America's Benefit Specialist June 2023

CRITICAL-THINKING SKILLS SITE-NEUTRAL PAYMENTS CANDIDATES FOR NABIP’S BOARD

NABIP offers health insurance professionals a multitude of educational opportunities, including advanced designations, certifications, continuing education and online learning.

June 2023

YOUR INDUSTRY

YOUR SALES

3

27 The Impact of Critical Thinking Skills on Executive Leadership By Gordon Zellers

Mergers and Acquisitions

6

Dissecting the CAA GAG Clause Prohibition By David Ostrowsky

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YOUR ASSOCIATION

9

Product News

31 2023-2024 Board of Trustees Candidates

13 Site-Neutral Payments By Jackson Hammond

41 Welcome to NABIP

16 People on the Move

43 CPC Quiz

18 Noteworthy

45 Congratulations, Registered Employee Benefits Consultants!

22 Industry Events

13

MEDICARE MATTERS

46 NABIP’s Board of Trustees

23 Research Highlights Costs and Trends

47 Your NABIP Staff

48 Association Events

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Delivered 10 times per year to the country’s top benefits professionals.

VOLUME 70, NO. 5

EDITOR Martin Carr (202) 595 0724

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The Rise of Telehealth Examining the Insurance Workforce Strategies for Reducing Prescription Costs

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advertisements or published articles. Send editorial submissions to: America’s Benefit Specialist Editor, 999 E Street NW, Suite 400, Washington DC 20004. America’s Benefit Specialist (ISSN 2475-5826, publication no. 238660), 2023, volume 70, number 5 Published 10 times per year (January/February, March, April, May, June, July, August/ September, October, November and December) by the National Association of Benefits and Insurance Professionals, 999 E Street NW, Suite 400, Washington DC 20004. $25 annual subscription price is included in NABIP member dues. Periodical postage paid at Washington DC and additional mailing offices. POSTMASTER: Please send address changes to America’s Benefit Specialist, 999 E Street NW, Suite 400, Washington DC 20004.

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MERGERS AND ACQUISITIONS

team of agents. Consolidated Marketing Group offers thor ough, ongoing field training for agents at all stages of their careers with a focus on helping seniors obtain the crucial coverage they need to prepare for the good days ahead. By emphasizing and developing deeper connections with the individuals and families it serves, CMG has brought timely and effective solutions to thousands across Tennessee and the Southeast. Integrity has also acquired Sellyei & Rundle, an indepen dent marketing organization based in Tucson, Arizona, and led by Lisa Rundle, president. With more than 40 years of industry experience, Rundle is well versed in how clients can utilize Medicare coverage to meet their healthcare needs. She discovered a passion for serving seniors after working as a sales manager for a leading insurance carrier and went on to found Sellyei & Rundle in 2002. From its inception, the agency has set a much-needed tone of peace and security for seniors entering retirement and transitioning to Medicare. Over the past two decades, Sellyei & Rundle has served over half a million clients. RISK STRATEGIES BUYS EMPLOYEE BENEFITS SPECIALIST Risk Strategies has acquired HollandStivers Employer Solu tions, a specialist in employee benefits located in Paducah, Kentucky. The purchase marks the first acquisition by Risk Strategies in Kentucky. The firm brings several compli mentary capabilities to the Risk Strategies National Employ ee Benefits Practice, including expertise in group medical, individual medical, group life and dental. HollandStivers also offers clients payroll administration and other HR services. With almost 30 years of experience in the benefits insur ance industry, HollandStivers has established deep rela tionships with its clients. Along with customized employee benefits solutions, HollandStivers offers clients an array of val ue-added services including data analytics, carrier rate nego tiation, compliance assistance, and employee communication and education. The payroll administration services directly provided by the firm include product selection and imple-

NORTHWIND ACQUIRES HEALTH BENEFIT ADMINISTRATOR QVI RISK SOLUTIONS

Pharmacy services platform company Northwind Pharma ceuticals has announced the acquisition of QVI Risk Solu tions, a health benefit administrator based in Bend, Oregon. “The self-funded employers, unions, advisors and health care providers with whom we work feel that the economic and experiential value of healthcare has become disordered,” said Phillip Berry, CEO. “They continue to ask us to help them create options that drive value back to those who pay for and access the healthcare system. “Northwind’s mission is to re-center healthcare around self-funded payer and employee plan members by leverag ing points of health influence to remove cost, access, and complexity barriers,” continued Berry. “With our acquisition of QVI Risk Solutions, we add another piece to our Nexus of Care vision by supplementing our direct contract pharmacy ben efits services with the ability to administer a complete health plan for our clients. We are building a future that re-localizes and re-centers healthcare around the self-funded payer and the employee member.” QVI Risk Solutions, Inc. was founded in 2003 to provide TPA services to employers that choose to self-fund their employee benefit program and Business Process Outsourcing ser vices to other TPAs and commercial health insurers. Led by Founder and CEO Carolyn Jarschke, QVI has grown to serve thousands of members and their sponsoring organizations across the country and will continue to operate out of Bend. TWO COMPANIES JOIN INTEGRITY Integrity Marketing Group LLC has acquired Consolidated Marketing Group, an independent marketing organization based in Knoxville, Tennessee, and led by Steve Ruth, presi dent. CMG focuses on Medicare and supplemental planning solutions. Since 2010, CMG has been dedicated to providing exceptional agent training to ensure the agent’s success in the industry. With more than 25 years of industry experience, Ruth has dedicated his efforts to ensuring the success of an impressive

