healthcare

It's The Great Health Insurance Renewal, Charlie Brown!

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It’s you and your health insurance broker.  You’re thinking, this year I’m really going to get tough with this insurance company and I’m gonna ‘em them who’s boss.  I’m gonna be a tough negotiator and this is the year I’m gonna to get a better deal for my employees.  Seriously, you might as well be Charlie Brown saying to himself, “This year I’m really gonna kick that football” and like every other time, Lucy swipes the football away from you at the last second—just like she always does.  There you are, lying flat on your back wondering what just happened.

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Don’t be that guy this year, when your BUCA (Blue Cross, United, Cigna, Aetna) plan sends you this year’s increase—you need to fight back. When you hear your broker tell you that healthcare costs “just go up”, or when they bring you this year’s gimmicky product that’s supposed to make everything better—you need to fight back. Find that broker who is more like Snoopy, the Flying Ace, shooting fake reasons for increasing costs out of the sky. You can find one at www.healthrosetta.org. Or just call me. I’ll fight for you.

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Your employees are counting on you to look for a plan that provides transparency and lowers costs.  They’re hoping you’re going to come up with a plan that reduces out-of-pocket and gives them better access to high-quality healthcare.  I know what you’re thinking, “Better care, lower out-of-pocket? But I’m already paying more than I can afford.  Better care is going to cost even more!”  All I can tell you is that you’re wrong.  You’re not listening to the right advice.  Stop being a blockhead!

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Let me give you an example of what happened at one of my clients this week.  We uncovered that an employee is taking a high cost brand name drug.  After some research, we determined that the brand name is just a quirky dosage of the generic ingredient.  The drug was costing the employer $733.00 per month.  I know that’s not much, but when we found out a local, independent compounding pharmacy could make the same dosage of the generic that the brand had for only $75.00 per month, we rejoiced like we’d won the lottery!  Transparent Advisor = 1, Big Bad PBM = 0.  And that was only one prescription! Imagine what we’ll find when we analyze every drug in their claims report.

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Don’t let your employees be the one kid who looks in their treat bag and all they have is a rock.  That’s no good for anyone. Be the employer everyone wants to work for because your health plan is the best around. It IS possible! You CAN do it! And it’s NOT scary! #letsfixhealthcare

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Need help designing the best health plan in town? You can count on us. Message us at cristy@custombenefits.work. We can help.

How Running a High-Performing Health Plan is Like Driving a Toyota Prius--and that's a good thing!

I finally got myself a Prius which I’ve been wanting for a long time.  Watching the technology “do it’s thing” in the background while I drive really got my "wheels turning” (pardon the pun) about how health plans with great design and technology behind the scenes are similar.

I finally got myself a Prius which I’ve been wanting for a long time. Watching the technology “do it’s thing” in the background while I drive really got my "wheels turning” (pardon the pun) about how health plans with great design and technology behind the scenes are similar.

For about a decade my Mom had a Toyota Prius.  She absolutely loved it and I got to drive it from time to time.  Sometimes I’d meet up with her midway between my NC home and her SC home and I’d swap my GMC Yukon loaded down with my kids and our clothes for the weekend.  Then I’d get to drive the Prius around visiting a few clients on the way to reunite with them in SC.  I loved scooting around in that little thing and set my sights on owning one someday.

Well, it finally happened.  This week I became the proud owner of a cute pearl white Prius and I couldn’t be happier.  There were 9 miles on it when I drove it off the lot and today (2 days later) there are 400 miles on it.  Funny thing is, half of the “free” tank of gas the dealership put in still remains.  I’m in love.

I’m sure I know what you’re thinking…”but you’re supposed to be a successful benefits broker.  Can’t you afford anything better than a Prius?”  Trust me, with the abuse I put my work car through, I can’t be trusted with a car worth any more than this.  It’s just not a good idea.  After all, I’m not Contorno with his big, fancy car and his personal driver.

Yesterday, as I was driving, I began to pay close attention to the monitors and displays that light up with every touch of the gas pedal.  It shows me when the battery is providing all the power, when the power is coming from a mix of battery and gas and when the car is using 100% gas.  This really got my “wheels turning” (pardon the pun).

