The Impact of Expanding Pre-Deductible Coverage in HSA-Eligible Health Plans on Employee Choice of Health Plan and Cost Sharing

IRS Notice 2019-45 allows health savings account (HSA)-eligible health plans the flexibility to cover 14 medications and other health services used to prevent the exacerbation of chronic conditions prior to meeting the plan deductible. There is currently no research on the impact of expanding pre-deductible coverage on plan members. In this Issue Brief, we use claims data to quantify the effect of expanding pre-deductible coverage on enrollee choice of health plan and cost sharing.

Key Findings:

Cost sharing shifted from deductibles to copayments and coinsurance among enrollees in HSA-eligible health plans for a number of services impacted by IRS Notice 2019-45. The same shift was not observed for enrollees in other types of health plans.
IRS Notice 2019-45 appears to have had a negligible impact on overall cost sharing as a percentage of total spending on a number of services impacted by the notice. This may be due to the fact that employers were more likely to change cost sharing instead of eliminating it.
Enrollment in HSA-eligible health plans among individuals with health conditions impacted by the IRS notice does not appear to have changed, as it was already trending in the direction of higher enrollment among individuals with health conditions prior to the issue of the notice.

Employers would add additional services if allowed by the IRS. There is also bipartisan, bicameral legislation that has been introduced in the U.S. Congress that would provide additional flexibility to extend pre-deductible coverage to services that manage chronic conditions. Employers and policymakers have an appetite for more flexible plan designs or "smarter" deductibles, because rising health care spending has created serious fiscal challenges.

This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, ICUBA, JP Morgan Chase, Pfizer, and PhRMA.

Figure 2 Chronic Disease Management Services in the Expanded Safe Harbor Figure 5 Figure 9 F Fiig gu ur re e 7 8 Fi gure 8, Cost SharPercent ing by Typ ag e e of Ch H ea an lth C gea rin e Se Enro rvice llees , Among With Ot he Healt r Hea h lth P Cola nd n Enr ition olle , e by s ................................ Type of ...... 13 c A I I S A Yn th nt ond om e cppendi c te , or re w it e na d ion r e ing second e l Re c sea Sur s, v annot tv o rx v e c a e N nue h ha cy p ot c , c a ina ic onc 20 r tS s e tof e 14 ions e 20 lude rxa v.tic he 19 N m , e e a . - ine ta w 45 ha nd 20 n d a Y ,t13 ly b or tthow he he ir si . kts, , " h cont P lis IN RS e r we Y t e xp : v of n e The a st rnt ot nding ol. p udie riv ic ee C e P v om la e d w he nt n p a tr he a m iv s r sponsor e lte onw - h se d e cser e sponsi ha de uc nge r va v ic s lt ic te ible h Fund. e ha s in b s t s r lev ha c e e for c ov q tost b ui e c e ta r A e he r e a n b sh n cd g c p highe e e aund e r ss rohib ting o ceov e d m rr in t it e Se e inc P e rd e ublic d p ic he d r ta fe e rp se a tom m ions r se e H b r-e e e d in im a spe r e t lt o d 15 p e h Se uc nr osin c m , ttollm iv a 20 ible na re g v 21 ic p g a e la w e e ny . nt ill ns A c hr in HSA for cb tae onic m sect m rong e of v - ion 2713 c ie e ond c ligib w