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mentation of a payroll human capital management system as well as ongoing technical support for their payroll HCM. ARTHUR J. GALLAGHER & CO. ACQUIRES LEAVITT INSURANCE SERVICES Arthur J. Gallagher & Co. recently announced the acquisition of Woodland Hills, California-based Leavitt Insurance Services of Los Angeles. Leavitt offers commercial property/casualty insurance as well as employee benefits consulting to clients in the Southwest U.S. Teri Frankel, Kenneth Blaich and their team will remain in their current location under the direc tion of Scott Firestone, head of Gallagher’s Southwest region retail property/casualty brokerage operations, and Charlie Isaacs, head of Gallagher’s West region employee benefits consulting operations. BRIGHT HEALTH GROUP LOOKS TO SELL MEDICARE ADVANTAGE BUSINESS Bright Health Group Inc. is exploring strategic alternatives for its California Medicare Advantage business, which consists of Brand New Day and Central Health Plan, with a focus on a potential sale. The proceeds would substantially bolster the Company’s financial position and establish a strong founda tion for long-term sustainable growth. As it takes this action, the company will continue to focus on capturing the shift to value-based, consumer-driven healthcare through its Con sumer Care Delivery business, while working to wind-down and exit its ACA insurance business. Bright Health is also announcing that it has extended a waiver and amendment to its credit facility through June 30. Manny Kadre, lead independent director of Bright Health’s Board of Directors, said, “We have received inbound interest in Bright Health’s California Medicare Advantage business, and given this, the Board has decided to review strategic alternatives alongside other financial options. Bright Health’s California Medicare Advantage business is strong and uniquely positioned to deliver culturally competent, localized care to nearly 125,000 aging and underserved consumers in California. Throughout this process, we are committed to enhancing value for all stakeholders and remaining true to Bright Health’s mission of making healthcare right, together.” There can be no assurances as to the timing, terms or structure of any potential transaction or that a transaction will be consummated at all, and any decision with respect to a potential transaction remains subject to approval by the Bright Health Board of Directors.

Moelis & Company LLC is serving as Bright Health’s finan cial advisor and Simpson Thacher & Bartlett LLP is serving as Bright Health’s legal advisor in connection with this process. KAISER TO FOLD GEISINGER INTO NEW VALUE BASED CARE COMPANY Kaiser Permanente and Geisinger Health have agreed to create a new company called Risant Health, which plans on making more acquisitions in the years to come. Under the deal, Geisinger would become a part of Risant and keep its name. The agreement is subject to federal and state regu lators. Like California-based Kaiser and Pennsylvania-based Geisinger, Risant would be a nonprofit, and it would be head quartered near Washington DC. According to The Wall Street Journal , Risant seeks to acquire four or five more hospital systems and get to total revenue of $30 billion to $35 billion over the next five years, and Kaiser is expected to provide about $5 billion in funding to Risant. Risant Health will operate separately from Kaiser Permanente, while health systems that join the new firm will also retain distinct identities in their communities. Jaewon Ryu, MD, JD, who became Geisinger’s CEO in 2019, will become the new CEO of Risant Health. “Through Risant Health, we will make our value-based care expertise, technology and services available to communi ty-based health systems, like Geisinger, to strengthen their ability to provide value-based care models with a focus on high-quality and equitable health outcomes,” said Greg. A. Adams, chair and CEO, Kaiser Permanente. AXIM FRINGE SOLUTIONS GROUP ACQUIRES PERKS SHOWCASE AXIM Fringe Solutions Group, a provider of employee bene fits and engagement solutions, has announced the acquisi tion of PERKS Showcase, an employee communications and engagement platform. By integrating PERKS’ Showcase platform with AXIM’s suite of fringe benefits solutions, the two companies hope to create an all-inclusive employee engagement experience. The combined offering will drive employee satisfaction, productivity and loyalty while helping organizations attract and retain top talent. Features of the combined AXIM and SHOWCASE offering include: Personalized Benefits: AXIM’s comprehensive range of fringe benefits solutions, including healthcare, retirement plans and wellness programs, will be tailored to meet the

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unique needs and preferences of each employee, ensuring maximum satisfaction and engagement. Strategic Communications: The combined platform will incorporate educational elements, such as live events, videos and chatbots, across mediums like text, email, push and more, with personalization to each individual employee. Full Enrollment Cycle Support: The combined platform will allow for all new and existing employees to complete the entire education-to-enrollment process in a single platform while including all vendors and providers (core, voluntary,

perks or other) into a single front-door experience custom to the employer brand. Real-time Answers: The platform will facilitate real-time benefits troubleshooting and navigation, saving HR teams hours in redundancies and inefficiencies around benefits. Comprehensive Analytics: Organizations will have access to in-depth analytics and insights, helping them better understand employee engagement behaviors and trends, identify areas for improvement, and optimize their benefits and rewards programs.