I was reminded of how a transparent, high performing health plan works and how a successfully run plan only spends about half as much as a traditionally funded plan that has no view into the actual unit cost of healthcare.  What I’ve told clients and prospects is that because of the technology operating behind a transparent, high-performing plan, it allows the plan to save money even when you’re using the high cost sources of funding like hospitals and facilities.  On the other end of the spectrum, you completely level out your exposure to claims costs (why don’t we call this renewable energy) by embedding Direct Primary Care into your plan design.  That’s just like when your Prius is only using the battery to get you from point A to point B.  Everything in between is a mix of great technology and a smarter use of your plan’s resources.  Just like the gas in your car.

Why is this so important?  Well, we all know that the Kaiser Family Foundation just reported that American families and employers are spending around 67% more on healthcare than they were 10 years ago.  Healthcare has exponentially outpaced inflation and it’s killing our economy, causing wage stagnation and keeping workers from being able to retire on time.

Why do we tolerate this?  Because big insurers are marketing geniuses.  And we bought it hook, line and sinker.  Even though the net promoter score of the major insurers is in the single digits, many American employers are too afraid to design a plan that isn’t run by one of them.  Until now.

At a very grassroots level, employers of all sizes and makeups are seeing the Direct Primary Care practices build a presence in their communities.  Many seek out that care and then decide they want to try it out for themselves.  They’re hooked instantly.  They want to provide it as an option to the rest of their workforce.  They ask their current broker to help them implement it and that’s where the difficulties start.  They hear things like, “this is just an added expense” or “your employees already have all of the doctors in the network” or “this won’t work with your health savings account”. 

As a Health Rosetta Advisor that’s music to my ears.  My most recent client acquisition told me just before I was hired that it was refreshing to hear someone say “yes you can” when cost containment solutions like DPC, transparent pharmacy benefits and bundled surgical agreements were inserted into the conversation.  They told me all they heard from their incumbent broker was how the status quo was the best they could do. 

But not all employers are so bold.  Many are too afraid that their employees are going to revolt at the mere mention of a different insurer.  Well, I’ll just describe the open enrollment meeting at this new client.  The changes were explained, the booklets were passed out, heads knodded, frowns turned to smiles and several employees were giving high fives to the CFO as they walked out of the conference room.  I’d say those employees were pretty happy with those changes.  Here’s the difference.  Instead of employees being given bad news, they were told the following:  “your primary care visits are free” and “your generic prescriptions can likely be dispensed right in your DPC provider’s office, no need for a separate trip to the pharmacy” and “if you follow the surgical advocate’s recommendation of the high-quality provider for your procedure, it’ll be no cost to you.”  I’m no genius, but that sounds a whole lot better than “copays, deductibles, co-insurance and premiums are going up again.”

What’s my point?  As an employer you have options.  More importantly, so do your employees.  Someday you may have to come to the sad reality that your outdated benefits package just cost you the great new hire you were recruiting.  When that day comes you know where to reach me.  I’ll show up in my cute, pearl white Toyota Prius that got me there at a rate of about 60 miles per gallon.

Look Backward to Plan Forward | North Carolina Employee Benefits

We have entered Open Enrollment season and that means you and everyone in your office are probably reading through enrollment guides and trying to decipher it all. As you begin your research into which plan to choose or even how much to contribute to your Health Savings Account (HSA), consider evaluating how you used your health plan last year. Looking backward can actually help you plan forward and make the most of your health care dollars for the coming year.

Forbes magazine gives the advice, “Think of Open Enrollment as your time to revisit your benefits to make sure you are taking full advantage of them.” First, look at how often you used health care services this year. Did you go to the doctor a lot? Did you begin a new prescription drug regimen? What procedures did you have done and what are their likelihood of needing to be done again this year? As you evaluate how you used your dollars last year, you can predict how your dollars may be spent next year and choose a plan that accommodates your spending.

Second, don’t assume your insurance coverage will be the same year after year. Your company may change providers or even what services they will cover with the same provider. You may also have better coverage on services and procedures that were previously not eligible for you. If you have choices on which plan to enroll in, make sure you are comparing each plan’s costs for premiums, deductibles, copays, and coinsurance for next year. Don’t make the mistake of choosing a plan based on how it was written in years prior.

