IRS Notice 2019-45 allows health savings account (HSA)-eligible health plans the flexibility to cover 14 medications and services used to prevent the exacerbation of chronic conditions prior to meeting the plan deductible.
In this Issue Brief, we report on the findings from a 2021 Employee Benefit Research Institute (EBRI) survey of employers that collected information on their response to the 2019 guidance. The survey examined not only whether employers added pre-deductible coverage as a result of Notice 2019-45, but also examined each of the allowed services individually; the type of cost sharing, if any, used in lieu of deductibles; and other relevant questions.
Key findings:
- Three in four employers (76 percent) say that they have added pre-deductible coverage as a result of IRS Notice 2019-45.
- Pre-deductible coverage was often added for health care services related to heart disease and diabetes care. Two-thirds added pre-deductible coverage for blood pressure monitors and insulin/glucose lowering agents, 61 percent added coverage for glucometers, and 54 percent added coverage for beta blockers. Health care services least likely to have pre-deductible coverage include peak flow meters and INR testing (25 percent each).
- Nearly two-thirds (64 percent) of employers covered six or fewer of the 14 health care services allowed per IRS Notice 2019-45. Only 8 percent added pre-deductible coverage for all 14 services.
- The percentage of employers that eliminated cost sharing for the pre-deductible services ranged from a low of 25 percent to a high of 40 percent. Between nearly one-half and two-thirds require a copayment from employees, depending on the health care service.
- Between 57 percent and 69 percent provide pre-deductible coverage for both brand and generic drugs in the specified drug classes.
- Most employers would add pre-deductible coverage for additional health care services if allowed by law.
- Employers offered several reasons for adding pre-deductible coverage: for the sake of their employees (74 percent), employee retention (64 percent), employee attraction (52 percent), and as a long-term cost-saving measure (48 percent).
- Nearly all (96 percent) employers adopted pre-deductible coverage for telehealth services under the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Three-quarters (76 percent) prefer to make the provision permanent, while only 20 percent would like the provision to remain temporary.
- Among employers that did not add pre-deductible coverage as a result of IRS Rule 2019-45, most either plan to do so later (32 percent) or are exploring whether to do so (61 percent).
While a substantial amount of pre-deductible coverage has been added, there is an appetite among employers for adding more services if allowed by the IRS, and there is also an appetite among policymakers as evidenced by The Chronic Disease Management Act, which was reintroduced in the U.S. Congress as recently as May 2021. This bipartisan, bicameral legislation would provide HSA-eligible health plans additional flexibility to provide pre-deductible coverage for services that manage chronic conditions.
This study was conducted with the funding support of the National Pharmaceutical Council.
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EBRI invites comment on this research. 60% 50% S Emp epúlvedloy a, a Innd hae le Rd or e co bUp ruc tico k st (2013) t era oidk s; e Fron o stin, f Pre Roebuc -De k, Buxb dau um, c t and ibl Ast Fe hme nd a Cov rick (2020) e;r Go ald g ma en, f Jo oyr ce Pr , ande Zhe ve ngn (2007) tive ; 61% Individual Family Individual Family Individual Family Limit Hyperlipidemia 64% Health Plan $319.77 $113.84 73.70% Deductible I c N Hov nt ow SA e-r , re a o w ligib gduc it eht h for le tIp RS N t s:/ he ser ion a /ww v lt ot ic h p ic ew e s t la .c 20 n. ha om 19 t m m -45 o anw na in p g ea e lt la chf hr ce und.o onic , all H crond g SA /s-it it ee ligib ion s/d s. e le fa hult ea/f ltile h p s/do lans c um aree nt now s/_ a __ ble m e to dia ad _f op ilets_ a pm ub or lic e aflexib tions_is le b su en ee _br fit ief_20 pre-d de 60 ed d % uc ucttible ible . c ov The erab gill e w wa es r re e m in or tre od lik uc ee lyd tin t o bhe e self Se-na ins te ur in Ja ed. nua They w ry 20 e20 re a (ls S. 96% o 32 mo 00 or f E e ) m lik ap nd loy elyA e rs tpo ril 202 contr1 (S. 1424 ibute to the ) aw nd ork in er’s 69% Insulin and other glucose lowering agents Diabetes Trivedi, Moloo, and Mor (2010); Wharam et al. (2017); and Wharam et al. (2018). FiH gyur poe - fu 11 nct , io Pn oint ing th of yro Vi ide g w la n on d CARES Act Provision Allowing Pre-Deductible Telehealth Coverage on a Temporary Low-density Lipoprotein (LDL) Testing 44% HSA-Eligible Health K Se aiser r v Faice mily Founda s in tion. HS (2A 015) -Eli . Preg veibl ntivee Se Hea rvices Clt oveh re Pl d by a Prn ivas te Health Plans under the Affordable Care Act. 2004 $1,000 $2,000 $2,600 $5,150 $5,00Ad 0 opte$ d 1Pre 0,00 -D 0 eductible $500 design off 15 e_m r R ing eta iny m o_ por 18 ath e17 y p scr _ rot ceollin e ec nitn ion for s_ g prob c le em rt_of_ ain m unde edicrains l se ur ra vic nc ee s t _ib.p hr Doug ia dbfe h a tes value-based insurance design (V-BID) plan the 60 % House of Representatives in May 2021 (HR. 3563F ), igure build10 ing on the IRS guidance and previous versions to H The SA.Me dicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) included a provision that created Su Infg lag mes mated tory ci botatio wel dise n:a se Fronstin, Paul, and A. Mark Fendrick, “Employer Uptake of Pre-Deductible Coverage for Plan With Targeted Basis ................................................................................................ Coverag................................ e for Telehealth .................... 14 11 50%Washington, DC: Kaiser Family In hFounda aled Corti tion. costRe eroid trie s ved September 15, 2021, from https://www.kff.org/health- See Lee, Mac Peaik efje low w sm ki, ete Rraju, Shrank, and Choudhry (2013). Asthma 43% 2005 Additio1 n ,0 al 00Pre-Ded 2,0u 00 ctible C 2o ,6v 0erag 0 e T 5h ,1at Emp 50 lo 5y ,0 ers 00 Wou1 l0 d, 0L 00 ike to Ad 600 d (based st ructure. As the market for HSA-eligible health plans grows, it is important that these plans use this flexibility to allow wA ha dutfur l t a rh rte e he u c m rom ainc tom id re only aa rtse hr ik tp is now re-dn a educ s high tible- d cov ede uc ratg ible e D for rhe ug c a s hr lt Ch p onic ovela re n d ds is P(e rH e a-D se HP ms) a$ na . 3 2 A g5 te .1 m the 1e nt ti.m $ 1 e1, 0t.he 45 se pl7a 4ns .6% ha d to have a deductible By Paul Fronstin, Ph.D., Employee Benefit Research Institut Se e rv aices nd in A. 20Ma 20 rk Fendrick, M.D., Preventive Services in HSA-Eligible Health Plans,” EBRI Issue Brief, no. 542 (October 14, 2021). Figure 3 Glucometer Diabetes Federal Re refor gism te/f r. a(c20 t-sh 19e )e . tI/pr mperv ov ent ing ive P-rser icev a icnd es-Qua cov one lit r oe yp dTr en -by a-ns en -pp rd iv aed ra etnc e q -he y u esti in A alth o m -n pe) la ric ns a/ n He althcare To Put Patients First, 50% There are also a few notable differences by industry. Employers that adopted pre-deductible coverage were more likely FiB grur eae st 12 ca, nce Pla r ns to Add Pre-Deductible Prevent De iv de u ct Ciov blee W raitg he , AmongIn E cr m ea pse loyerD s Wh ecreo ase Have In cr Ne ot a se AddeId n cr Suc ease h Increase for 12 effective hea A ltnh ma 2006 gioten na sin ge C 1m ,o 0n 5 eve 0 ntrti for ng E a2 n ll b ,zym 10e 0ne e (ACE ficiar 2 ) In ie ,70 s. h 0ibito A t rs arg 5e ,4t5 e0d strate 5g ,2 y5 0 exploring 10,5c 0ov 39% 0 erage for 700 certain high-value, U of niv at le ea rs stity $1,000 of Michiga for indivn idua l coverage and $2,000 for family coverage (see Appendix Figure 1). As will be discussed Fielding of the survey was conducted by independent research firm Greenwald Research. Respondents were sourced by Hemoglobin A1c testing Diabetes Firm Characteristics 40% $5/$40/10% Copay of $5.34 of $3.38 of 0.09% of 1.7% of $189 Multiple scl Exe erc out sisive Order 13877. Retrieved September 15 F, igure 20217 , from to be in the information service sector and less likely to be in the education sector. Coverage .............................................................................................................................................. 14 c Thi lins st icalludy w y indic aa s c teond d he uc alt te h se d writ vh th ices p e fun riord ting o msu eeptp ing ortt he of td he ed N uc attible iona w l P illha pr rod mauc ceeut m icor al C e e off unc ectiliv . e clinically nuanced designs, Copyright Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). You may copy, in more detIa ntil b erne alow tio 2007 na , l H ND orH mP a 1s ,li1 z0 m e0 da R y ap tiroov (2 IN ide ,2R 0) 0 tc eov stie ng ra2 g,8 e5 of 0 certa5 in p ,6L 5i0 v re erv d eint seiv a 5se e ,5 0 ser a 0nd v E /ic o m re p b s p ll1 o e1 y e ,e r 0 dior r0 is n 0g T t h d o a iso tsa E rd tm is e800 p rfa s locyteion o rs Tha f th t De id health plan OpinionRoute, an online pane No l t S ag ug re/W reg ou ato ld N r.ee d to Discuss Statins 38% 26% L ee, J. 40 L% ., Maciejewski, M. L., Raju, S. S., Shrank, W. H., and Choudhry, N. K. (2013). Value-Based Insurance Design: Cost-Sharing ArN ran oteg : A em V = en act t u as aria a l v R aesu lue; P lt Mo Pf M IR =S peR r u mle e m201 ber p 9e -45 r month. https://www.federalregister.gov/documents/2019/06/27/2019-13945/improving-price-and-quality- Low-density Lipoprotein (LDL) testing Heart disease Adopted Pre- Not Adopt Pre- without fundamentally altering the original intent and spirit of these plans. 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Thus, these plans are also commonly known as HSA-eligible health 30% 40% 48% 11% 20% 2009 1,150 2,300 3,000 5,950 5,800 11,600 1,000 Statins Mental Health/Substance Abuse HeaT rto d ta ise l ase 10% and/oC r d oiv ae bre atg ee s Coverage a nd-provider-networks/. Retinopathy Screening 35% Reform-Brief.pdf Fi gure 20 14 % , Impact of Pre-Deductible Drug Coverage on Total Spending ................................................................... 16 patient-centered outcomes, allow for lower premiums than most PPOs and HMOs, and substantially reduce aggregate provided that you do so verbatim and with proper citation. Any use beyond the scope of the foregoing requires EBRI’s plans. In 2021, these plans must have a deductible of at least $1,400 for individual coverage and $2,800 for family Pany, M. J., Fd ire m B Sria znt e es, F., Levin-Scherz, J., and Fendrick, A. M. (2021). The Essential Role of Employers in Aligning Key Finding Sous rc e: https://vbidcenter.org/initiatives/hsa-high-deductible-health-plans-2/ Fronst VB in, P ID H ae ul a lt ah ha nd2010 M. s q Cu A hr a nti nt is -R 1 tifi es op ,2e 0 orpti d he 0 tv rhe e Roe Ther p He ot 2 b ap , art- 4 e uc y0 nt Rel 0kia , ate " l fina H de Care a3 lt nc ,h C 05 ia 0l im a40% rep Sp ac6 e t, nding 1on 50 pa taie ftnt e 5r, 9 out A 5d 0op -of t- ing poc 11 ak , 9e Fu 0t0 ll c 54% o -Re sts, p pla 1c la ,0 e0 n e m 0expe nt, H ndit igh ur -D e 6% e s a duc nd tible 7% 43% 14 42% Anti-Resorptive Therapy 29% 20% he S ae lte h ca http re s: e //xp vbe id ndit heaur lth.c es. om/ docs/HSA-HDHP-Reform-Brief.pdf. 40% 39% p cov rior er e axpress ge. Enr p 2ollm e 0r 0m toe is nt 4si 9on. 9in H For SA -p ee ligib rmis lesi he ons, p alth p lea lase ns cm ont aya c atc c Eount BRI afor t p e ov rm eris 21% one sions -ha @e lf b orfi.or those g 22% . with private he 18% alth coverage Plan Design & Payment Reform to Improve Quality, Enhance Equity and Promote Value. VBID Health. Appendix Figure 1, Statutory HSA L36% imits, 2004–2021 ............................................................................................. 