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DISSECTING THE CAA GAG CLAUSE PROHIBITION

By David Ostrowsky The Phia Group dostrowsky@phiagroup.com

While the primary purpose of the Consolidated Appropri ations Act of 2021 may have been to provide fiscal relief to tens of millions of Americans in the depths of the pandemic, the CAA has also proven to be a landmark piece of health care legislation by virtue of initiating sweeping reforms for employer-sponsored group health plans, arguably the most influential ones since the Affordable Care Act was enacted in March 2010. BUT, AS IS SO OFTEN THE CASE WITH COMPLICATED LEGISLATIVE INITIATIVES, THE AFOREMENTIONED CONCEPTUAL PREMISE CAN POTENTIALLY DIFFER FROM REALITY.

One such reform ensures there is heightened price trans parency for healthcare consumers, a development that is en capsulated in the legislation’s “gag clause” prohibition. This provision of the CAA bars health plans or health insurance issuers from entering into contracts with a healthcare pro vider, network or third-party administrator providing access to a network of providers that restrict a plan from releasing data and information for public consumption. For example, if there is a contract between a TPA and a plan in which the plan sponsor’s access to provider-specific cost and quality of care information is solely at the discretion of the TPA, such a contractual provision would be deemed a pro hibited gag clause. Meanwhile, the CAA-issued guidance also clearly stipulates that even any provision indirectly limiting access to data/information or the ability to disclose informa tion is forbidden. Further, per this CAA provision, plans are required to submit an annual attestation that they have not engaged in any such prohibited contractual arrangements. The first attestation is due December 31, 2023, which covers the pe

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THE CAA GAG CLAUSE PROHIBITION

riod starting December 27, 2020 (or the effective date of the applicable group health plan or health insurance coverage, if later) through the date of attestation. Subsequent attesta tions must be submitted by December 31 of each year and cover the period since the last one was delivered. (It should be noted that while this attestation, which can be done by the TPA on behalf of the self-insured plan so long as there is a written agreement between the plan and the service provider in place, is applicable to grandfathered plans, it does not pertain to HRAs, stand-alone retiree health plans and issuers of only excepted benefits plans or short-term limited-duration insurance.) The underlying concept of this provision is that removing gag clauses on price and quality metrics, effectively ensur ing that electronic claims data and provider-specific cost or quality of care information as well as claim-related financial obligations included in the provider contract is accessible to plan members, will spark enhanced transparency and is in the same vein as other wide-ranging price-transparency provisions of the CAA, including patient protections against surprise billing, prescription drug cost reporting and mental health parity comparative analysis disclosures. But, as is so often the case with complicated legislative initia tives, the aforementioned conceptual premise can potentially differ from reality. While on the surface it may appear that the gag clause prohibition is a surefire way to facilitate healthcare price transparency, there is still an untold number of owners of provider networks devising crafty workarounds, potentially leaving healthcare consumers deprived of critical claim-related financial data and provider background information. Consider the following hypothetical scenarios: • A self-funded plan cites the CAA in requesting access to its claims data. The TPA sends a file of claims data containing merely 22 of the 170+ fields needed to process and evalu ate claims. Subsequently, the plan obtains a file of virtually meaningless claims data and is left unable to discern what it is being charged for each claim. • A self-funded plan in a rural one-network region, also referencing the CAA, requests access to its claims data for review. Unfortunately, the network responds by saying it will not remove the gag clause and noting that the plan can terminate the contract if it is an issue. What is even more unfortunate is that not only does the plan receive no pricing data but, at the same time, it cannot terminate the contract for further use because it does not have access to any competing networks given its remote, sparsely popu lated location.

• A union fund with well over $450 million in yearly health care spending asks to review its claims data. The TPA ref erences its contract, which only allows for an audit of 200 claims per year, arguing this meets the CAA requirement for access to claims. Resultingly, the fund can only review .0004% of its members’ total claims, while being unable to identify whether it is paying claims appropriately and thus getting a square deal. Such situations are highly unfortunate given that the overwhelming majority of plan sponsors and TPAs across the nation are doing their due diligence to ensure compliance with the CAA gag clause prohibition when signing contracts and agreements with networks and other service providers. But, ultimately, with the CAA gag clause provision still being so new, there are some networks and TPAs that have been able to expose loopholes. In sum, the evolution of the gag clause prohibition is a promising development for Americans covered by employ er-sponsored health plans who have a vested interested in understanding the financials behind their patterns of consumption. That said, considerable roadblocks still exist for full price transparency to become a staple of the American healthcare system. ULTIMATELY, WITH THE CAA GAG CLAUSE PROVISION STILL BEING SO NEW, THERE ARE SOME NETWORKS AND TPAS THAT HAVE BEEN ABLE TO EXPOSE LOOPHOLES.