Third, make sure you are taking full advantage of your company’s services. For instance, their preventative health benefits. Do they offer discounted gym memberships? What about weight-loss counseling services or surgery? How frequently can you visit the dentist for cleanings or the optometrist? Make sure you know what is covered and that you are using the services provided for you. Check to see if your company gives discounts on health insurance premiums for completing health surveys or wellness programs—even for wearing fitness trackers! Don’t leave money on the table by not being educated on what is offer

Finally, look at your company’s policy choices for life insurance. Taking out a personal life insurance policy can be very costly but ones offered through your office are much more reasonable. Why? You reap the cost benefit of being a part of a group life policy. Again, look at how your family is expected to change this year—are you getting married or having a baby, or even going through a divorce? Consider changing your life insurance coverage to account for these life changes. Forbes says that “people entering or exiting your life is typically a good indicator that you may want to revisit your existing benefits.”

As you make choices for yourself and/or your family this Open Enrollment season, be sure to look at ALL the options available to you. Do your research. Take the time to understand your options—your HR department may even have a tool available to help you estimate the best health care plan for you and your dependents. And remember, looking backward on your past habits and expenses can be an important tool to help you plan forward for next year.

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Ask the Experts: FSA Limits | North Carolina Employee Benefits

Question: Our company offers flexible spending accounts (FSAs) for health care and dependent daycare. Our plan limits are the maximum amounts allowed by federal law. Will the IRS increase the limits for 2019? We hold open enrollment in November for employees to make their FSA elections for the following year.

Answer: The maximum annual limits for Dependent Care FSAs and Health Care FSAs are set forth under § 129 and § 125, respectively, of the Internal Revenue Code.

The § 129 (Dependent Care) limits do not change from year to year. They are currently $5,000, or $2,500 if married and filing separately, and they apply on a calendar-year basis. To change them would require a change in law, which is unlikely in the current Congress.

On the other hand, the maximum limit for elective contributions to a Health Care FSA (HFSA) may change from year to year depending on inflation. The limit applies on a plan-year basis and the HFSA limit for a 12-month plan year beginning in 2018 is $2,650. The limit is one of over 50 different tax provisions that is subject to annual cost-of-living or inflation adjustments. Each fall, the IRS announces any changes for the following year. The announcement usually is released in mid-October, which should give employers time to prepare 2019 enrollment materials.

Based on estimated inflation, it appears the HFSA limit will increase from $2,650 for plan years beginning in 2018 to $2,700 for plan years beginning in 2019. The increase will not be official, however, until the IRS announcement is released.

Originally published by www.thinkhr.com

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Look Backward to Plan Forward | North Carolina Employee Benefits

We have entered Open Enrollment season and that means you and everyone in your office are probably reading through enrollment guides and trying to decipher it all. As you begin your research into which plan to choose or even how much to contribute to your Health Savings Account (HSA), consider evaluating how you used your health plan last year. Looking backward can actually help you plan forward and make the most of your health care dollars for the coming year.

Check out these four things to look at as you go into Open Enrollment season!

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Is Your Health Plan Affordable for 2019? | North Carolina Benefit Advisors

The Affordable Care Act’s employer shared responsibility provision — often called the employer mandate or “play or pay” — requires large employers to offer health coverage to their full-time employees or face a potential penalty. (Employers with fewer than 50 full-time and full-time-equivalent employees are exempt.) Large employers can avoid the risk of any play or pay penalties by offering all full-time employees at least one group health plan option that meets two standards: It provides minimum value and it is affordable.

Minimum value means the plan’s share of total allowed costs is at least 60 percent and the plan provides substantial coverage of physician services and inpatient hospital services.

Affordable means the employee’s required contribution (payroll deduction) for self-only coverage, if elected, does not exceed a certain percentage of the employee’s household income. The affordability percentage changes slightly each year based on the law’s indexing rule. For 2018, the percentage is 9.56 percent. For 2019, however, the percentage increases to 9.86 percent.

Although the change is minor, it means that employers may increase their plan’s employee-only contribution rate and still meet the affordability standard next year.

Determining Affordability

The first step in determining whether a group health plan option is affordable is to define the employee’s “income.” Employers do not know their workers’ total household income, so the play or pay rules offer employers three optional safe harbor methods to define income using information known to the employer. Employers may use any of the safe harbor methods. They also may use different methods for different classes (such as one method for hourly employees and another method for salaried employees), provided that the chosen method is applied uniformly to all employees in the class.