17 I Thr RS N eeot in four ice 20 19 em -p 45 loy ae llow rs (7 s he 6 paelt rh sa centv ) ings a say tha cctount they ( H ha Sv Ae ) -a ed ligib ded le p he re- ad lteh p duc latns ible t he cov flexib erage ili tb ye tco aus coe v e of r 14 IRS N meot dic icaet ions 2019 a-nd 45 10% plan H ae ca tua lth P riala l va n Wit lue h a of p H rov eaiding lth Sa p vrings A e-dedc uc coun tible t: cA ov Fi ev ra eg -Y ee fa or r S 57 tudy. drug " E cB la RI ss I ess s us uee B dr ie to f,t rno. eat 38 118 c(hr Em onic ploy ce ond e Biteio ne ns fit 2011 1 A,ny 20thi 0 ng We A2 re A ,40l0 lowed to A3 dd ,050 6,150 5,950 11,900 1,000 6% 31% Blood Pressure Monitor 38% 57% 4% 500 to 999 17% 17% 18% A 2020 sur1vey from the Kaiser Family Foundation found that 29 percent of employers with 200 or more employees 4% International Normalized Ratio (INR) Testing 25% ( 15Figure 1). Retrieve 14 d September 30, 2021, from https://vbidhealth.com/wp-content/uploads/2021/09/Employer- ( ser Fig vur ice es us 4). e Thi d to s is pr e av su ent b st the ant e ia xa l inc cerrb ea atse ion o com f cphr aronic ed w cit ond h dit aions ta ob ptraior ine td o b m ye te he ting Katis he er pFa lam n d ily e d Founda uctiblet. ion in early 2020, These estimates should be considered “ballpark,” as limitations tend to both overestimate and underestimate the effect. (Figur Re esea 13) rc .h I nstitute, July 2013). 10% 1,000 to 4,999 33% 34% 35% 2012 Add1 iti,2 ona 00l Care/Tes 2ti ,4 n0 g f 0or Diabet3 ic,s 100 6,250 5% 6,050 12,100 1,000 According to Notice 2019-45, the list of preventive services that can be covered pre-deductible will be reviewed on a Report availability: This report is available on the internet at www.ebri.org increased the number of drugs and services covered pre-deductible in HSA-eligible health plans as a result of IRS Low-Density Lipoprotein (LDL) Testing 36% 49% 15% 13 0% Whitepaper-092021.pdf Peak Flow Meter 25% 81% of Employers Would w Sehic e http h found ://vb id tha heta only lth.c o2m 9 p /do ec rc s/ eH nt S A ha -HdDH mP a-d Re e fo su rm ch a -Bri c eha f.png df e fo . r a The summa likery lih o ood f limit of am tion aks ing . such a change was not 5,000 to 9,999 12% 10% 16% 4 periodic baA sido s. pted In fa Pre-D cte, du the ctibl e g Tel uida ehe nc alte h Co spe vec raifi gecally Ado s pted tat P ers e-D th ea du t ct tihe ble Tel pe eh riod ealtic h Co re vv erie age w is e Dixp d No ec t A te do d pt t P o roc e-Dc ed ur u ca tibl pe Tel proxim eheaa lth tely Emergency/ER/U2013 rgent Care for 1, Ca 250 tastrophic2 Ev ,50 en 0ts/Accidents 3,250 6,450 5% 6,250 12,500 1,000 Under the IRS guidance, until the deductible is met, coverage does not include "any service or benefit intended to treat Notice 2019-45. However, no details are available regarding the specific services that were included in these design In this Issue Brief, we report on the findings from a 2021 Employee Benefit ResearcA h I ddns Ptre it-ut Ded e (uE ctib BRI le ) survey of 10,000 to 24,999 8% 8% 6% C Fro onst nc An HSA in, P lusaion -ul e ligib and le M. he Cahr lt Re h p is tit nop ola pan he thy w r S it Roe ch a reenb in $2 uc g ,000 k, "Qua ded lituc y tof ible H ew aa lts us h Ca erd e a As a fte rb A ad seline opting for a tFu hell -aRe nap ly la sics (a eme cnt tua , r H ia igh l va -D lue ed uctible statistically d an iff d P erre efe nt rs to by Ma fir km e P si rov ze isi, onindust Permane ryn, t or the and P prre efe senc 36% rs Pre ov iof sionuni Rem onize ain Tem d e po m rary ployees. 53% However Co , self verage -insured11% employers 0% 16 0% 22 0% 40% 60% 80% Coverage for Additional ev S ee ry e fiv Buxb e ta o um, 10 y Mafi ear,s. anFor d Fe p nd atric ient k ( s a 2017) nd e fo mr pfu loy rthe ers a r dlik eta eil , 10 on y the ea rma s m gnitud ay be e a o f long pote tntia imel s to avw ing ait s a for s w su ellc h cov as praecrtical age Cancer-Related Care and/or Screenings a cha n e nge xists. ing Fu illrne t2 he 5ss ,0 r, m 0 2014 inj 0or our e r m , yb o , y ror e 1t, h 2ce 5ond 0 tim ite ion, the 2,in 5 I 0c RS 0luding rele a 3 dsed ,r 3ugs 00 Not oric m e6 e 20 ,d 55 ic 5% 19 0at-ions 45, ." it 6 ,w 38% 5Thi a 0s t s na oo la r1r2 toe ,7 w 0for 0de 9% m fin ait ny ion o 1 ,e 0m 00 f th ploy ee "rsa s t 6% fe o m haod rbify or" has Trivedi, A. N., InMoloo sulin and Oth , H., erand S Mor elec, tivV. (20 e Seroto10 nin, Janua Beta ry B 28 lock )e . rs Incre Aa ng sed iote ns Aim n Conv bula erti tor ngy Care S C tat op ins aymentIn s a halnd ed Cor Hospit ticostea roliz ids ations employers that collected information on their response to the 2019 guidance. The survey examined not only whether apprH oxim ealta h P ted la 74 n Wit peh a rce nt H) e. aOnc lth Sa e t vhe ings A plan d ccoun educ t: tA ible Fi vw ea -Y s sa eart is Stfied udy. , " this EB RI sim Iula ssue te dB r pie lafn im , no. p40 ose 4d ( E 10 m p ploy erceeent B enefit are more likely to report having made changes — 90 percent added pre-deductible coverage, compared with 75 percent I n response to IRS Notice 2019-45, three-quarters of large employers offering HSA-e Hea ligib lthle Care hea S lte h p rvices lans If expanded pre- Glucose Lowering Reu G plta uc ko em In eh te ib ritors 36% Enzyme (ACE) 50% 14% Source: Empl Sou oyee rce: BE en mef plioy t Res ee ea Ben rcef h iIns t Res titut ea e rs curv h Ins eyti .tut 5 e survey. s dtra ecis teions gies tfo o r bw ea m ste ad aev o gid iva enc n th e. e pace of research on plan design and medical innovation. There are already examples of Table of Contents likely caused harm to plan members as it is well established that increases in cost sharing for health care have been their health plan for 2015 2020. 