David Ostrowsky serves as a content special ist for The Phia Group, a position in which he generates a wide range of written content for both internal and external functions. A graduate of Brandeis University, David was previously a content specialist for the recruiting company formerly known as WinterWyman. He is also a regular contribu

tor to the Atlanta Jewish Times and has authored multiple books, including his most recent, Pro Sports in 1993 , published by McFarland & Company in 2020.

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PRODUCT NEWS

applications and policy delivery. It gives policyholders unique built-in features such as Advanced Benefit, COBRA Premium Benefit and Good Health Benefit. There is also a new combi nation of benefits and coverage periods. The product also offers a Student Loan Repayment rider, which can help pay toward student loan debt if a disability due to an illness or injury prevents someone from earning an income. For more information, visit ameritas.com/disability- income/dinamic-foundation. NEW CLOUD PLATFORM SIMPLIFIES BENEFITS FOR BUSY HR LEADERS Colonial Life has launched Gathr, a cloud platform to transform the way small businesses deliver benefits and address common human resources needs. Gathr enhances and elevates benefits enrollment, administration and HR experience so employers and their brokers can save time and focus on what matters most. Gathr combines Colonial Life’s proprietary technology to help workers sign up for medical, voluntary and group benefits in a secure digital experience. “Gathr provides an intuitive benefits and HR experience for small and medium-sized businesses,” says Tim Arnold, president and chief executive officer of Colonial Life. “Lever aging Gathr eliminates the need to coordinate with each carrier, which saves time and simplifies open enrollment for companies, their employees and our broker partners.” Gathr provides these flexible, digital solutions: Benefits Enrollment: Centralized portal for open enroll ment; custom enrollment communications and easy-to-un derstand educational materials Benefits Counseling: Delivers one-to-one benefits; available in person, virtually, over the phone, or with a hybrid approach Digital Documents & Workflows: Digitally sign, complete, and track all benefits and HR documents Compliance: Centralized recordkeeping helps businesses maintain compliance with the most recent ACA, ERISA, CO BRA, HSA, and FSA regulations Premium Add-on Features—Time tracking, paid time off, performance management and custom workflows can be add ed to help businesses manage their HR needs as they scale up See more on ColonialLife.com.

SIMPLY EASIER PAYMENTS RELEASES ENHANCED SOLUTION FOR AGENCY INVOICING Simply Easier Payments has announced its release of an innovative insurance invoicing and billing solution. Called Intelligent Invoicing, this integrated solution takes insurance payments to a new level of convenience by combining agen cy billing and finance. Intelligent Invoicing combines a suite of digital tools that delivers a new level of efficiency in agency billing. This new solution enables insurance agents, brokers and premium financing providers to give policyholders the option of pay ing now or using payment plans through a single invoice. Traditionally, agency billing and premium finance contracts have been presented separately, with multiple steps in each process. Intelligent Invoicing marks a new way to combine those into a single step, while leveraging the advantages of enhanced invoicing and billing features, such as electronic signatures, expanded agency management system integra tions, and more. “With Intelligent Invoicing, agency billing and premium financing can now be a single-step process without sacrific ing other capabilities, that eliminates tedious and repetitive tasks for insurance professionals,” said Duke Williams, CEO and founder of Simply Easier Payments. Calvin Churchill, VP of product management, added: “Intel ligent Invoicing delivers significant time savings to agencies because it requires little or no additional data entry. Once a finance contract is signed and the payment is made, Intelli gent Invoicing can route all receipts and paperwork automat ically, with no other manual intervention by the agency.” An additional benefit of Intelligent Invoicing is an en hanced customer experience. Among its features are the ability to invoice customers automatically, import open invoices from an agency management system, and provide automated reminders. To learn more, call 800-768-0907 or visit www.simplyeasier. com. AMERITAS UNVEILS NEW DI PRODUCT Ameritas has announced the launch of DInamic Cornerstone Income Protection, a disability income insurance product that includes greater strength and flexibility for policyhold ers. DInamic Cornerstone offers three new riders: Lump Sum Savings, Enhanced Plus Residual and Benefit Increase. DInamic Cornerstone’s features also include coverage up to the maximum benefit period for mental, nervous, drug and alcohol conditions, along with discounts for digital

PAN-AMERICAN LIFE INSURANCE GROUP ANNOUNCES PAN-AMERICAN ACCIDENT & HEALTH Pan-American Life Insurance Group, a provider of life, accident and health insurance throughout the Americas,

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PRODUCT NEWS

Matrix’s patented workforce productivity tool, Absence Radar, conveys this information to line managers through just-in time notifications as well as a unique calendar interface. Paired with Matrixlink, the company’s proprietary data integration product, this time-sensitive data is then shared seamlessly with each employer’s human capital management system. Visit www.RelianceMatrix.com for more information.

recently announced the launch of Pan-American Accident & Health, a brand for the accident and health portfolio of products and administrative and agency support offered in the United States. Pan-American Accident & Health offers a diversified portfo lio of group and individual supplemental accident and health products and is proficient at working with a wide variety of distribution partners, including traditional retail brokers, general agents, and managing general underwriters, as well as non-traditional digital platforms. For more information, visit palig.com.