The three IRS safe harbor methods are:

1. Federal Poverty Line (FPL)

The FPL method is the easiest of the three methods. Multiply the mainland FPL amount for a single-member household by the affordability percentage, then divide by 12. As long as the self-only contribution rate does not exceed the resulting amount, the plan’s coverage is deemed affordable. For instance:

  • 2018: ($12,060 x 9.56%)/12 = $96.08 per month

  • 2019: ($12,140 x 9.86%)/12 = $99.75 per month

The FPL chart is updated every year in late January. For 2019 calendar-year health plans, the employer needs to refer to the current FPL amount ($12,140) since the new FPL amount will not be available until after the plan year starts. If the health plan year starts February 1, 2018 or later, however, the employer may refer to the new FPL amount which likely will be a little higher.

2. Rate of Pay

This is the most convenient method to define income when applied to hourly employees. Multiply the employee’s hourly rate of pay times 130 hours per month (regardless of how many hours he or she actually works), then multiply by the affordability percentage. As long as the self-only contribution rate does not exceed the resulting amount, the plan’s coverage is deemed affordable. For instance:

  • 2018: ($11* x 130) x 9.56% = $136.70 per month

  • 2019: ($11* x 130) x 9.86% = $140.99 per month

* Replace $11 with the hourly employee’s rate of pay.

For salaried employees, the rate of pay method is somewhat complicated so employers generally avoid using this method for non-hourly employees.

3. W-2

The W-2 method requires using current W-2 wages instead of looking back at the prior year. W-2 wages means the amount that will be reported in Box 1 of Form W-2. Pretax contributions, such as § 125 plan contributions and 401(k) or 403(b) plan deferrals, are not included in Box 1, so using the W-2 safe harbor method may understate the employee’s actual income. Coverage will be deemed affordable if, for each month of the plan year, the self-only contribution does not exceed the Box 1 amount multiplied by the affordability percentage.

Summary

Large employers can avoid the risk of potential penalties under the ACA’s play or pay rules by ensuring that they offer full-time employees at least one minimum value plan option that also is affordable. Affordable means the employee’s contribution to elect self-only coverage would not exceed a certain percentage of the employee’s income.

The percentage used to determine affordability changes from year to year is based on the law’s indexing formula. For 2018 plan years, the affordability percentage is 9.56 percent, but it increases to 9.86 percent for 2019 plan years. Employers and their advisors will want to keep this information in mind as they finalize their group health plan offerings and employee contribution rates for 2019.

Originally published www.thinkhr.com

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The News about Association Health Plans | North Carolina Employee Benefit Advisors

On June 19, 2018, the U.S. Department of Labor released its Final Rule regarding Association Health Plans (AHPs). AHPs are not new, but they have not been widely available in the past and, in some cases, they have not been successful. The Final Rule is designed to make AHPs available to a greater number of small businesses as an alternative to standard ACA-compliant small group insurance policies.

This article answers common questions about AHPs under the current rules (which groups can continue to use) and the new rules.

Is group medical insurance the same for small and large employers?

Yes and no. Federal law imposes certain basic requirements on all group medical plans, regardless of the employer’s size. For instance, plans cannot exclude pre-existing conditions nor impose annual or lifetime dollar limits on basic benefits. If the plan is insured, it also is subject to the insurance laws of the state in which the policy is issued.

Small group policies, which are sold to employers with up to 50 or 100 employees, depending on the state, are subject to additional requirements. These policies must cover 10 categories of essential health benefits (EHBs), including hospitalization, maternity care, mental health and substance abuse treatment, and prescription drugs. (Some states allow certain grandfathered or grandmothered policy exceptions.) For most small employers, their options for group medical insurance are limited to small group policies that comply with the full scope of ACA requirements. On the other hand, the policies are subject to guaranteed issue and adjusted community rating rules, so carriers cannot refuse to insure a small employer nor use any past claims experience in setting rates.

Large group policies, which can only be sold to groups with at least 50 or 100 employees, depending on the state, are not required to cover all EHBs. Carriers have more flexibility in designing coverage options and developing premium rates in the large group market. This means larger employers have more options to choose from and may be able to purchase coverage at a lower cost than would apply to a small group policy. Note, however, that there is no guaranteed issue protection, so carriers can accept or reject each employer’s application or use the employer’s past claims experience in setting rates.

Lastly, self-funded plans are subject to the ACA and other federal laws, but generally are exempt from state laws. They typically are not feasible for small employers, however, due to the financial risk of uninsured programs.

What is an Association Health Plan (AHP)?

