David 0:00

You know, in our business, no matter what you see happening or not happening above the water in the swamp, there's always stuff going on under the water. And a lot of times the stuff that goes on under the water, that regulatory and compliance stuff, can absolutely just make or break your practice or make her break some of the plans that you've put in place with your clients. And so because it's a new year, we invited our absolutely most favorite person in the world to come and explain this to us. She is amazingly talented and really good at explaining complicated stuff to simple people like me.

Announcer 0:36

Change either paralyzes or energizes. The choice is yours. You're listening to the Shift Shapers Podcast. You're about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change you want to see.

David 0:58

This episode is brought to you by Triune Technologies, creator of the market-leading benefits connector Ben Admin software. Now with special pricing for smaller groups. To learn more, call Carol Motznick at 336-253-5722. That's 336-253-5722. Let Triune help you get out of the admin business and back into the selling business.

Announcer 1:27

And now, here's your host, Story Brand Certified Guide and Chief Transformation Strategist at Shift Shaper Strategies, David Saltzman.

David 1:39

So, welcome Jessica Waltman, Vice President of Compliance at MZQ Consulting. We have a lot to talk about, Jessica.

SPEAKER_03 1:46

We do. Also, how I'm not going to tell your girls that you just called me your most favorite person in the world. I am not that, but I love David Saltzman. I'm so glad to be back on the podcast to explain all this complex stuff that's going on to help the clients a little bit better.

David 2:04

Well, let's dig in. So we're going to talk about eight things that are at the top of the agenda, and then we're going to finish up by talking about what might go on in Congress, this new divided Congress that we have, and what might go on in the states. And no snickering. They'll get there eventually. So the first thing is RXDC reporting. What is it? Why is it important? And what's happening with it?