ZELIS LAUNCHES REFERENCE-BASED PRICING SOLUTION

Zelis, a healthcare technology company modernizing the healthcare financial experience for all, has announced the launch of its open-access pricing solution. Self-funded em ployers, which represent 65% of U.S. workers, often struggle to sustain the cost of traditional health plan premiums, and existing solutions are often fragmented and have not deliv ered a satisfactory experience for members in accessing and navigating care. To overcome these challenges, third-party administrators need to bring alternative strategies to stabilize claims costs, improve provider accountability related to rising fees, and free patients from network limitations. Zelis Open Access Pricing is a reference-based pricing solu tion that empowers self-insured employers and third-party administrators to put their members’ experience first while also stabilizing rising healthcare costs. The new solution allows clients to set maximum reim bursement amounts using pre-defined prices which allows for more predictable cost forecasting. At the same time, Zelis Open Access Pricing employs a member-advocacy team that provides pre-service member education, navigation support, provider contracting support, balance-bill resolution and legal escalation support to ensure seamless interactions among payers, providers and members. The technology-en abled solution includes modeling and analytics, contract management, and performance reporting, as well as a price and provider transparency application to drive member adoption. Open Access Pricing gives members the freedom to choose their preferred healthcare providers, and offers fair, established pricing benchmarks that keep medical expenses under control. “TPAs and self-funded groups want reference-based pricing for lower claims costs, configurable options, more predictable healthcare cost forecasting, and more,” said Rick Ellsworth, SVP, GM Payer Compass at Zelis. “We are excited to bring to market a fully integrated solution that fits their needs and enhances the experience for their members.” To learn more, visit www.zelis.com.

RELIANCE MATRIX INTRODUCES TEXT BACK TECHNOLOGY TO ITS CLAIM- MANAGEMENT EXPERIENCE

Reliance Matrix, a provider of employee benefits solutions and technology-enabled absence and productivity services, has launched Text Back technology into its integrated claim experience across all solutions and services. This innovation allows employees to easily confirm or change their return- to-work status through text-messaging, enhancing the employee experience and rapidly updating employee infor mation across proprietary Matrix platforms as well as client HCM systems. The return-to-work process is one of the most important phases of any employee leave, for both the employee and the employer. As a best practice, Reliance Matrix absence-man agement specialists proactively reach out five days prior to the employee’s scheduled return to confirm the date and other important information. Historically, this important touchpoint took the form of a phone call and, as such, was subject to delays from missed calls and voicemail. “In research jointly conducted with some of our largest employer clients, we confirmed what I think we can all agree on: Few of us are willing to answer a call from an unidentified number on our mobile phone,” said Mark Marsters, president of Matrix Absence Management and Chief Operating Officer of Reliance Matrix. “The resulting communication delay actually grows and expands, like ripples in a pond, resulting in data gaps and even missed deadlines. Our new Text Back feature resolves that issue, making it safe and intuitive for the employee to provide necessary information in real time. That data is then immediately available to managers and HR teams so that vital staffing decisions can be made accordingly.” With Text Back, employees can quickly confirm their RTW date, and indicate whether they are returning full-time and full-duty, by responding to a simple text inquiry. Once con firmed, all integrated systems are updated so employers stay informed real-time on the status of their workforce. Reliance

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PRODUCT NEWS

“The healthcare-related challenges facing employers and their employees today continue to expand, and they require a flexible member-navigation and care-coordination ex perience platform that brings all the administrative, tech nological, digital health and human support components together in one simple and effective experience that drives better engagement and outcomes,” said Zane Burke, CEO of Quantum Health. A 2022 McKinsey Employer Health Benefits Survey found that over 40% of employers now believe introducing advo cacy and care-coordination tools will help employees more easily navigate the healthcare system, engage in preventive physical and mental care, and manage chronic conditions. To learn more visit Quantum-Health.com.

QUANTUM HEALTH TO OFFER NEW HEALTHCARE-NAVIGATION PLATFORM TO SELF-INSURED EMPLOYERS

Quantum Health, a consumer healthcare-navigation and care-coordination company, announced that it will join with Health Plans Inc., a third-party administrator, to leverage their Employer Health Network to deliver a new health care-navigation platform for self-insured employers nation wide. These different delivery and navigation solutions will provide alternatives to the high cost of traditional managed care networks and will help drive better member experiences and clinical outcomes. As part of this new collaboration, Quantum Health will combine its navigation and care-coordination platform with HPI’s TPA capabilities and regional health plan networks to provide members better access to providers and proactively intervene earlier in the healthcare process. The goal of this partnership is to ensure that members receive the most ap propriate, cost-effective care and an unparalleled experience throughout their healthcare journey.