Group insurance covers the employees of an employer (or an employee organization such as a labor union). An AHP, as the name implies, covers the members of an association. Unrelated employers can obtain coverage for their employees through an AHP provided the employers form a bona fide association. Traditionally, this has meant that the employers had to have a “commonality of interest” and their primary interest had to be something other than an interest in providing benefits. For this reason, AHPs generally have been limited to associations formed by employers in the same trade, industry, or profession.

The Final Rule makes AHPs available to a wider range of businesses by expanding the meaning of “commonality of interest.” Once the Final Rule takes effect, an association may be formed by employers that are:

  • In the same trade, industry, or profession, regardless of location; or
  • In the same principal place of business; i.e., in the same state or in the same multi-state metropolitan area.

Under the new rules, the employer’s primary interest in associating may be benefits coverage, although they still will need to have at least one other substantial business purpose other than benefits. This is a key difference from the current rules.

When does the new Final Rule take effect?

The Final Rule expanding the definition of an association for purposes of an AHP will take effect on staggered dates:

  • For fully insured AHPs: September 1, 2018
  • For self-funded AHPs:
    • If in existence on or before June 19, 2018: January 1, 2019
    • If created after June 19, 2018: April 1, 2019

As noted, the new rules do not replace existing rules. Employers and associations may continue to follow the existing rules (which generally limit AHPs to employers in the same trade, industry, or profession). The new rules merely expand the opportunities for AHPs, such as making them available to employers in the same state or metropolitan area even if they are in different industries.

Are AHPs limited to employers with employees? What about sole proprietors?

Currently, sole proprietors, such as mom-and-pop shops without any W-2 employees, purchase medical insurance in the individual market. Individual policies often cost more than group policies or AHPs. The new rules will expand the availability of AHPs to include sole proprietors who work a minimum number of hours (so-called working owners).

What about state laws? Will AHPs be available nationwide?

Insurance products, including AHPs, are regulated by state law. Under both the existing and new rules, AHPs are multiple employer welfare arrangements (MEWAs). State laws on MEWAs are quite complicated. In some states, MEWAs are prohibited. In others, insured MEWAs are allowed but self-funded plans are prohibited. The laws vary from state to state, so different carriers will make different decisions about whether they want to design and market AHPs in various jurisdictions around the country.

A number of states are very concerned about AHPs and may prohibit them in their states or impose strict requirements to ensure they will provide reliable and effective coverage. Other states will view AHPs as cost-effective alternatives to ACA-compliant policies for small employers and look to encourage their expansion.

What’s next?

There is no clear answer to what’s next. Over the coming months, carriers across the country likely will review the reasons they have or have not offered AHPs in the past, and whether they want to consider new approaches in the future. Along with economic and market issues to consider, carriers also must consider the state insurance laws in different jurisdictions. At the same time, many state legislatures and insurance commissioners will be reviewing their existing rules and whether they want to promote or expand the availability of AHPs in their area.

Oh … and the lawsuits. Yes, that also is what’s next. As of this writing, attorneys general in different states are planning to join together in challenging the federal government’s Final Rule on AHPs. Their stated concern is that effective regulation is required to ensure that plans provide adequate coverage.

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Price Shopping Health Care | North Carolina Benefit Advisors

As the costs of health care soar, many consumers are looking for ways to control their medical spending. Also, with the rise of enrollment in high deductible health plans, consumers are paying for more health care out-of-pocket. From medical savings accounts to discount plans for prescriptions, patients are growing increasingly conscious of prices for their healthcare needs. Price shopping procedures and providers allows you to compare prices so that you are getting the best value for your care.

Check out this short video to learn more!

Opioids in America | North Carolina Benefit Advisors

Lately, there’s been a big focus on America’s opioid addiction in the news. Whether it’s news on the abuse of the drug or it’s information sharing on how the drug works, Americans are talking about this subject regularly. We want to help educate you on this hot topic.

Opioids are made from the opium poppy plant.  Opium has been around since 3,400 BC and it was first referenced as being cultivated in Southwest Asia. The drug traveled the Silk Road from the Mediterranean to Asia to China. Since then, the drug has gained popularity for pain relief but it also has gained notoriety as an abused drug. Morphine, Codeine, and Heroin are all derived from the opium poppy and are all highly addictive drugs that are abused all around the world. As the demand for these drugs has increased, so has the production.  From 2016 to 2017, the area under opium poppy cultivation in Afghanistan increased by 63 percent. In 2016, it killed some 64,000 Americans, more than double the number in 2005.