tost heose it d le ion sh on he w a s a ra it ing nd ha a h lts h C Pao ul Fr ngr ons es tin sional is DirectE or ff of or Htes a lt th oB Fur enefit the s Re rsea Ex rcpand h at th eP Er m ep-loy Deduc ee Bene tib fit le Re sea Co rc vh I er ns age titut e (EBRI). Eden The Impact of Per Ex cent paage ndin of Plan g Pr Enrollees e-DedPay ucing tibl Dedu e Co ctibv le e forrage in HSA- Preventive Care Service For Individuals Diagnosed With 5 Cos C t o Ss hta S rih na gr ib ny g T by yp T ey o pfe H o efa H lte ha C lta hr C e a Sre er v Sie cr e v, iA ce m , o An m go H nS g A O -t E hle ig ri b Hle ea H lte ha P ltlh a n P lE an nr E oln le ro es llees Health Plan, 2020–2021 See Kaiser Family Foundation (2015) and Internal Revenue Service (2013). ( p t p bhe i.e la e er ens se ., iod n conduc da a ic em ff d b p ht e ong uc a r cte si tp te v ible s. s:/ t d e e e nt d nr he I/ww s n fa iv , a olle a s w e clt op w c c h condit e ta .c e s w , a rll. y e tom he m fo it One e m h th rg nt io uida p on s, nw ur su e s fr or p c re nc ose e h st a le c om lt eoins v hf s of spe udy w a und.o 20 nt ur c 18 H he ifi ae nc c a a a rta s g o lt lt e lly /s c h condit h Sa )20 ond it on st e 21 a s/ v uc p t ings Ac e d t as t o te re ions tfa t d ic ha e ult ipa s bt t.e c /f for w t Int ount he n th ile he s r e sp t/do I e he e s. e RS c r" te iod r hr civ A um N tc e he ing ic ot c ee e - ic rI ss y nt e tRS noti e e he v e s/ aie 20 d rse _ w p Se __ 19 eser is rp m - c iod 45 te ee e v xp m le d ic w p ia e d e b ra s c _f e ior to .s r tr e ile 15 d a teo s_ le t, co tha a p 20 he se oc ub ng 21 d c rlic e ur e . a la e nd in c ta aions p se e post xa rof oxim _is m sh tsu he ine a a e rtI _br d ing e RS ly 57 . ie e W f_ d ve re 20 ug r y Volkov is a Health Research Associate at EBRI. This Issue Brief was written with assistance from the Institute’s Health Care Service, by Type of Health Plan Fi Eli gurg e 9, ibl Pere ce Hea ntage of lt Plah n Pl Enrolle aen s P sa on ying D Em eductible ploy for He eae lth C Cho are Seic rvice e, of by Ty Hea pe of Helt alth h P la Plan n .................. and 14 Congestive heart failure, diabetes, and/or coronary artery Building on the momentum of Executive Order 13877 and IRS Notice 2019-45, Sens. John Thune (R-SD) and Angiotensin-converting enzyme (ACE) inhibitors fiv c spe nla ot e ss ic c tifi e e o s us ,c 10 a the lly ht 15 e y t _m d e p fo p a e s:/ tcrr o a us s. c/ww y e t _ r e nt For e 18 da a w t on g 17 p .ir 11 ea _ c of s.go t c os ie collin hr nt p t- la v onic s a s/pub n e ha s_nd p r nr ing c r/i ond ob e olle rm sle c-ha p id e m tloy ions rs w op nge _of_ e/n it r ( s s h a HS unde - VB 13 a for A lik I -- he E D 57 e si lr i gi , ins a H x bl .p 10 lt e of eh condit ur d a Hea lt f. y ta h n.d e he nc la thr P e 14 s m _ib.p lan .) ion im c .a la I ytd ss b found f. Oe e p the s aa c rof tlong Heal ed m tha th e b d t y t Pim ic lc an tov he a et ion e t I o rRS ing w aa n n ia d tot ll t for ser iche e v su w se icc a eh co s a s drspe ug lrv e e c c ar ifi la d ay e ss g d e te r a e s p ds nding ecris e- ions up t, o 6 research and editorial staffs. Any views expressed in this report are those of the author and should not be ascribed HSA Plan Enrollees 2018 HSA Plan Enrollees 2021 disO