NAVA LAUNCHES MEMBER EXPERIENCE Nava Benefits, an outcome-driven benefits brokerage that makes benefits easier for growing companies, recently announced the launch of its Member Experience offering. Anchored by the Nava Benefits App, this comprehensive solution simplifies key aspects of the employee benefits

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PRODUCT NEWS

With MyBlueRxTX, BCBSTX members with employer cover age that includes pharmacy benefits through Prime Thera peutics can: • find available lower-cost drug options • compare drug costs at different pharmacies • manage prescription drug care for their dependents • get reminders when it’s time to refill a prescription • access information about prescription drugs, including medication details, claims history, coverage, clinical review approvals and refills • search for and contact in-network pharmacies “Knowing when to get a drug refill and track medication approvals is key for our health and well-being,” said Jill Firch, divisional senior vice president of pharmacy for Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklaho ma and Texas. “We know that our members need a simple, handy tool that does all of this.” Members can download MyBlueRxTX from the Apple Store or Google Play. If members already use the BCBSTX mobile app or has a Blue Access for Members account, they can use the same login for MyBlueRxTX. Members can also create a new account using the number on their member ID card. Visit BCBSTX.com for more information. BAN PARTNERS WITH MEDICAL RISK MANAGERS TO OFFER STOP-LOSS SERVICES Benefit Advisors Network, a network of employee benefit brokers and consulting firms from across the United States and Canada—has created a strategic partnership with Medi cal Risk Managers, a stop-loss underwriting service company. Under the terms of the new partnership, MRM—through a collaboration with Windsor Strategy Partners—will of fer BAN member firms end-of-year reserve studies on all stop-loss cases. BAN members will also receive incurred but not reported (IBNR) financial analysis with unprecedented transparency into the reserve analysis through proprietary software. In addition, members will receive client-specific re ports illustrating estimated claims reserves as well as a com prehensive output package that details the reserve estimate, assumptions, and methodology. This partnership is part of BAN’s Stop-Loss Coalition, a group of carriers tailoring risk-management strategies to support the financial demands of clients’ insurance agencies that brokers serve. For more information, visit www.benefit advisorsnetwork.com.

journey, from open enrollment to member support and benefits communication. HR leaders at companies of all sizes face the same three issues when it comes to supporting their employees: helping them understand what their benefits are, educating them on how to use those benefits, and supporting them when they need help. With 80% of employees confused by their plans and 50% unaware of their coverage details, the complexity of managing employee benefits programs has become a burden for HR leaders. Nava’s Member Experience offering reduces this workload by providing employees with a cen tralized portal and in-app support that drives their benefits adoption and utilization. “For employees, their benefits are the onramp to their healthcare journey. The launch of Nava’s Member Experience offering is a key step in making it easier for employees to actually use the benefits they already have,” said Brandon Weber, CEO and co-founder of Nava. Built on insights from Nava’s clients, HR community, and Benefits Advisory Board, the Nava Benefits App serves as an interactive benefits wallet and the front door to a member’s benefits usage. With carrier and plan information preload ed into the app, members can access their digital ID cards, links to carrier and provider portals, and coverage details in one place. Most importantly, the Nava Benefits App provides in-app support to the company’s dedicated team of bene fits advocates. Instead of contacting HR with sensitive and urgent questions pertaining to carrier enrollment issues, plan summary explanation, provider search support, medical bill clarification, and claims guidance, they’ll now be able to get direct support from some of the industry’s most experienced benefits experts. The Nava Benefits App is available for free for all Nava clients on both Android and iOS, and will begin rolling out to existing customers soon. BCBS OF TEXAS LAUNCHES MOBILE PHARMACY BENEFIT APP Blue Cross and Blue Shield of Texas has launched MyBlueRx TX, a mobile pharmacy benefit app that delivers a personal ized pharmacy benefits experience to members through an integrated digital platform. MyBlueRxTX combines the information members need to manage prescription drugs and out-of-pocket costs for themselves and their dependents. This free app puts the pharmacy benefit at members’ fingertips and helps them make informed decisions about their health.

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By Jackson Hammond Healthcare Policy Analyst American Action Forum Washington, DC

As Medicare spending continues to increase, policymakers have been routinely focused on ways to reduce costs while preserving access to care for beneficiaries. As discussed at a recent hearing 1 of the House Energy and Commerce Commit tee’s Subcommittee on Health, site-neutral payments in Medicare Part B provide an avenue for reducing program costs THIS TREND HAS CAUSED A MAJOR SHIFT IN THE HEALTHCARE SYSTEM: IN 2021, FOR THE FIRST TIME EVER, MORE PHYSICIANS WERE EMPLOYEES RATHER THAN OWNERS OF THEIR OWN PRACTICE.

