Expert

On August 1, 2011, the Department of Health and Human Services (HHS) issued new preventive care guidelines for women. These new guidelines, which are effective for plan years beginning on or after August 1, 2012, require non-grandfathered health plans to cover women's preventive health services (such as well-woman visits, breastfeeding support, domestic violence screening and contraceptives) without charging a copayment, a deductible or coinsurance.

COVERAGE GUIDELINES

On August 1, 2011, HHS issued the HRSA-supported preventive care guidelines for women to fill the gaps in the current preventive health services guidelines for women. According to HHS, these new guidelines will help ensure that women receive a comprehensive set of preventive health services without having to pay a copayment, a deductible or coinsurance. Non-grandfathered health plans will need to include these services without cost sharing for plan years beginning on or after August 1, 2012 (January 1, 2013, for calendar year plans).

The new preventive care guidelines for women cover the following health services:

• Well-woman visits - Includes an annual well-woman preventive care visit for adult women to obtain the recommended preventive services, and additional visits if women and their providers determine they are necessary.
  
• Gestational diabetes screening - Screening for women 24-28 weeks pregnant, and those at high risk of developing gestational diabetes.
  
• Human papillomavirus (HPA) DNA testing for women age 30 and older - Women who are age 30 or older will have access to high-risk HPV DNA testing every three years, regardless of Pap smear results.
  
• Sexually transmitted infection (STI) counseling - Sexually active women will have access to annual counseling on STIs.
  
• Human immunodeficiency virus (HIV) screening and counseling - Sexually active women will have access to annual screening and counseling on HIV infections.
  
• FDA-approved contraception methods and contraceptive counseling - Women will have access to all FDA-approved contraceptive methods, sterilization procedures and patient education and counseling. These recommendations do not include abortifacient drugs.
  
• Breastfeeding support, supplies and counseling- Pregnant and postpartum women will have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment.
  
• Domestic violence screening and counseling - Screening and counseling for interpersonal and domestic violence.
  

According to HHS, health plans may use reasonable medical management techniques for women's preventive care to help define the nature of the covered service, consistent with guidance provided in the interim final rules. For example, health plans may control costs and promote efficient delivery of care by continuing to charge cost-sharing for brand-name drugs if a safe and effective generic version is available. In addition, the interim final rules confirmed that plans may continue to impose cost-sharing requirements on preventive services that employees receive from out-of-network providers.

Appeals Court Rejects Health Coverage Mandate

In an August 12th ruling, the U.S. Court of Appeals for the Eleventh Circuit struck down the "individual mandate" under the Patient Protection and Affordable Care Act (PPACA), but it stopped short of declaring the entire statute unconstitutional (Florida v. U.S. Dep't of Health and Human Services).

In its 304-page opinion, the court said Congress exceeded its authority in enacting the provision, scheduled to take effect in 2014, that requires most Americans to buy health insurance or pay a penalty.

The decision sets up a circuit split, as the Sixth Circuit reached the opposite conclusion in an earlier ruling. Similar cases are still pending before other federal appeals courts, but PPACA's constitutionality is ultimately expected to be decided by the U.S. Supreme Court.

Employers are continuously faced with the challenge of the escalating costs of health insurance and providing a comprehensive employee benefit plan to their employees. According to a recent report by the Kaiser Family Foundation, in 2009 the average annual premium for employer sponsored health insurance was $4,824 for single coverage and $13,375 for family coverage. To address the cost of health insurance, employers have responded with any of the following strategies:

1. Adjusting the premium cost share,
   
   
2. Increasing the cost for health care services (deductibles, copayments, or coinsurance),
   
   
3. Restricting eligibility for benefits, and/or
   
   
4. Introducing a tiered physician and/or hospital network
   
   

It is without question that adjusting an employee's cost share for health insurance or their access to health care services does not provide a long term solution toward reducing the cost of health insurance - it is simply a temporary solution.

For employers to have a long term impact of the cost of health insurance, they must recognize that an average of 85% of health insurance premiums is paid to health care providers (physicians, hospitals, etc.). As a result, for employers to have a lasting impact on health insurance premiums - a focus on health care costs will provide the employer with a more effective solution.

Employers must consider that over 70% of health care costs are the result of preventable health care conditions and an estimated 66% of U.S. adults are either overweight or obese. It is imperative for employers to embrace the opportunity to improve the health of their employees and their dependents to reduce the cost of health insurance. Comprehensive wellness programs have proven successful to reduce expenses influenced by the health and wellness of employees, improve productivity, and reduce absenteeism. A study by the Center for Prevention and Health Services shows that employers get back $3.48 in reduced health care costs and $5.82 in lower absenteeism for every dollar invested in employee wellness.

For any wellness plan to be successful, it must include the following:

1. Wellness Business Plan: Employers must create a plan that will ensure a long term solution to address the costs of the unhealthy behavior and habits of employees.
   
   
2. Assess Human Capital and Environment: It not practical to develop a plan to have a meaningful impact on health care costs without a clear understanding of the issues that face our employees and their environment. Most health plans today provide the opportunity for your employees to participate in health risk appraisals (HRA), which provide a low cost solution to educate your employees. Additionally, with an expectation that the wellness program will reduce absenteeism, employers should collect data from prior years to demonstrate improvement.
   
   
3. Retain a Wellness Coach / Consultant: The occupation of improving the health and wellness of employees requires the engagement of a successful wellness coach. This person would be responsible for the execution and management of the wellness business plan and the encouragement of the employees.
   
   
4. Senior Management Support: Without the support of senior management, a majority of wellness programs will fail. It is imperative that all members of the senior management team participate in any program and make their participation visible to the employees.
   
   
5. Wellness Teams: The first step in building successful teams within an employer is to identify those employees that are considered leaders by their peers and will be able to motivate the employees - these individuals will be the "team captains." The team captains will recruit teams of 8 to 10 employees, who will serve as a support system to those employees engaged in the wellness programs.
   
   
6. Engaging Programs: Successful wellness programs will enroll 75% or more of your employees; however, employees will not voluntarily enroll in program unless they consider the program engaging, motivational, and supportive.
   
   
7. Perpetual Programming: The goal of improving the health and wellness of your employees will not be accomplished over a period of months. Wellness programs are an investment in your business for the long term and will only be successful as a long term solution. Wellness programs are a proven tool to improvethe health and wellness of your employees,while reducing the cost associated with thewell-being of your employees.