ea ths ee r Plan Enrollees 2018 Other Plan Enrollees 2021 See https://www.irs.gov/pub/irs-drop/n-04-50.pdf. Appendix Figure 1 On Co Ses ptt e Sha mber 7, 2022 ring , Jud ge Reed O’Connor of the U.S. District Court for the Northern District of Texas found a key Tom 30% Carper (D-DE) introduced the Chronic Disease Management Act of 2019 in the Senate (S. 1948), followed Appe60 ndix % Figure 1, Statutory HSA Limits, 2004–2023 ............................................................................................. 17 d p a bnd e r ee d m sc uc ita r tipti d w ible ea on s t g iv w re d e itn th rnding h a ugs e c a om p n fa adc st b e ser ina e of r v tin ion o ic ree H sea s t SA f c ha r-c e op h o tligib caould n p ym le e lhe a nt now n d a s a lte h p nd si be gla n c coins ns ov and e(r4 p ur em d ae e nc p d rrc ic e e e a -nt w d l innov e oul )d tuc ha d tn in inc ible ation. re ot d aue se he Ther r t p orhe e e tm he aalt ium r h p e IRS a s b la lrn e ns y ot a d 1.7 p ic (y1 p e e . xa The e erm rcce p ent m nt lee ) s of .. d Mor So icaser ,t e ion it v ris e ic sc e e as nt nd ly, to the officers, trustees, or other sponsors of EBRI, Employee Benefit Research Institute-Education and Research Antiresorptive therapy Osteoporosis and/or osteopenia 28% 7 July 27, 2023 • No. 587 SSRIs for Depression Insulin & Other Glucose-Lowering Agents C p K a a ong Sr is ete eof rrthe e Fa ss the iona m lite ily pra r l B eFounda ture ve udg nt re iv ev e ttie ion. Offi ser wsv cin 20 ic e. eBund 15 20 pr . 12 ov Por. is rf eOffs ion unc v(e 2012) nteiv tS teing t onst a a Se nd tu E rv tiff Ag to ic u er e tc ry iona s C a t s of w Ha ov S l. l, A P e M Sp r r L e a ee z d sc im ure c ifi b riipti y tc nko, s a P,on lly r2 iv, 0 a a D t0 nd the r e 4 ug – H Me d 2 ee Use 0 a na c2 lt ish P 3 c ion o he on la mi Me ns n ( 2017) d B unde irca aid rew r ’a s Sp t ood she w e e A M llnding ff a a or na s d re g a s e b for e m le a rc eM C nt h a e rd in I eic nc A Brot a.c l tv.. - by the introduction of the companion bill in the House of Representatives (H.R. 3709) by Reps. Earl Blumenauer ser a p tha n EB oss v t ic ible m e RI a s y w tst ha m e udy e rte et the ins us the uli e trd e c n a nd r cit lae nd im b ria es t ot w for d h e ae e trp a n r gte 20 luc o -de 18 e ose st d im uc a-nd low a tible te 20 e tr he 21 c ing ov e w e a ff r ould g e ae c gnt te of s, ha tha e sele vt xpa e w oc c e nd tc riv e ur ing e om r ser e d p it rot t in t e e- onin r dd he e frd om uc ae bt upta senc ible Not ic k e ce e ov 54% o 20 inh f I er19 RS a ibit g- e45. n or b ot s e ic y For (ond SSRI e, a e s e xa IsRS N )m , nr s p ollm tle a ot t, ins ic te he ent , 20 b n w eot 19 taas ic -e SSRIs for Depression Insulin & Other Glucose-Lowering Agents Fu B nd eta( E blB oRI cke -E rsRF), or their staffs. Neither EBRI nor EBRI-C Eo RF lob ngestiv b eie hs o earr t ftaailk ue re s p anosit d/orions coro on naryspe artc eifi ryc d ip solic easy e proposals. Paul Fronstin, Ph.D., and Eden Volkov, Ph.D., Employee Benefit Research Institute for Diabetes Go Bec ldebre ra rg r,W Se e Cha fe a rsh v ric s t nd ingt eo s. ra t,on, C he H ong a p nd Dar C re e: tl, ss of Ka iona and is the e Kols r l B A Fa C udg ta m A d itly e ha (t 2017) Founda Offi t rec qe ;uir . Cha tht e ion. s c tnd p:/ ov ra A/ww c e ,c rG e arub ss g we.c e e d of b r, o.g Se p ar nd p e ov tv e e Mc /s m nt ib tKnig e iv es/ r e d 15 ser ht efa , (v 20 2010) ult ice 21 /f s w ile . ;ht s it C/c hout he tpbs:/ rne ofile /ww cw os s e /ta t w sh ta.k tl. aa ff c( rhm .or 2008) ing g et/h n o t;e s/ w Colli a4 hic lt37 hns - h th 41 , -e (D-OR) and Tom Reed (R-NY). This bipartisan, bicameral legislation would provide fH oSA r D -e ia ligib betle es health plans ide a b 45 lr loc e nt ta o kd ifi e116 y B re s ls a o t,r o e a d cnding nd ngio la prs ea ses stnt s e uin t ns ir rof e ein c sor m his m oe n p on d d it tiv o 2 ic ir v r 0e e e a1c r t8 tittons he ing ion. r2 a .e 0 p The nzy 2 y1 . m im e p(a Ac CtE on ) inh pribi em tor ium s ts of o p Hr ye e pxpa v ee rtnt ending n seio xa nc e prrb ea -d tions educ for tible indivi cove drua agls e d to iag 11 nosed 6 drug wit cla h sses EBRI invites comment on this research. Maximum Out-of- Per-Person 2018 2021 50% Rasmussen, Beutel, and Doty (2015) 24%; Fronstin and Roebuck (2019); Fronstin and Roebuck (2013); Fronstin and Roebuck U.S. 2 P 5r% evMe re ent for div ic m e a /f lOff Se acrt sets v-ic sh ee - s Ta 11 et/pr -29 ske -For v 1e 2.p nt ce iv d f. e (USP - serTF vic)e s — -c ov a g erroup ed-by the -p rA iv ga etnc e-y he for alt h H-e pa la ltns hc/. a re Research and Quality has been additiona 47% l flexibility to provide coverage for services that manage chronic conditions prior to meeting the plan 2018 2021 c re on lag te ed st In t h iv o ae le c he d hr conic a or rtti cfa o ds ilu is tee r rM a o eise i d n (s iC m m H uF m a)na , Dd e gia d eu m b ce te itb nt ele s, a me nd/o dicartM ions ca or xiona m in H um ry SA C ao r-t n e A e tligib rs rib y th u d m tile is o an ehe ase. alt h p Patla iens nt P s w is oc r kho e elta L teiv im ite he itlyr sm do anot ll, r arnging espond Catch fr -u om t po or 1.3 ha tv o e 76% 24% 80Th % e Impact of Expanding Pre-Dedu 23% ctible Cove 2r 01a 8ge 20 i 21n HSA- 45% 73% 23% 60(% 2020); Fronstin and Roebuck (2014); Fronstin and Roebuck (2016); Fronstin, Sepúlveda, and Roebuck (2013); Fronstin, a For Itut ishor bpot oss ize h se ible d b ts of y t ha the t r e tU. su heS. lt C sC ,OVI ong weD e r-e v 19 ss alua p to atnde e cd onv c m ha e ic ne nge im si p sn a c ov ce te e19 d r tt98 im he e — c a ha m ass nge ong igns a s in e enr olle rnr atollm ing es in HSA of ent “ A b”e -or te w ligi e “B eb n 2018 ”le . hea ltah nd pla 20 ns 21 b.ut In o alsur o used the 55% Contribution deductible. The bill was reintroduced in the Senate in January 2020 (S. 3200), April 2021 (S. 1424), and March Insulin and other glucose-lowering agents Diabetes a 4.7 p In a ntd rev o re cduc rese nt.r e t a ion ction to AC E inhibitors are usually switched to angiotensin receptor blockers (ARBs) to prevent the same 80% Suggested Citation: Fronstin, Paul, and Eden Volkov, “The Impact of Expanding Pre-Deductible Coverage in Figure 6 70% 71% Eli L Fr eonst e, Joy L g in, P ibl ., aul e Ma , Hea " ttC he an w ' C Lonsu . lt Mah c m ie Pl ejr eis wm sk a ' i, Slow n Shv s e ton he ta S. Ra Ra tEm e jof u, H W p eill aloy ilt ah B m H ee ne . Shr e fi4 t Cho 5 a C % nk ost , a Ind ncic re Na ite ses? ee of sh ," KE . Hea BCRI houd Isshr ue lt y 70% . Bh 20 