1A ,3 0m 0ore rec 2e ,6 Dr nt 0ug 0 su s (g rv en eey r3 a, l3 )of 50insurer6 3% s found ,650 tha 6t ,4 m 50ost mod 12ifi ,90 e0 d their H 1,SA 000 -eligible health plans employeras a mong dde d the pr e E-lde der dly uc . tN ible ew cEov ngla erand ge Jour as ana rel sof ultMe of dN icot ine ic, e 36 20219 (4) -4 , 5, b 320ut -32 a8. d lso e oi:10.1 xamine 05 d6 e /N acEh o JMsa f th 09 e 04 allow 533e d services Allowed by Law Agents (SSRIs) Inhibitors coins Re ursea ancrec h I forns all c titut ov ee , rSe edp s te em rvb iceers (i 20nc 14luding ). drugs) until reaching the out-of-pocket maximum of $6,500. among those who were fully-insured or partially self-funded. deductible coverage for medications and services that prevent the exacerbation of chronic conditions, up substantially Some or All Employees Unionized services that may meet the criteria for pre-deductible coverage that were omitted from Notice 2019-45. For example, Hemoglobin A1C Testing 36% 56% 8% t ao sscoc ovia etre m d or we it h d sere vle ictees on riousa c p onseq re-deue duc nc tible es. b Thu asis, w s, the ith 75 p U.S. D ee rc peant rt m de oing nt of so in Treaful suly ry ins issu ure ed d g puida roduc ncte s a in 201 nd 809 pveia rc I eR nt S Introduction .......................................................................................................................................................... 5 individually; the ty2016 pe of cos 1t, 3sh 00aring, Asthif a 2ma ,60 -ny Re 0 , lated us e Car d 3 ,e in lie 350 u of d 6 3% e ,7d 5uc 0 tibles; a 6,55 nd 0 other 1 3r,e 1le 00vant que 1,st 00ions 0 . Conditions and drug classes were selected based on the disease prevalence and contribution to member- and Y Se ou srce: Employee Benefit Research Institute survey. 24% 24% 26% from 2020. Employers would add additional services if allowed by the IRS, according to EBRI’s survey results. t W he ha N ra ot m ic, eJ. ide F., ntZh ifie as ng, angio F., tE eg ng sile n conv ston, e Er. tM., ing e Lu, nzy Cm . e Y ., (ASoum CE) inh era ibit i, S. orsB t ., o apnd re vRoss ent e -D xa ec ge nra bn, ations D. ( 20 for 18 indiv , Maidua y). E lsff d eia ctg of no sed Notice 2019-45 to further increase the flexibility of HSA-eligible health plans to cover specific low-cost preventive Fr doing onst so in in, Paself ul a-nd ins ur M. eC d hr pris od top uche ts. r Roe The bsu ucr kv , e"y The also Im found pact of tha atn HSA most -rEl eigib spond le H ent eas r lth P epor lan o tedn He eithe alt r h C no a prre e m Se ium rvic inc es Use rease or Pre-deductibleNo coverage was often added for health care services related 69% to heart disea 69% se and diabetes c69% are. Two- Peak Flow M COete VID- r Related Care 34% 55% 8% 2017 1,300 2,600 3,400 3% 6,750 6,550 13,100 1,000 plan-paid expenditures. Background ........................................................................................................................................................... 6 Furthermore, there is bipartisan, bicameral legislation that has been introduced in the U.S. Congress which would High-Deductible Insurance on High-Acuity Outcomes in Diabetes: A Natural Experimen3t for Translation in with congestive heart failure (CHF), diabetes, and/or coronary artery disease. Patients who either do not respond or Key findingsD : on't know 6% 6% 5% p ser rev m icium es t o inc prre ea vses ent of thele e ss xa tc ha ern ba 1 tion o perce f nt chr . onic conditions on a pre-deductible basis (Figure 2). and Spending by Worker Income." EBRI Issue Brief, no. 425 (Employee Benefit Research Institute, August thirds added pre-deductible coverage for blood pressure monitors and insulin/glucose lowering agents; 61 percent It Depends on What Is Permitted 3% 2018 1,350 2,700 3,450 6,900 6,650 13,300 1,000 Beta Blockers provide additional flexibility to extend pre-deductible 33% coverage to services that mana 59% ge chronic conditions. E9% mployers Data and Methods ................................................................................................................................................. 7 who have D ia a b re ea te cs (NEXT tion to AC -DE ) St inhi udy. bitor Ds iaa breet eus s C ua ally re ,swit 41(c 5) he , d 94 t0 o -w 94 ha 8.t d aoi:10.2 re know 33 n a 7/d s ca17 ngi -11 ote 8ns 3 in receptor blockers (ARBs) a ddeH dS cA ov 2016 -e Elig rag ) ib e for le H gluc eaom lth eP tela rs; a n W nd it 54 h P pre erc -e Dnt e d auct ddeib d c le ov D er rug age C for ove bera ta ge bloc kers (Figure 5). Health care services Figure 12 Plan Funding Vision Care 1% and policymakers ha 2019 ve an a 1,p 3p 50 etite for 2 ,m 70or 0 e flexib 3,le 50 0plan de7 si ,0 g 0ns 0 or "sm 6,7 a5r0 ter" ded 13 uc ,50 tible 0 s bec 1a ,0 us 00e rising health care • Three in four employers (76 percent) say that they have added pre-deductible coverage as a result of IRS In this Iss Inter ue nat Bir on ie alf No , w rma e r lie zep d R ora t tion o (INR the ) T es fin ting dings from a 30% 2021 survey of employers 50% requesting information on 19%their response to prevent the same exacerbations. However, ARBs areFigure 9 not included in the list of 14 services in Notice 2019-45, thus Figure 6 Findings ................................ Plans to Add................................ Pre-Deductible Prev................................ entive Coverage, Amo ................................ ng Employers Who ................................ Have 9 least likely to have pre-deductible coverage include peak flow meters and INR testing (25 percent each). Nearly two- Self-insured (Administrative Services Only/ASO) 18% 21% 8% Vitamins/Nutritional Supplements W spe ha nding ram, ha J. F., s crZh eaa te ng, d ser F., ious Egg fis lest caon, l cha E. lle M., nge Ls. u, C . Y., Soum 1% Figure erai, 1S., and Ross-Degnan, D. (2017, March). Diabetes 2020 1,400 2,800 3,550 7,100 6,900 13,800 1,000 Notice 2019-45. to the 2019 guidance. RThe easo su n N rs fo vu emb y re A xa er dm d oine if nPr gd ev Pre not en - D only tied ve u w Ser ctib hev tlhe ie ces C r o em C verag o pv loy ere e fo ed rs a Pr rd Prev d ee -D d ed p en ru eti - ctib d ve e Serv dluc e tible ices coverage as a result of Fronst An HSA in, Pa-ul e ligib andle M. he Cahr lth p istop lan hew r it Roe h pb euc rmkit , t" eD do pA re c-cd ue m dula ucttible ing d HrSA ug B ca ov laenc rae gs A e for ffe c the t Use spe of cifi H ee da 57 lth d Craug re c Se larss vic es w es a and s t hey cannot be covered pre-deductible in HSAN -eo ligib t Ad led he eda Su lth p ch la C ns o.v erage Insulin a Pn ad Oth rtially er G selluc f-in os su e rLo ed we (lre ing ve A l-g fu en nd tsed) 30% 41% 60% 40% 44% 11% thirds (64 percent) added six or fewer types of coverage of the 14 health care services allowed per IRS Notice 2019-45 Percentage of Persons Enrolled in a High-Deductible Health Plan (HDHP), by Firm Profile ....................................................................................................................................................... 9 Outpatient Care and A Bc irut th e Cont Com rol/Co plic ntrac ation eptivs B es efore and After High-Deductible Insurance Enrollment: A Natural 45 80% % 1% 2021 1,400 2,800 3,600 7,200 7,000 14,000 1,000 Notic si em 20 ula Sp 19 te e -nding d 45 . F, u Cllb ons y u ? in " tsu um E arls B eRI e o dre c Ixa ss ost m ue ine s h Ba rdr ie ing e fa , c no. w h o a s $5 for 482 f the ( E am llow g pe loy ne ede r e ic ser B dv e ric u ne g es, $40 fit s indiv Resea idua for r41% c b h I lly ra;ns n td he te itd ut t y non ep, eMa -of 39% sp yc e ost 20 cia1 lt sh 9 y) .a d rring, ugs, if a and 48% ny10 , us pe ed rc in ent 70% (Figure 6). OnlyEmp 8 pe lo rcy eer nt C ad od ne tr di b pu re ti-o dn e d to uc H tible SA c oov r H erR aA ge ,* for Amo all 14 se ng Thr ovse iceW s. ith On Pr aivv eate rag-e Secto , pre-r d e Hdeal uctth ible coverage Sm arter deductibles accommodating services preventing the exacerbation of chronic conditions might be a natural Inhaled Corticosteroids 26% 61% 13% • Pre-deductible coverage was often added for health care services related to heart disease and diabetes care. Experiment for Translation in Diabetes (NEXT-D) Study. JAMA Internal Medicine, 177(3), 358-368. 74% Other (specific) 14% lieu o Key f d Fiending ductible s ................................ s; and other relevant ................................ questions. The next ................................ section provides more................................ information on HSA-e ...................... ligible health 9 coinsurance for specialty drugs. Coverage and Employee-Only Coverage, 2016–2020 was added for five services, and the me39% dian number of services added was six. evolution of health plans. Value-based reimbursement promot es the delivery of evidence-based, high-quality care that Two E-m thir plod ye s a r Cd od ne trd ib u ptr ee s -td oe H dS uc Atible coverage for blood61% pressure monitors and insulin/glucose lowering agents, 61 40% FronstS in, P eled coi:10.1 tia ve S ul eroto and 00 ni M. n Re 1/jC a up m hr taa is kint et In op e hr ihe bnm itorr se Roe (d S.201 SRIs buc )6.84 k, "Ma 11 naging Use of Health Care Services After People Satisfy Their 25% 63% 11% plans, the impact of deductibles on Othe us re (n of on-rhe espo alt nsh ca ive) re serv 1% ices, and the 2019 guidance. The section following contains 70% Cost Sharing for Pre-Deductible Coverage...........................................................................................................11 60% Yes 88% 91% 79% encourages use of — rather than creating barriers to —high-value services. Interventions that improve patient- percent added coverage for glucometers, and 54 percent added coverage for beta blockers. Health care Financial Impact of Expanded Drug Coverage Ame Dn edi duc nt g ible IR : S W S ha af t e D H o a Cr op bor aym to ent Is a nclu nd de Coins Chro uran nic ce Dis Do?e "a EsB eRI Me Iss di ue c a Btrio iefns , no. 519 (Employee Benefit 64% information on the data and methods. We then present the findings and our conclusions. Angiotensin Converting Enzyme (ACE) Inhibitors 25% 0% 5% 10% 59% 15% 20% 25% 16% 30% No 10% 8% 18% 35% cent Fu etrur ed e out Cha cnge omess w ................................ hile maintaining affor ................................ dability may be found ................................ in the form of a clin................................ ically nuanced HSA-eligib ................ le health 13 80 ser %vices least likely to have pre-deductible coverage include peak flow meters and INR testing (25 percent References Figure 4 Research Institute, November 2020). Don't know 1% 1% 3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 60% Source: Employee Benefit Research Institute survey. plan th Ima ptle b m ee ttnt era m tion o eets f p wr or e- kd ee rs’ duc clin tible ica l a drug nd c fin ov ae nc raia gl ne e caen ch ds. ange plan-paid expenditures in three respects: Figure 14 shows expected changes in plan- and member-paid expenses between the baseline HSA-eligible health 50%each). Percentage of Employers That Expanded Pre-Deductible Coverage Agr The awaC l,A R., RES Ma Ac zur t ................................ enko, O., & Menachem ................................ i, N. (2017, October)................................ . High-Deductible Hea................................ lth Plans Reduce Healt ................. h Care Cost 13 30% Zero Cost HDH to Em Pp O lonl yey e Emplo HDH yee Pa P W ysi Co th E pmp ay loyer Co Empntri loye be uti Pa on ys to Co HS insA ura or HRA nce Some Other Amount 70% Fronst pla in, P n and aIul nda , un HSA M. stryChr-is eligib tophe le rhe Roe altb h p ucla k, n w Jason ith eBxpa uxba nde um d , darnd ug A cov . Ma era rk g e Fe , a ndr s w icekll , a , s im "Do pPaecop t ole n p Choose lan ac tW uais ria ely l vA aft lue er. 52% in HSA-Eligible Health Plans for Preventive Services Allowed Under Background And Utilization, Including Use Of Needed Preventive Services. Health Affairs, 36(10), 1762-1768. Employers That Did Not Add Pre-Deductible Coverage .........................................................................................13 (a) Volume: Lower patient out-of-pocket costs tends to increase utilization. An estimate of enrollees’ Manufacturing 17% 17% 18% Not •e s Nearly two-thirds (64 percent) of employers covered six or fewer of the 14 health care services allowed per 25% E50 st% im Sa atte isd fy inc ing re H ae ses alth P in p larn D emie um duc s a tible nd s? de E dv uc ide tible nces ne From ed etd he t o Use kee of p p Lla ow n -e Va xpe lue ndit Heur alt eh C s ne aut rer a Se l a rv re ic e as. ls" o E pB re RI sent Isseue d. Source: Employee Benefit Research Institute survey IRS Rule 2 . 019-45 48% Until I 40 25 RS N % %doi:10.1 otice 2019 377/hlt -45 ha wff a.2 s 01 rele 7.06 ased 10 on July 17, 2019, when it came to providing pre-deductible coverage of health Professional, scientific, or technical services 13% 14% 11% responsiveness to changes in price (i.e., elasticity of dem and) was used to determine increases in utilization and 57.7% The CAR 60 IRS N % ES Ac otic t e 2019-45. Only 8 percent added pre-deductible coverage for all 14 services. C onclusion ................................................................ .......................................................................................... 16 The modest increase in plan expenditures were split between increases in medication utilization and shifting Brief, no. 516 (Employee Benefit Research Institute, October 2020). 55.3% Health care or social assistance (hospitals, non- 11% 11% 13% care services in HSA-eligible health plans, employers were guided by the Internal Revenue Service (IRS) safe harbor 20% 53.6% 1 related expenditures. 32% 53.0% The In 2020, Corona 57. vir 7 us pe A rcid, ent Re of lie ind f, iv and idua Els c ow nom ith he ic a Se lth cur coit vy e ra (C gA eR thr ES) oug Ac h t a of priv 20a 2te 0 -p sr eov cto ide r ed s ta ec bo linom shme ic nt re wlie erf r e in ela at e pd la n to w the ith a C OVID- allocation of drug exp De on' ndit t k ur now es. IfC overing all 57 targeted classes on a pre-deductible basis with $5/$40/10 Brot-Goldbergi, nZ. C suran ., ce C h ha eand lth rse a, rv A ice ., s) Handel, B. R., and Kolstad, J. T. (2017, October). What Does a Deductible Do? The 20% Refere 40 nc %es .......................................................................................................................................................... 17 section 223(c)(2)(C) of the Internal Revenue Code (IRC). Employers could only provide coverage of the following • The percentage of employers that eliminated cost sharing for the pre-deductible services ranged from a low of 30% 50% Fronstin, P., Sepulve47.1% da, M. J., and Roebuck, M. C. (2013, December). Medication Utiliz15 ation and Adherence in a Health 19 ded p uc ande tiblem tha ic.t Fme I in t ainc t nce the lude , i nd su C e dd rov a a uc n erage W ce p tib r,ov le or is re re ion th a qluire as est a a me tte a nts llow toe d b eH H SA SA -e eligib ligible le .he Haoltw h p eve la 10% r, ns w t eo dp or ov noide t kno 11% pr w e -ho dew d uc ma tible ny o c f ov the e 8% s ra eg eenr fo oll r ees percI em ntp c aost ct of shC aost ring -Sha would ring ron equir Heea lt ah C n inc arre e a Pse ric e in p s, Qua remnt ium itie of s, a lend ss tSp hae n 2 nding pe rD ce ynt na.m ics. The Quarterly Journal of (b) Shift: Independent of volume effects, lower consumer cost sharing shifts the cost burden from the patient to services prior to satisfaction of the plan deductible: Notes ................................ 25 peE rc de unt ca tt io o na al se high rvi................................ ce of s (40 aca p de erm ce ic nt. Betwe................................ en nearly one-half and 10% ................................ two-thirds req9% uire a c ................................ opayment 13% from . 19 Expanded, 6% Savings Account-Eligible Plan. American Journal of Managed Care, 19(12), e400-e407. 25.7% were in an HSA-eligible health plan. Some were enrolled in a health plan with a health reimbursement arrangement (HRA). telehe 15 a% lth services. This provision is temporary, ending Dec. 31, 2021. Nearly all (96 percent) employers adopted pre- 24.4% Economics, 132(3), 1261-1318. Retrieved from http://www.nber.org/papers/w21632.pdf the plan. The institup tiroior ns/ u an na ively rsi sits a ies)ccounted for changes in the 2 4a .8p %portionment of expenditures. 