IRS Notice 2019-45 allows HSA-eligible health plans the flexibility to cover 14 drug classes and other health services used to prevent the exacerbation of chronic conditions prior to meeting the plan deductible. Research examined claims data to quantify the effect of expanding pre-deductible coverage on medication adherence among enrollees with certain chronic conditions. This week’s Fast Fact reviews the key findings of this research as all HSA-eligible health plans are now able to adopt a more flexible benefit design offering more protection for certain medical services through a value-based insurance design (V-BID) plan structure.
Similarly, it is not a surprise that the magnitude of the effects is small, as the majority of employers substituted Key Findings From the Study: copa yments and/or coinsurance for deductibles when they expanded pre-deductible coverage. Whether employers moved • fB rom y 2022, t deduct her ible was es to no co evidenc st sh e of ari a ng w rebha ound tsoeve in m r var edica ied by tion adhe the di renc ffere. W ent m e f ed oiund cations. that t Sta he p tins we ercent rage e m o os ft likely to b enr e c olov lees er w ed i ith d n fu iab ll, et wes ith 40 usin per g insu cen lti of n in ecr mea plse oye d 4 pe rs repor rcen titng t age hat poi t nh tey di s, and d no the p t rer equi cent re a age ny co of en st rsha ollee ring s wi as a th July 18, 2024, #509 result ofhea the I rt d Ri S not sease o ice, wh r diabe ich tem s us ay ing st explai atn w ins hy s incrtea atse ins d b wy er 1 pe e onre of cen ttag hee po two int m. ed Wh icat ile ions the m tha agni t exp tude erienc of ed a the ef fect rebound i mn ay adhe seer m en sce m. I aln co l, it int s i rm ast po , onl rtan y one t to r-equa mem rter be o r t f e hat m w ployer hen m s e ed xem icapt tion ad ed AC her E in enc hi e bi fe to llr s, SSR as a res Is, o ult of r i nh the aled corticostier nto roduc ids frto ion o m any c f an HS ost sh A- ar eliing. gibl e health plan, the magnitude of the declines was relatively small as well. Medication Adherence Improved After Furthermore, the implied out-of-pocket elasticities of demand are closely aligned with previously The fact that we did not see a change in adherence for most of the medications examined is not surprising. Since published estimates. 2021 was the Empl first year oyers that many em A pl d oy ded Pre ers expanded pr -De e-dedu du ctibl ctible e coverage, Cover it may take t age in ime for en rollees to learn that their health plan has changed coverage for certain preventive services. They may not be aware of the • The lack of a large increase in medication adherence may also be due to the fact that adherence rates were Response to Increased IRS Flexibility change in plan design, despite employers’ best efforts to inform enrollees of a plan design change that is already relatively high, averaging 77 percent to 89 percent, with the exception of inhaled corticosteroids, considered an improvement in benefits. which are often used as a rescue medication and not necessarily filled in a way that would suggest that an IRS Notice 2019-45 allows health savings account (HSA)–eligible health plans the flexibility to cover 14 enrollee was adherent. m Abou edica t E tions a BRI:nd se The E rvm ice ps us loyee ed t Bo p ene rf ev it R ent es tea he e rch I xace nsr ti bat tutie i on of s a pr chr iva on te, ic nonpa conditritons isan, pr and nonp ior to meret of ii ng t re the seapl rch an institute deduc based tiin blWa e. A sh 2 ing 021 E ton, D mpl .C oy ., t ee ha B t f ene ocus fit R es on h esearea ch I lth, nssa titv ut ings, r e (EBet RiIr)e su me rvey o nt, and e f em cono ploy m er ic s s ce ol cur lec itty ed isisue nfor s. EB matiR on o I does n not thei l robby response and do to es the 2 no019 g t take pol uidan icy po ce and sitifo ons und t . Th hat e work mFigure an of