We can see that the danger from this drug is growing rapidly. What can we do to recognize potential abuse problems and to get help? Here are some facts about opioid addiction:

·       How do they work? Opioids attach to pain receptors in your brain, spinal cord, and other areas that recognize pain signals. As they attach to the receptors, it reduces the sending of pain messages to the brain and therefore reduces the feelings of pain in your body.

·       Short-acting opiates are typically prescribed for injuries and only for a few days. They take 15-30 minutes for pain relief to begin and this relief lasts for 3-4 hours. Long-acting opiates are prescribed for moderate to severe pain and are used over a long period of time. Relief typically lasts for 8-12 hours and can be used alongside a short-acting drug for breakthrough pain.

·       Dependence is common with long-term use of an opiate. This means that the patient needs to take more of and higher doses of the medicine to get the same pain relieving effect. This does not necessarily mean the patient is addicted. Addiction is the abuse of the drug by taking it in an unprescribed way—like crushing tablets or using intravenously.

·       Americans account for less than 5% of the world’s population, but take 80% of the world’s opioid medications. About 5% of the people who take opiates become addicted to the drug.

·       Help is available through many channels from private recovery centers to insurance providers. The Substance Abuse and Mental Health Services Administration helpline is 1-800-662-HELP. This line is confidential, free, and available 24-hours a day and 7 days a week. Family and friends may also call this number for resources for help. Additional resources can be found at www.drugabuse.com.

Make sure you are educated about the dangers of opioid abuse. But, don’t be discouraged and think that the abuse is incurable! There are many resources that can be used to break the addiction cycle and can make real change in the lives of its victims. Ask for help and offer help.

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Benefits of an Annual Exam | North Carolina Employee Benefits

Becoming a well-informed patient who follows through on going to their annual exam, as well as follows the advice given to them from their physician after asking good questions, will not only save your budget, but it can save your life!

Check out this short video so you too, can be a well informed patient!

 

Discount Drug Programs | North Carolina Benefit Advisors

Did you know that you can save time and money on your prescription drugs by simply signing up for a discount card online? With savings as much as 80% off, these discount cards keep your health care costs down even when the prices of prescriptions are sharply rising.  At no cost to the patient, discount drug programs negotiate the price of medicines with pharmacies and then pass the savings on to the consumer.  These programs give subscribers a personalized discount card to be used at any pharmacy. While the discount card cannot be used in conjunction with health insurance, the consumer may see that the cost of their medicine is actually LESS with the card than it is with their insurance.

Another benefit to the consumer is that these programs will publish at which pharmacy you can find your medicine. This is especially helpful to the person who has specialty drug prescriptions. For example, Rebekah is prescribed a specialty drug for pain and neuropathy due to Multiple Sclerosis. This drug is not commonly stocked in pharmacies and so many times, she has had to wait for them to order it. By using the discount drug program, Rebekah is able to see which pharmacies have her medicine in stock and the estimated price.

So where do you start? Here are a few discount drug programs to investigate costs and providers for your prescriptions:

·      Provides free drug cards to reduce the out-of-pocket cost of prescription drugs.

·      Click on your state and the site will redirect you to your corresponding prescription assistance program.

·      Compares prices and discounts at thousands of pharmacies.

·      Receive coupons via phone, email, or text to print or present for discounts.

·      Free drug card to present at pharmacy for cost savings on prescriptions.

·      Earn rewards each time you use their card—similar to credit card rewards. Each fill is 500 points and when you reach 5,000 points, you earn a gift card to various retailers.

Being a savvy consumer can save you money! Shop around to find the best cost for your prescription drugs and save time by locating the pharmacy that has your meds in stock. Discount drug programs are a great resource so do your research and find one that fits your needs.

 

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Emergency vs. Urgent – What’s the Difference in Walk-In Care?

We’ve all been there – once or twice (or more)—when a child, spouse or family member has had to gain access to healthcare quickly. Whether a fall that requires stitches; a sprained or broken bone; or something more serious, it can be difficult to identify which avenue to take when it comes to walk-in care. With the recent boom in stand-alone ERs  (Emergency Care Clinics or ECCs), as well as, Urgent Care Clinics (UCCs) it’s easy to see why almost 50% of diagnoses could have been treated for less money and time with the latter.  

It’s key to educate yourself and your employees on the difference between the two so as not to get pummeled by high medical costs.