without hurting beneficiary care. This article discusses what site-neutral payments are, how they work, the current extent of their use in Part B, and their fiscal impact on the program. SITE-NEUTRAL PAYMENTS AND MEDICARE PART B Site neutrality is the policy of having Medicare Part B pay the same amount for the same service with the same case mix regardless of where the service is provided. Medicare generally pays different rates for the same service depending on where it is provided. This payment disparity results from differences in how payments for services at hospital outpa tient departments (HOPDs), ambulatory surgical centers (ASCs) and physician offices are calculated. Payments for HOPD services are done through Part B and cover two parts: hospital costs (i.e., labor including staff salaries, resources such as medical devices and supplies, and capital costs including rent), which are paid through the Outpatient Prospective Payment System 2 (OPPS), and professional services (including physicians, nurse practi tioners, physician assistants and other advanced clinicians)

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paid through the Physician Fee Schedule 3 (PFS). The PFS payments have different rates depending on whether the physician provided the service in a facility (i.e., a hospital or ambulatory surgical center, known as the “facility rate”) or in a private practice (known as the “non-facility rate”). The PFS non-facility rate is higher than the facility rate because the non-facility rate is reimbursing the physician for costs related to running a private practice, including labor, resources and capital costs, which do not apply to a facility-based physician. ASC rates 4 are calculated similarly to OPPS payment rates and have a separate PFS payment for physician services, but the conversion factor (i.e., the starting dollar value before all adjustments for procedure type, case-mix, etc. are made) is lower for ASCs than for OPPS payments. Despite this lower PFS reimbursement, HOPD services are generally more expensive than the same services provided at a physician’s office. As an example: In 2017, the total Part B payment for a standard outpatient visit for a new patient was $184.44 and made up of two parts: the OPPS payment of $106.56 and the PFS facility rate of $77.88. But the exact same procedure for the same patient at a physician’s office cost only $109.46—the standard PFS non-facility payment rate. 5 In another comparison, HOPD rates are on average almost dou ble ASC rates, in part due to the different conversion factors. 6 It is worth noting that, in Part B, the beneficiary general ly pays about 20% of the cost of a given service, regardless of site of care. In the above example, the HOPD visit would have cost the beneficiary $36.89 while the physician’s office visit would have cost the beneficiary $21.89. On average, Part B beneficiaries in 2019 paid a $9 copayment for a standard clinic visit at a physician’s office and paid $23 for the same service at a HOPD—256% more. 7 INPATIENT-ONLY PROCEDURES In addition to procedures that can be provided both in HOPDs and physicians’ offices, Medicare implicitly ties pay ments to the site of care through its Inpatient-Only (IPO) pro cedures list. As the name implies, this list specifies services that Medicare will only pay for if those services are performed in an inpatient setting (thus paid under Medicare Part A). Traditionally, procedures were designated as IPO if they were determined to be “highly invasive, result in major blood loss or temporary deficits of organ systems (such as neurological impairment or respiratory insufficiency), or otherwise require intensive or extensive postoperative care.” 8 However, as medicine has advanced and more procedures have become viable to perform in outpatient settings, this list has evolved. In fact, CMS had decided in its final 2021 OPPS rule to eliminate the IPO list entirely, though the agency later reversed this decision in its final 2022 OPPS rule. 9

The potential savings of eliminating the IPO list entirely or just removing certain procedures are unclear and vary from procedure to procedure and hospital characteristics. For example, using 2020 payment rates for a total joint replace ment, a suburban hospital without a teaching program would see a 10% decrease in payment if the procedure were done in an outpatient setting and not an inpatient one, while a large urban teaching hospital would see a 57% decrease in payment if done in an outpatient setting and not an inpa tient one. 10 Removing some frequently performed proce dures from the IPO list could reap major savings for the Part A trust fund: The 2023 Medicare Trustees Report cited the removal of hip and knee replacement surgeries from the IPO list as one of three major reasons Part A had a surplus in 2022. 11 THE FISCAL EFFECTS OF SITE-NEUTRAL PAYMENTS The Medicare Payment Advisory Commission (MedPAC) estimates that its recommended site-neutral payment policy in Part B would have reduced Medicare and beneficiary spending by $6.6 billion and $1.7 billion, respectively, in 2019, including a 13.2% reduction in beneficiary cost sharing. 12 The Committee for a Responsible Federal Budget calculated that a site-neutral payment policy would, between 2021 and 2030, reduce Medicare spending by $153 billion and beneficiary spending by $94 billion, reduce total national health expen ditures by $346 billion to $672 billion, reduce the national deficit by $217 billion to $279 billion, and reduce cost sharing and premiums in private insurance by around $140 billion to $466 billion. 13 Some of these savings are a direct result of the lower payments that Medicare would be making for the services performed. Other savings would be from the indirect effects. The current payment differential for outpatient procedures is widely regarded as a major reason for the cost-increasing consolidation of the U.S. health system, incentivizing hospi tals to purchase physician practices in order to receive higher payments and reduce competition. 14 It should be noted that this trend has caused a major shift in the healthcare system: In 2021, for the first time ever, more physicians were employ ees rather than owners of their own practice. 15 THE CURRENT STATE OF SITE-NEUTRAL PAYMENT POLICY To combat the above-mentioned consolidation, Congress passed as part of the Bipartisan Budget Act of 2015 new leg islation that required CMS to pay the same rates to off-cam pus provider-based departments (PBDs) of hospitals for