y em EB p 2R loy I ier s s madde ade pos d prsi eb -ded le by f uctiund ble c ing ovfer ro am ge a its m s a r em esbe ultr s of the IRS notice. A recentPercent EBRI repor age t bas Poin ed on t Ch cl an aim ge s d in at a Med from icat about ion 2 m Adhe illiren on H ce, SA2022 -eligible health plan and sponsors, which include a broad range of public and private organizations. For more information, visit w enr wo w ll.ebr 5% ees iconf .org.i rmed the expected findings from the 2021 EBRI survey: As a result of fewer enrollees in HSA- eligible health plans having deductibles for services impacted by the IRS notice, use of health care services A incr Tea han sed f k Y or ou som to e of Our Fu these nder serv s: icThi es. s study was conducted through the EBRI Center for Research on Health 4%*** 4% B enefits Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, Johnson & Johnson, JP Morgan Chase, and PhRMA. IRS Notice 2019-45 3% 3% ### The U.S. Department of Treasury issued guidance on July 17, 2019, via IRS Notice 2019-45 to further increase the flexibility of HSA-eligible health plans to cover specific low-cost preventive services to 1 preve nt the exacerbation of chronic conditions on a pre-deductible basis. 2% Figure 1 1%* Chronic Disease Management Services in the Expanded Safe Harbor 1% 1% 1% Preventive Care Service For Individuals Diagnosed With Congestive heart failure, diabetes, and/or coronary artery 0% Angiotensin-converting enzyme (ACE) inhibitors 0% disease Antiresorptive therapy Osteoporosis and/or osteopenia 0% Beta blockers Congestive heart failure and/or coronary artery disease Blood pressure monitor Hypertension I-n 1% haled corticosteroids Asthma -1% Insulin and other glucose-lowering agents Diabetes Retinopathy screening Diabetes P -2% eak flow meter Asthma Antiresportive ACE Inhibitors Beta Blockers Inhaled Glucose-Lowering Insulins SSRIs Statins Gluc ometer Diabetes Therapy Corticosteroids Agents Hemoglobin A1c testing Diabetes Note: Statistical significance denoted as follows: *** p<0.01; ** p<0.05; * p<0.10 International normalized ratio (INR) testing Liver disease and/or bleeding disorders Low-density lipoprotein (LDL) testing Heart disease Selective serotonin reuptake inhibitors (SSRIs) Depression Our f S itndi atinngs s may be influenced by the ways in which empl H oye eartr s dii sm eapl see m ane dnt /ore d ch diabeange tes s in response to the IRS notice . First, while the overall employer response to the notice seemed overwhelming, with three-quarters Source: https://vbidcenter.org/initiatives/hsa-high-deductible-health-plans-2/ reporting that they expanded pre-deductible coverage for at least one of the 14 services, we would expect the With IRS Notice 2019-45 in place, all HSA-eligible health plans are now able to adopt a more flexible largest impact on medication adherence for diabetes medications and beta blockers, as 66 percent and 54 percent benefit design offering more protection for certain medical services through a value-based insurance design added pre-deductible coverage for those services, respectively. Less than one-half added pre-deductible coverage (V-BID) plan structure. for inhaled corticosteroids (43 percent), angiotensin-converting enzyme (ACE) inhibitors (39 percent), statins (38 percent), selective serotonin reuptake inhibitors (SSRIs) (35 percent), and anti-resorptive therapy (29 percent). 1 See https://www.irs.gov/pub/irs-drop/n-19-45.pdf. EBRI on Twitter @EBRI or twitter.com/EBRI LinkedIn: linkedin.com/company/employee-benefit-research-institute E EB BR RI I on on T Twitt witte er r: : @ @E EB BR RI I o or r twit twitte ter r..c com/ om/E EB BR RI I L LinkedI inkedIn: n: li linke nkedin. din.c com om/compa /company ny/e /empl mploye oyee e- -be bene nef fit it- -r re es se ea ar rc ch h- -ins insti titu tute te © 2024, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 2 3