  1. Most Emergency Care facilities are open 24 hours a day; whereas Urgent Care may be open a maximum of 12 hours, extending into late evening. Both are staffed with a physician, nurse practitioners, and physician assistants, however, stand alone ECCs specialize in life-threatening conditions and injuries that require more advanced technology and highly trained medical personnel to diagnose and treat than a traditional Urgent Care clinic.
     
  2. Most individual ERs charge a higher price for the visit – generally 3-5 times higher than a normal Urgent Care visit would cost. The American Board of Emergency Medicine (ABEM) physicians’ bill at a higher rate than typical Family-Medicine trained Urgent Care physicians do (American Board of Family Medicine (ABFM). These bill rates are based on insurance CPT codes. For example, a trip to the neighborhood ER for strep throat may cost you more than a visit to a UC facility. Your co-insurance fee for a sprain or strain at the same location may cost you $150 in lieu of $40 at a traditional Urgent Care facility.  
     
  3. Stand alone ER facilities may often be covered under your plan, but some of the “ancillary” services (just like visit rates) may be billed higher than Urgent Care facilities. At times, this has caused many “financial sticker shock” when they first see those medical bills. The New England Journal of Medicine indicates 1 of every 5 patients experience this sticker shock. In fact, 22% of the patients who went to an ECC covered by their insurance plan later found certain ancillary services were not covered, or covered for less. These services were out-of-network, therefore charged a higher fee for the same services offered in both facilities.  

So, what can you and your employees do to make sure you don’t get duped into additional costs?

  1. Identify the difference between when you need urgent or emergency care.
     
  2. Know your insurance policy.  Review the definition of terms and what portion your policy covers with regard to deductibles and co-pays for each of these facilities. 
     
  3. Pay attention to detail. Understand key terms that define the difference between these two walk-in clinics. Most Emergency Care facilities operate as stand-alone ERs, which can further confuse patients when they need immediate care. If these centers, or their paperwork, has the word “emergency”, “emergency” or anything related to it, they’ll operate and bill like an ER with their services. Watch for clinics that offer both services in one place. Often, it’s very easy to disguise their practices as an Urgent Care facility, but again due to CPT codes and the medical boards they have the right to charge more. Read the fine print.

It’s beneficial as an employer to educate your employees on this difference, as the more they know – the lower the cost will be for the employer and employee come renewal time.

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The New War on Drugs: Opioid Outliers Detectable in Health Plans

Opioid addiction is a growing epidemic in the United States, with opioid overdoses killing 91 Americans every day. In 2015 alone, more than 33,000 people died from an opioid overdose. Read on to learn more about opioids and to learn how to recognize the signs of opioid addiction.

Winning the War on Diabetes

Winning the War on Diabetes

Diabetes is affecting over 29 million people in the United States.  That's 10% of every man, woman and child and according to the Centers for Disease Control, another 86 million have pre-diabetes and some don't even know it.  Of the $245 Billion being spent annually on the treatment of diabetes and its complications you can bet some of that money is coming out of your health plan.  At Custom Benefits Solutions, we work with our employer clients to develop a wellness strategy that helps employees with diabetes to better manage that disease and reduce their employer's financial burden associated with it.  #custombenefitswork

Custom Benefits Solutions Starts a Monthly Newsletter

Be one of the first to sign up for our new monthly newsletter!  You'll have plenty of cool resources at your fingertips.  Learn benefit tips and tools to help understand your insurance plans better.  Get "tricks of the trade" from the experts.  Have "real life" explanations of why insurance is the way it is.  Ask questions, get answers.  It's not your typical newsletter.  You'll really like it!  Fill out the form below.  That's all you need to do!  You'll be connected with a cache' of resources to help you manage your employee benefits plans in a much smarter way.

Custom Benefits Solutions Signs On With Freshbenies

There are many barriers to quality healthcare.  Sometimes it's money, more often than not, it's time.  Ahh, time!  That commodity no one can seem to get more of.  You say, "I don't have time to go to the doctor"...and you know what?  I believe you!  Enter freshbenies.  A totally revolutionary membership that we actually WANT you to use.  It saves time, it saves money, it helps you live a healthier, happier, more productive life.  At the end of the day, that's what we're all about.  Go to www.freshbenies.com/gupton, and watch the video to learn more.  Then click on "individual", select your features and click "checkout now" to get your family signed up.  You're gonna love it!