SPEAKER_03 2:25

Okay. So there's a bunch of new requirements that are hitting January or January one-ish for group benefit plans. And a lot of them stem from the Consolidated Appropriations Act of 2021. So we're recording in January of 2023. We just saw Congress pass a mammoth bill that funds the government and does a whole bunch of things. In 2021, they did one and it had actually had about 750 pages in it that uh dealt with employee benefit plans. So one of the things that's just hitting now from that is this thing called RXDC reporting. And it stands for prescription drug cost, like the RX is prescription drug and it's claims cost for prescription drugs. But really, they need health plan claims data and prescription drug data. So it's it's both. And it is this massive new federal reporting requirement that affects all group health plans of all sizes of all funding structures. So it doesn't matter if you are a fully insured group of two or you know the Amazon's health plan, which I'm assuming is self-funded and covers many, many, many, many, many, many thousands of people. So everything, everybody has to do this. Now, it requires reporting information that is group specific, that really only employer would know a little bit, but stuff about like where your employees live, where you're located, your tax ID, stuff like that that is employer specific and your health vendors and your PBM may or may not know. Then it requires the reporting of all kinds of data that, you know, if you're fully insured, the carrier only has. If you are self-funded, the TPAs basically have, or maybe some other vendor. And then if you're fully insured, your drug coverage is coming through a PBM somewhere. So even if the carrier looks like it all comes through your carrier, it's coming through some type of PBM somehow, somehow. And in many cases, the carrier doesn't even have a data, the pharmacy benefit manager has it. And same thing on the self-funded side, it's coming from your pharmacy benefit manager. And it is both data fields of numbers and it's also a narrative component where you have to explain those numbers. And it's asking for things in ways in which no one's really collected data before. So saying things like, what are the top 50 most commonly prescribed medicines for your plan specific to your group? What were the top 50 costliest medications for your plan specific to your group? You know, what were claims data in buckets of like health buckets that are not our traditional buckets of looking at things? So everybody's kind of phlemmox because nobody's pulled data this way, and no one has all the pieces together. So there's different data segments, and you have to report them online through a CMS-facilitated website, which used to be until a few weeks ago, you had to get a special ID number called a HiOS number to submit through it. And it took about two weeks to get this number, and it was a very complicated process, and people were not getting them, and there was all kinds of submission issues. It was supposed to be due. This data was the first round of collection was supposed to be due last December 27th, 2021? Yeah, 21. The Biden administration had come in and they were like, we can't get this together. Like, you know, no one can do this this fast. So they delayed it a year. So they said this year on December 27th. And if you're like, why December 27th, that was the anniversary of that big omnibus law being passed. So this December 27th, we have to get two years worth of data in. And again, people just didn't know what they were doing. I mean, it took CMS a long time to build the system. The specs were hard. Everybody, no one knew how to put all the pieces together. There weren't a lot of vendors in the market that were doing it for people. So now they have actually delayed the requirement again. And so you will not be deemed out of compliance if you get your stuff in by January 31st, 2023. Also, they're putting out a good faith compliance standard because a lot of these questions and fields are like, I can't track this, I don't know. You know, what if my vendor doesn't give me the information? What if I can't pull together? So if your plan tries hard, they're saying they're gonna not do like enforcement. Now, much like when we first started doing ACA reporting, no one really knew, like, they're not ready to enforce it yet, in my opinion. It took a couple of years for ACA, the mandate penalties were enforced force. And then actually doing the reporting, they got to second. So I don't know that they're going to start enforcing any of this anytime soon, but they will go backwards like they did with ACA reporting. And the penalties for not doing it are the standard scaled off of $100 a day per plan participant. Like so, kind of your standard if you mess up with your group health plan penalty. So that is out there. So if you are somebody with a self-funded plan or help self-funded plans, you would probably want to be looking for a vendor to like help you pull all these pieces together, talk to your TPA, see how they're going to support you. The good thing is they made that number to get a lot easier. You can really send it in via an email now. So the parts that the employer has to do, you don't have to get a number anymore. You can get your employer-specific information. They've broken the report down into segments. You can put your stuff in via an email. You know, if you go on the CMS website, you will be able to find this. I would Google RXDC reporting, and you will get kind of into a website that will help you out. If it's fully insured, you want to talk to your carrier and make sure that they're doing it for you. If so, the other thing that's interesting with kind of a lot of these requirements I'm going to talk about is the liability rests with the employer. So the employer, if it's fully insured coverage, can kind of push that liability off onto their carrier with a written agreement. So, like, you know, something in writing agreeing that they're going to do it for you. Self-funded plans never lose ultimately their liability. So their vendor can help, but they're the ones ultimately in charge of making sure it all gets done. So they have to be on top of their vendors and kind of make sure that their drug cost information is being reported, their health cost information is being reported, and the employer specific information being reported.

David 9:05

Sounds like a load of fun.

SPEAKER_03 9:07

Oh, and then the other thing is moving forward, we're gonna have to do this every year on June 1st. So this is the 2021 and 2020 data being reported now. 2022 data, buckle up, you're gonna have to do this again by June 1st, and then every year by June 1st. And if you ask me what they're going to do with this data, like why are we doing this all? It's so that the federal government can get information and get a better understanding of where our healthcare callers are going, what they're going to do with all this information, other than they are mandated by Congress to write a report. I don't know is the mystery of our times. We'll see what they do with it.

David 9:51

I guess we'll find out. And now a word from our sponsor, Triune Technologies. As a salesperson or an agency leader, your most valuable commodity is time. That's why it's critically important that your benefits administration doesn't sneakily eat up time that you could be using to build your book or grow your agency. If you or your team is still doing case setup, working on creating and managing EDI feeds and dealing with ACA reporting, it may be time to look for a better tool. Benefit Connector is a done-for-use solution that understands your needs because it was created by benefits professionals just like you. For over 20 years, the system and its amazingly mature business rules have been honed to accept any type of group parameters and to keep you out there selling. Now, with special pricing for smaller groups, let Triune help you to get out of the admin business and focus on what you do best. Call Carol Motznick at 336-253-5722. That's 336-253-5722. And now back to our interview. Okay, so the next thing on our list of happy things that are going on is online plan transparency tools. Now we've been talking about transparency since before things were transparent. What's happening and is it really going to have any impact and is it going to have any teeth?