30% 40 em % ployees, depending on the he 2a 5.9 lt% h care service. OtheP rs r ov we iding re in p he rea-lth ded puc lans tible th act ov me ert athe ge for ded ov uce tib r le 50 re dqruire ug c me lass nt eb s us ut ma ed yt o hatv re ea no t ct om mem t on othe chr r re onic quire cond ment itions s, su c w h ould as the low er deductible coverage for telehealth services. Three-quarters (7 6 percent) prefer to make the provision permanent, while 20% • PreveInt nfo iv rm e aser tionv (ic ine cl s r ude incgom pum blie sh nde ing,d by the U.S. Preventive Service9% s Task Force 11% (USPSTF), the Advis 3% ory 22.4% Fronstin, P., Sepúlveda, M.-J., and Roebuck, M. C. (2013, June). Consumer-Directed Health Plans Reduce The Long- 10% restrictio consu n o m n ep r re out ve-ntiv of-p eoc sekrv etic c es. os ts and increase utilization of essential medications. Such a change would lead to a Bundorf, M. K. (2012, October). Consumer-Directed Health Plans: Do They Deliver? Research Synthesis Report No. 24. only 20 percent te le w co ould mm ulik nica e ttihe ons, p b rov roais dion to r casting, e am nda iin t nfore mm atp ioor n ary (Figure 11). 8% For t(he c) Off six c sets lass : e In som s of pre e sc clin ripti icaon l scderna ugs, rios, g emp re loy ate errs som utiliza ettion o imes im f hig pose h-va dlue othe the r r ra ep sti 7% e ric s c tions a an des w cree all. se spe For nding exam p on le, ot so he mre Committee on Immunization Practices (ACIP), the Health Resources and Services Administration's (HRSA's) • Between 57 percent and 69 percent provide pre-deductible coverage for both brand and generic drugs in the Figures 30 Te %rm Use Of Outpatient Physician Visits And Prescription Drugs. Health Affairs, 32(6), 1126-1134. 20% technology) small increase in plan actuarial value and would require a small increase in premium or deductible for payers Retrieved from http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf402405 2 e m Sepeser loy Inte e vr ic Bs a rna r eight s (e. d l op R e Fu g tve ., etd nu ur hospit p D e e rid e P S-r e N doje rv a e ot liz d ic c uc Ex e a t,, tt ion 2004 ible pand and s) c . H .ov The RSA era p a grnd e ior only ta he na for Ily ns si tg s d iteut nid e er not ic of dMe ra ugs. cd cic ount ine Mo ( for rIe OM) c spe these com ific offs a m lly itet , tes. b ee on twew eo n m 57 en' ps c erc lin ent ica a l p nd re69 ventive 10% specified drug classes. 5% Retail trade 9% 9% 8% 6% Employers That Did Not Add Pre-Deductible Coverage interested in keeping the financial impact of the benefit change cost neutral. In addition to "blunt" approaches Figure 1, Percentage of Persons Enrolled in a High-Deductible Health Plan (HDHP), by Employer Contribution to HSA or Coverage, 18% percent p ser rov vide icC eo s (r p nst ree r- uq d ct uir e io dn e uc d or t b ible uy til iSe t ie cs ov ction era g 27 e 13 only of for the g P ea ne tie ric nts (F Prot igur ece ti on 8).a nd 6% Affordable Care 7% Act of 2010 (ACA 5% ) and IRS Goldman, D. P., Joyce, G. F., and Zheng, Y. (2007, July 4). Prescription Drug Cost Sharing: Associations With 3 20% B uxba See http um, s:J. //w Dw ., w M .irs afi, .go J. v/N p., uba/nd irs- Fe dro ndr p/nic -19 k, -A 45. . M. pdf( 2017, November). Tackling Low-Value Care: A New “Top Five” for Eighteen percent of employers did not add pre-deductible coverage as a result of IRS Rule 2019-45. However, most such as increasing premiums for all beneficiaries or raising deductibles on all services, plan sponsors could 10% HRA, EBRI Is Among sue Thos Bri 6ef e is re W git ist h P ered riv ina tt he e -U Se .Sc . t Por ate n H t e an adlt Tr h C adov eme arrka O gfe fi ca end . ISS E N m : 0 p8loy 87 –e 1e 3- 7Only X/90 0C 88 ov 7 –e 1r 3a 7g Xe /9, 020 $ .5 16 0+– .52020 0 ............. 5 There is alread W yh a oln a esap lep te ra tit de e, for tran sp adod ring tatio m n o or r w ea se reh rv oic usi en s, a g s evidenced by The 5%Chronic Dise 5% ase Management 5% Act, which • Most employers would add pre-deductible coverage for additional health care services if allowed by law. 0%Notice 2013-57). 32.0% Medication and Medical Utilization and Spending and Health. JAMA, 61-6 30.9% 9. doi:10.1001/jama.298.1.61 28.8% 0% either pla Pn to d urchao ser so Ala cttion. er (32 He a plt eh Af rcent fa ) iror s B 27.1% alog re e . xplor Retrie ing ve d w h fre om the r to do so (61 percent) (Figure 12). Most have not yet pursue a rP aung blie c 1 a to of d3 m m inor iste ra nua tion nced cost 4 to -6reducing strategie 7 s t to o 9 create "he 4%adroom" 10 to 13 for 3% additional spending 14 5% on high- 4 © 2021, E24.7% mployee Benefit Research Institute –Education and Research Fund. All rights reserved. Employers offered several reasons for adding pre-deductible coverage for the 14 health care services allowed under IRS w S ae s r e e Fiint gure rod 13. uce 14 d in t in http he s U. :/S. /wC wong w.kff re .o ss rg a /r s r epe ocrt e-nt sely ction/ as Ma ehb y s20 -2020 21. - sThi ection s bipa -13r-te is mp an, loy be icra -p m ra ec rtice al le sg -a is lte larna tion w tiveould -site sp -of rov -cide are - Plan to Add Additional Preventive Care Currently Reviewing Whether We Will Add No Plans to Add Additional Coverage • Periodic health evaluations such as annual physicals and select preventive screenings not listed above 10% Figure 2, Chronic Disease Management Services in the Expanded Safe Harbor ........................................................... 