Insurance Exchanges

Health Care Reform

Sibson can help your organization assess options and determine next steps for your health benefit programs. Our compliance, compensation and communications experts can assist plan sponsors in evaluating the impact of important ACA changes on future medical benefit choices, costs and strategies. Sibson’s extensive resources, including the New Exchange eXamination Tool (NEXT) and modeling tools such as WORKFORCE composition, review full-time status look-back analysis, and excise tax exposure can guide plan sponsors through the maze of new federal regulations. We can also help organizations explain these rules to plan participants.

Plan sponsors need to make sure that their future benefit offerings comply with new rules that address:

  • Reporting requirements for plans and employers concerning quality and plan eligibility/enrollment and new W-2 reporting for employers
  • Notices (grandfather, waiver, March 1 notice about exchanges, etc.)
  • Medical Loss Ratios evaluation (for insured plans only)
  • Assuring that plan documents are updated correctly
  • HIPAA Electronic Data Interchange (EDI) certification
  • New Summary of Benefits and Coverage (SBC) statements
  • Whether and when a plan loses grandfather status — implementing the additional mandates for non-grandfathered plans such as new internal and external appeals rules and 100% coverage for preventive benefits
  • Non-grandfathered plan mandates such as new limits on out-of-pocket maximums and payment for clinical trial-related services
  • New 90-day maximum waiting periods
  • Elimination of annual dollar limits on essential benefits (and no waivers of existing limits)

Sibson offers several applications to help clients test their plans to determine:

  • Pay or Play Mandate Modeling: What does the pay or play mandate mean to workers, plan sponsors and contributing employers? Sibson’s models allow decision makers to make informed decisions now that the public state health exchanges are up and running. Models assess the impact of federal premium assistance subsidies available to low and moderate-income employees and the employer shared responsibility penalty on plan costs and aggregate financial gains or losses.
  • Excise Tax Testing: Modeling the probability and amount of paying the new 40% excise tax on high cost plans, now delayed to 2020. Sibson models whether and when a plan would hit the excise tax threshold and the cost of the tax from 2020 to 2027 using several different assumptions of plan cost trends.
  • Employee Affordability Testing: For plan sponsors that require employee contributions for health benefits, Sibson offers models that determine, based on current contributions and W-2 income levels, how many eligible employees/members could fail the affordability test and create new penalties for plan sponsors.
  • Other Fees: We analyze the impact of other ACA fees, including increased Medicare taxes on high-income earners, comparative effectiveness research fees, transitional reinsurance fees, etc.

Employers that wish to avoid paying the employer shared responsibility penalty will have to offer benefits to full-time employees (and likely to dependents as well). Employers with flexible workforces (e.g., part-time workers, contract workers, adjunct faculty) will have unique needs with respect to the penalty. These employers will need to test their workforces to determine which employees are full-time under the ACA rules and which are receiving benefits.

Sibson can evaluate an employer’s staffing policies to ensure that full-time workers are accurately identified and offered benefits in order to avoid being assessed the employer shared responsibility penalty.

Furthermore, many employers with large flexible workforces may consider modifying their staffing models to minimize the number of employees considered full-time (and therefore benefits eligible) under the ACA. Sibson can help employers explore these workforce planning opportunities.

Sibson’s team includes underwriting specialists, behavior modification experts and communications and compliance experts. Our consultants help clients develop new wellness plans that generate meaningful participation and comply with new federal rules:

  • Using the loss of grandfathered status and new 100% preventive benefit coverage rules to redesign a new wellness program
  • Adapting wellness programs to comply with the new 30% reward/penalty maximums (effective for plan years beginning on or after 1/1/2014)
  • Designing effective tobacco cessation programs, particularly in light of new regulations that will allow a 50% reward/penalty maximum for tobacco use (effective for plan years beginning on or after 1/1/2014)
  • Communications strategies and campaigns to improve member education and engagement rates
  • Sibson also has a Wellness Assessment tool, which can quickly review an employer’s current programs to identify opportunities for improvement, simplification or redirection

With the state- and federally-operated Public Health Insurance Marketplaces open for enrollment, and several large companies announcing their plans to move retirees and active employees to Private Health Exchange platforms, this is a very important time for employers and plan sponsors to examine the merits of exchange-based health benefit delivery models for their employees and retirees. Sibson is one of only a few national benefits consulting firms that is not operating its own exchange and consequently can provide our clients with:

  • Unbiased analysis of the viability of the private exchanges
  • Independent, objective evaluation of the various exchange administrators

Sibson’s New Exchange eXamination Tool (NEXT) helps employers identify the strengths and weaknesses of the various health exchange models available and compare them to traditional health benefits offerings. Using NEXT, employers can assess the impacts of different options and make an informed decision about whether to “pay or play.” When considering an exchange-based model, employers should consider:

  • The feasibility and affordability of transitioning active and retiree health benefits into a defined contribution approach, including the challenges facing health insurance exchanges such as readiness, effectiveness and product choice
  • Ease of navigation in the exchange (how easy is it to assess coverage options) as well as the administrative complexity and requirements of each exchange
  • Ability to exploit the low-income subsidies available in the Public Exchange
  • Flexibility of the model regarding plan design and coverage tiers
  • Costs (both directly through fees and rates and indirectly through commissions), including costs to the employee or retiree
  • Relationships between the exchange manager and coverage providers and availability of networks
  • Underwriting methodology and renewal expectations year after year
  • Account management model and the ability of the employer and employee to receive expected levels of service from the carriers

Private Exchanges

Benefits professionals need to understand the Private Health Exchanges marketplace so that they can make informed decisions and choices. With many of the new Private Health Exchanges administrators being the very same companies to which plan sponsors typically turn to for guidance, the important distinction between health benefits provider and advisor is blurred. Plan sponsors must be diligent in seeking objective advice as they consider changes to their benefits programs. Sibson helps clients:

  • Consider the business rationale for utilizing a Private Exchange
  • Understand how the Private Exchanges work 
  • Evaluate how many employees or retirees win or lose in this new model, and the ways in which to ease this transition
  • Weigh the advantages and disadvantages of implementation
  • Factor in the future costs to the employer
  • Create effective communications to inform and educate plan participants

The ACA is having a major impact on the relationship between providers and insurers/network administrators, with Accountable Care Organizations (ACOs) resulting in more “capitation-like” arrangements and health care providers taking on more risk for the cost of care. Sibson can help employers assess the impact of these new ACO models, as well as other new payment approaches, on future claims costs for budgeting, projections and during the RFP process when selecting a carrier.

Sibson can help employers analyze the feasibility of setting up public/private partnerships, co-ops, Accountable Care Organizations and other structures to maximize the effectiveness of health benefit programs.

Insurance Market Trends

Sibson has a dedicated team that focuses specifically on insurance organizations and closely monitors industry trends in order to offer insight and intellectual capital specific to this industry. Insurance markets are adapting to the constantly-changing economic times, and it is vital to stay ahead of these changes. Sibson will keep you informed of current trends and help predict future ones by applying our expertise to the insurance marketplace.

Surveys and Normative Data

Sibson has placed a long-standing emphasis on the importance of research and development that keeps our clients informed on all aspects of employee benefits programs. We have extensive experience in preparing comprehensive studies and reports on benefits-related topics involving legislative and regulatory issues. Sibson periodically creates, delivers and tabulates surveys and then reports on these survey results.

Considering Health Care Exchanges

Preparing for Health Care Exchanges, Part 1

Preparing for Health Care Exchanges, Part 2

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