SPEAKER_03 11:24

Okay, so this is another new thing, January 1. And there's kind of two components to this. The first was every health plan had to get online machine-readable files of their basically claims data and keep it up to date. And that was actually supposed to kick in last year in January, but again, no one was really prepared. It got delayed. And everybody that had a January one plan had to get it done by July. And then if you renewed, you know, throughout the fall, you had to do it on your renewal. So at this point, every health plan in the United States should have files up online. They can be maintained by a vendor. So if your self-funded TPAs are a lot of times doing it, if you are fully insured, your carrier is in all likelihood doing it. And they are maintaining it, hopefully. And this data is not designed to be read by humans. It is not pretty in a lot of cases. Sometimes they make it pretty, but in most cases not. But it's got all of this in network rate data, out of network rates and claims and maximum allowed charges, and all of that is out there. So that should be already done. Then on January 1, all plans were supposed to have live online a tool searchable for you, people like you and me, with information that we could understand. And if for some reason we don't like to look at it online or we don't have online access, you have to have a way to contact the plan to say, I would like this in paper and talk to me, and this is what I would like, and you have to mail it to me and I could get a paper copy. And that type of information should be kind of what you would see on an EOB, like an explanation of benefits, but before you look up the have the service. So if you were going to like say you woke up in the middle of the night and your throat was scratchy and you probably have strep throat, or maybe you just have a cold, I don't know, but you might think you have throat cancer, you could go onto your health plan specific to you and start looking at your tool to find out where I could go to get treated for my throat thing tomorrow? How much would it cost if I were in network, if I were out of network, if I went to urgent care, how much would those entities be paid? What would my specific to me cost sharing be? What specific, you know, estimate costs would I have? Would there be any prior authorization requirements? And I could get myself deep into if I had throat cancer and I needed chemotherapy and blah, blah, blah. And it has to be all searchable based on, you know, the hypochondriac in the middle of the night, also the CPT codes for the services. So you had to have by this January, so a few days ago, that tool available to search for 500 of the most commonly covered things. There was a list. The plans don't get to make it up. They have to follow the list. And then by next January, they have to have everything that is completely covered. All the things online searching.

SPEAKER_00 14:37

Every CPT code?

SPEAKER_03 14:38

Yes.

SPEAKER_00 14:39

Holy moly.

SPEAKER_03 14:40

Everything that they cover, anything that is covered by the plan, you should be able to search it out.

SPEAKER_00 14:45

Yikes.

SPEAKER_03 14:46

And it's specific to you, your cost sharing. You know, so it's it's got to be level to where you are and meaning you're deductible or all the things. So those are pretty powerful tools, but they're kind of two things. So, two questions. Will the machine readable data be out there now, which is out there now? Are there people that are way smarter than me and more computer savvy than me and companies trolling the internet and scooping up this data and are gonna be able to know how much everybody pays for everything? How will that affect network development, provider contracting, cost control, all these things moving forward? One would think that that would in some way move the needle. I think it's gonna take a little while for this to all pan out, but this has to be maintained all the time. So that data will be out there. How long will it take, you know, people like you and me to be able to get tools to be able to digest that and it affect the products that we work with, we sell, we use. You know, it's gonna take a little while, but it's out there. And then in terms of the tools, what plan participants can use, I don't know. I mean, plans have the some plans have had fairly sophisticated transparency tools online already. I mean, it's questionable how much people actually use them and does it affect their buying decision. I mean, I know you kind of get locked in as a parent to certain providers that are convenient. If your kid is sick or you are sick, you are going to your places where you know. I mean, it's questionable, but I don't think that information in this case is a bad thing. And it may, you know, move the needle, it may educate people a little bit more. But my guess is that machine readable data being out there that will have a much bigger impact on the cost curve going forward than the consumer-specific tools. That's just my guess.