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outpatient services as were paid under the PFS non-facility rate. Off-campus PBDs are essentially physicians’ offices that hospitals have integrated into their health system. This leg islation excepted off-campus PBDs that were billing services under OPPS prior to November 2, 2015, however—essentially all the off-campus PBDs in existence at the time of passage. Most OPPS services today still occur in the excepted off-cam pus PBDs, but in 2019 CMS created a policy to pay all off-cam pus PBDs the PFS non-facility rate for clinic visits, which is 40% less than the standard OPPS rate for the same service, though that rule was not fully implemented until 2021. 16 SOLUTION As mentioned above, CMS can make some changes as to which services receive site-neutral payments as well as to the IPO list, but the agency’s hands are generally tied when it comes to major programmatic changes. Congressional action is needed to implement site-neutral payments. In its 2022 report to Congress, MedPAC recommended that, of the 169 ambulatory payment classifications (APCs)—a set of services that have similar clinical attributes and costs—57 are reasonable and appropriate to set payment rates at the PFS non-facility rate, and another 11 can equalize payments between HOPDs and ASCs. The remaining 101 APCs generally involve emergency-department visits, critical-care services and trauma-care visits, which are either almost always per formed in HOPD settings or cannot practically be performed outside of HOPD settings. 17 This list may change as medicine advances, so lawmakers should build with flexibility in mind when designing legislation. As MedPAC notes, however, simply applying site-neutral payments without exempting the budget-neutrality require ments in Medicare would reduce the potential savings for Medicare and its beneficiaries, as a reduction in rates for one set of services would require an increase in rates for another set of services. Simultaneously, exempting the budget-neu trality requirements could result in a loss of revenue for hospitals that serve high amounts of low-income patients. 18 If Congress wishes to maximize the savings for Medicare and beneficiaries without harming these hospitals, it may need to design legislation that includes explicit safeguards for hospi tals that serve high shares of low-income beneficiaries. As Congress looks for ways to make the healthcare system more efficient and affordable, site-neutral payment policies are an intriguing prospect. The savings are in the hundreds of billions, but some care is needed when deciding which services are best suited for site-neutral payments and how to protect certain safety-net hospitals that may see a decrease in revenue.

1 www.youtube.com/watch?v=YqAsFm0qhzE

2 www.medpac.gov/wp-content/uploads/2022/10/MedPAC_Pay ment_Basics_22_OPD_FINAL_SEC_v3.pdf 3 www.medpac.gov/wp-content/uploads/2021/11/MedPAC_Pay ment_Basics_22_Physician_FINAL_SEC.pdf 4 www.medpac.gov/wp-content/uploads/2021/11/MedPAC_Pay ment_Basics_22_ASC_FINAL_SEC.pdf

5 www.federalregister.gov/d/2018-24243/p-1581

6 www.crfb.org/papers/equalizing-medicare-payments-regard less-site-care

7 www.federalregister.gov/d/2018-24243/p-1585 8 www.federalregister.gov/d/2022-23918/p-2056

9 www.federalregister.gov/d/2022-23918/p-2067 10 https://racmonitor.medlearn.com/the-demise-of-the-medicare inpatient-only-list-the-myths-and-facts/ 11 www.americanactionforum.org/weekly-checkup/no-time-to part-a/ 12 www.medpac.gov/wp-content/uploads/2022/06/Jun22_Med PAC_Report_to_Congress_v2_SEC.pdf 13 www.crfb.org/papers/equalizing-medicare-payments-regard less-site-care 14 www.federalregister.gov/d/2018-24243/p-1582 15 www.ama-assn.org/press-center/press-releases/ama-analysis shows-most-physicians-work-outside-private-practice 16 www.medpac.gov/wp-content/uploads/2022/10/MedPAC_Pay ment_Basics_22_OPD_FINAL_SEC_v3.pdf 17 www.medpac.gov/wp-content/uploads/2022/06/Jun22_Med PAC_Report_to_Congress_v2_SEC.pdf 18 www.medpac.gov/wp-content/uploads/2022/06/Jun22_Med PAC_Report_to_Congress_v2_SEC.pdf

This article was originally published by the American Action Forum (www.americanactionforum.org/insight/site- neutral-payments).

Jackson Hammond is a healthcare policy analyst at AAF. Jackson’s research focuses on healthcare policy, including Medicare, Medicaid, drug pricing and insurance. Prior to joining AAF, Jackson was a healthcare policy advisor for the Republican Governors Public Policy Committee. He also worked for three years in Congress, first as legislative

correspondent for Senator Todd Young (R-IN), then as legislative assistant to Representative Jim Baird (R-IN). Jackson received an A.B. in Political Science from Washing ton University in St. Louis.

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