6 Accommodation or food services 1% 1% 5% m ade the ht ctha ps:/ nge /ww du we.he to ae ltxp haeff ns air es.or : 90g p /do erc /1 ent 0.13 sa77 y t/h his blog pla20 ye17 d 1 at 11 le7.66 ast a 43 sm 55/ aful ll rlole / in the decision. But maintaining Coverage at a Later Date Additional Preventive Care Coverage value medications. For example, plans could steer patients to high-performing providers through centers of • Employers offered several reasons for adding pre-deductible coverage: for the sake of their employees (74 N and otic -pe ro 20 vid 19 er--45 netw . Tho orksse /. who made changes d 7 id so primarily for the sake of their employees, but many had business I Hnt SA er -na eligib l Re le v S e he ou nue ra clt e: h p S Ee mrpl la voy ic ns ee e . a B(d en 20 def it04 iiona t Res ). ea P l fle a rcrhtxibilit Ins III ti tut - y e A std urv o mp ey ini r.ov stide rativ pe re , -Pdre oc de uc dtuible ral, caov nd erMis age c efor lla ne seous, N rvices t ot ha ice t p 20 re04 ve-nt 23. the Re trieved 0%(optional, per IRS Notice 2004-23). Arts, entertainment, or recreation 1% 1% - fairness in benefit offerings played a role for many as well (76 percent). Only 6 percent have no plans to add pre- excellence programs or otherwise offer incentives for use of high-value sites of service. Plans could also target Figure 3, pFi errT c m o D e nt C o Ri ha ), gh e ra m t by cp te O loy ris ur E e tic e mp sr e l................................ oy te ee nt sion (64 Ep mp er loy ce ee nt Rete ), ................................ e nti m on ployee attrac Etmp ion (52 loyee ................................ A ttp ra ecrtc ion ent), and Aa ss a a Lo ................................ long ng-Term -teCos rmt- c Sost aving -saving . 8 considerations as well. Three-quarters (74 percent) reported that it was the right thing to do (Figure 9). 8Two-thirds exacerbaSe tion o pteA m fd b c m hr ein ronic ist 15 ra, t i20 c vond e 21 or it su , ions fr pom po. r t ht setrp vis:/ ces/www.irs.gov/pub/irs-drop/n-04 1% -23.pdf 0.4% 2% 5 • Ob 0%e Ssi outry ce: w Ee might ployee -loss Ben ef pir t og Res rea am rcs a h Insnd titutt e ob surv ac ey c.o cessation programs (option, per IRS Notice 2004-23). C ha See ndr http a, sA :., //w Gw rube w.ar hip , J., .org an /w d p Mc -co Knte nigh nt/ t, up R. loa (20 ds10 /20210 , Ma9 rc -h) AH. IP P_H atie DH ntP C -S ost urve -Sha y-vr03. ing pa dnd f. Hospitalization O Meff asset ures in the Elderly. deductible coverage. expenditures dev 20 ot 16 ed to specific low- 20 va 17 lue clinical service 20 s su 18 ch as non-recom 20m 19ended screenings, unne 2020 eded measu Ar ge ri cu (48 ltu rp e,e fr ocre est ntr) y. , fishing, hunting, or mining 1% 1% 2% reported that they added such coverage for employee retention, while one-half reported that they added it for • Drugs Sourct e: aE km en b ployee y a Bsy enef m it p Res tom eaa rcthic Ins indiv titute idua survey ls . to prevent the manifestation of disease (optional, per IRS Notice Figure 4, Percentage of Employers That Expanded Pre-Deductible Coverage in HSA-Eligible Health Plans for Preventive Expanded American Economic Review, 100(1), 192-213. doi:10.1257/aer.100.1.193 16 6 Management of companies and enterprises 1% 0.4% 2% Interim naal Re ging, venue wast S ee ful rv ic pe re . -(su 20 r04 gic)a . l te Par st t ing, III. a And dmm iniuc str h mor ative, eP . roc edural, and Miscellaneous, Notice 2004-50. Retrieved See Kaiser Family Foundation (2015) and Internal Revenue Service (2013). employee attraction (52 percent) and as a long-term cost-saving measure (48 percent). 9 2004-50). Coverage, 76% Services Allowed Under IRS Rule 2019-45 ................................................................................................. 9 Waste management or remediation services 0.3% 0.4% - * HSA = health savings account, HRA = health reimbursement arrangement. • Nearly all (96 percent) employers adopted pre-deductible coverage for telehealth services under the September 15, 2021, from https://www.irs.gov/irb/2004-33_IRB#NOT-2004-50 Data and Methods 7 Source: Medical Expenditure Panel Survey - Insurance Component (MEPS-IC). See Internal R Oe th ve ernu (pe le a Sse erv sp ice eci (f2004) y) . 1% 1% 2% Coronavirus Aid, Relief, and Economic Security (CARES) Act. Three-quarters (76 percent) prefer to make the Source: Employee Benefit Research Institute survey. Figure 5, Preventive Care Measures Covered on a Pre-Deductible Basis as a Result of IRS Notice 2019-45 ................. 10 Source: Employee Benefit Research Institute survey. 8 See Inte prna rovl is Rion p evenu er em Sa ene rvic nt e, (w 2004) hile .o nly 20 percent would like the provision to remain temporary. e e e e e e e e e e e e e e e e e e eb b b b b b b b b b b b b b b b b b br r r r r r r r r r r r r r r r r r ri. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i.o o o o o o o o o o o o o o o o o o or r r r r r r r r r r r r r r r r r rg g g g g g g g g g g g g g g g g g g IIIIIIIIIIIIIIIIIIIs s s s s s s s s s s s s s s s s s ss s s s s s s s s s s s s s s s s s su u u u u u u u u u u u u u u u u u ue e e e e e e e e e e e e e e e e e e B B B B B B B B B B B B B B B B B B Br r r r r r r r r r r r r r r r r r rief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief A re • • • • • • • • • • • • • • • • • • • s e O O O O O O O O O O O O O O O O O O Oa c c c c c c c c c c c c c c c c c c crtttttttttttttttttttc o o o o o o o o o o o o o o o o o o oh b b b b b b b b b b b b b b b b b b b e e e e e e e e e e e e e e e e e e e re r r r r r r r r r r r r r r r r r r r p 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1o 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4r,,,,,,,,,,,,,,,,,,,t 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 fr0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 m 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 t h • • • • • • • • • • • • • • • • • • • e N N N N N N N N N N N N N N N N N N N E o o o o o o o o o o o o o o o o o o o...................B 542 542 542 542 542 542 542 542 542 542 542 542 542 542 542 542 542 542 542 RI E ducation and R esearch Fund © 2021 Employee Benefit Research Institute 13 20 11 12 17 14 10 16 18 15 19 7 4 9 3 5 8 2 6