David 16:34

Along with the happiness of collecting all of this information and creating the machine readable language and all of that stuff, is there money set aside and is there planning for making the public aware of all this stuff and teaching them how to use it and why it matters? Or are they just going to have all this stuff and then it's every person for themselves good luck?

SPEAKER_03 16:53

Are you trying to say, like, did the federal government, when they require this, put some money aside to educate the people?

David 16:59

That would be the question, yeah.

SPEAKER_03 17:00

No.

unknown 17:00

No.

SPEAKER_03 17:01

Of course. Why would you do that?

David 17:02

Right.

SPEAKER_03 17:03

But the good thing is there's an opportunity for kind of probably the core listeners of this podcast to educate people and teach them how to use it and use those tools. And my guess is when that machinery file data becomes available, there's going to be a lot of data that comes from that that could help plans with negotiations, with products. So if you are a savvy person in the health insurance industry, I would think that the influx of new data, you know, as it comes, you should be looking for it. And it would provide, you know, I'm assuming there's going to be a lot of new opportunities. There's so many brilliant minds in this industry that people will have ideas about how they can use it and then better serve their clients. And then also educating clients, educating plan participants. I mean, that's that is something that brokers and other people in this industry are just born to do. But no, the federal government did not send any money to help us with that.

David 18:02

So we've got about three minutes left in this segment. Can we cover ACA reporting changes in three minutes?

SPEAKER_03 18:08

Sure.

David 18:09

Okay, go for it.

SPEAKER_03 18:10

Okay. So we've been doing ACA reporting for a long time. And the federal government has finally decided we're on our own, we've taken off the training wheels, there's no more good faith compliance. So cool. Your reporting better be tip top this year, because if you make a mistake, you know, with somebody's social security number, you code it wrong, what have you, doesn't really matter. It's, you know, these days where you're able to go to the IRS and say, oh, I made a mistake on my form. And really, we did offer people coverage. And you we don't owe a penalty of bazillion dollars, much, much, much harder. And then because of some changes to the law with something called the family glitch, it's making it a lot easier for people to leave employer coverage because it's unaffordable to them. And so, and they've also so they've made the affordability percentage as low as it possibly has been in the years. They've made it easier for people to leave group plans because it's unaffordable to them. There's no mandate on employers to make their coverage, you know, like make their anything more, you know, to cover anybody new or do anything for dependence, but it means more people may be peeling off of employer plans. And when people peel off of employer plans, if you are subject to the employer mandate, it means that your reporting really needs to be very precise and you need to document why they were off and that it wasn't because you didn't offer them affordable coverage. Like it doesn't change anything you have to do. And the other thing though, it is every year we get what we call an affordability percentage. And that is what employers that offer, you know, coverage to applicable large groups, like if they are subject to the mandate, they use that number to determine what is the lowest amount that you know that they could pay for coverage to their employees, to the single employee rate. And you use that percentage. And it used to be, you know, it was set the base rate was 9.5% in the law, and it always was a little above 9.5%, but it could go up or down with prices. Well, it's like the only thing because of inflation that went down because it reflects that consumers are paying more for everything. So now it's down a half a percent. So now instead of using 9.5% at your baseline to figure out what you can charge your employees for coverage, employers should really use 9%. And that's gonna make a big difference in the year ahead, especially if you really try to make your employees share a lot of the premium. And so employers have to be very careful to make sure that the coverage that they're offering to people meets that standard. So they were gonna want to use 9% to calculate it, not 9.5%.

David 20:57

And that's a good place to take a break. In our next episode with Jess, we're gonna talk about HSAs and telemedicine and that extension. We're gonna talk about what's happening with mental health parity, the status of the national health emergency, anything else that might be in her basket of goodies, and then we're gonna talk about what a divided Congress might do and what the states might do. So come back and join us next week for part two with Jessica Wallman.

Announcer 21:22

The Shift Shapers Podcast is a production of Shift Shaper strategies and may not be reproduced or quoted in whole or in part without our express written permission. Copyright 2020, all rights reserved.