rie Pl 13 f no.247 . "a Van lue -a Ban sed d 21% Sepúlveda, and Roebuc Indk iv i(d2013) ual ; Fron Fa sm tin, ilyRoebuc In kd , iBuxb vidualaum, and Fa m Fe ily ndrick (2020) Individ;u a Go l ldman, Fa Jm oy ilc ye, and ZheLng im i( t2007); 49% m com ethod paris olog on y g, roup healt of h condit the una ioff ns e cw te ed re e d nr eolle term es (t ined hose using in c ot lahe imrs d hea atlt ah . B pe lacns aus ) e to us sh eow of how healt th ca hese reout ser cv om icee s fe s wll in 202 ould ha0 a ve s 2023 (S. 655) and in the House of Representatives in May 2021 (HR. 3563), building on the IRS guidance and 40% Retinopathy screening Diabetes exacerbations. However, ARBs are not included in the list of 14 services in Notice 2019-45, and thus they cannot be 70% 50The % Me 40%dicare Prescription Drug, Improvement, and Modernization Act of 200 39% 3 (MMA) included a provision that created HSA-Eligible He Cao lts h P t S la hns ar on ingE a m sp a loy P ee er c Ce hoi ntca eg of e o Hfe T alt oh P talla Sn a pend nd C in ost g, b Sha y T ring yp,e ” o EB f R HIe Ia ss ltue h P Blra ie nf, no. 587 60% 40% 37% If this cour I (ns Em t ur d pe a loy c nc isee ion is up e D Be esi ne gn: Q fit he Re ld ua , sea e litm y rc pIh I loy mp ns e rr ov ts a ite um nd tee , nt he 20 a B 02 lt ut h p ). N o lan Cs c ostould Sav ings." impose H e som alth Af e for fam ir sof 32 c ost (7) :sh 12 ar51 ing -12 for 57 t. hese Trivedi, Moloo, and Mor (2010); Wharam et al. (2017); and Wharam et al. (2018). 2004 $1,000 $2,000 $2,600 $5,150 $5,000 $10,000 $500 lik a Co It re is ely su now 20 s tlt r %et of nde Sha poss the d ible in t COVI he r to ing D a e-b xa 19 senc m pine ae n d of te he m the ic im , Ip w RS int aec tsa of w etr he fe vew nt Ie RS ion. r en nr ot olle icee on s wp itla h he n ea nlt rolle h condit es. In th ionsis in 2 Iss02 ue0 (F Brie igur f, w ee 4) exa . Thi mine s w tahe s a im n pact prP ee va ious k flo w ve m rsi etons t er o further increase pre-deductible cove Ars atg he m a for chronic disease management. covered pre-deductible in HSA-eligible health plans. Similarly, serot 6onin 0% -norepinephrine reuptake inhibitors (SNRIs) may what( E am rep c loy om ee m 34% B only ene k fit now Ren a seas high rch Ins -d tit eu dt uc e, tible July he 27a, lt20 h p 2la 3)n . s (HDHPs). At the time, these plans had to have a deductible 35% 50p % reventivdeoi:10.1 servic37 es. Y 7/hlt et, ha em ff.2 ploy 012.09 ers m 02. ay continue to provide these services at no cost to members for at least a few 31% 40% 2005 1,000 2,000 2,600 5,150 5,000 10,000 32% 600 a 8 of rttifi he cia G not l c lucha ic om enge e on te, reonly nrollm oce cnt ur riing n HSA due -e tligib o the le fa heca t ltth p hatla us ns e, of withe h th Da ia ltb e h ca e k teesy r eq se uerst vic ion es ha s b 30% ed ing fall w ehe n. tW hehe r w n use e are of sehe eing alth ca morre e 31% b e S eaen http effe sc :/ tiv /w ew tw re .e ab tm ri.o ent rg /for doc p s/ ad te iefaul nts w t-so itur h d ce e/p fas retss -facts ion w /ffh-o 455 do -cnot ehc s 5 rh 0 ee % spond alth-2m to ar23. selep cd tiv f.e serotonin reuptake inhibitors of at least $1,000 for individual coverage and $2,000 for family coverage (see Appendix Figure 1). As will be discussed Fronstin, Paul, and A. Mark Fendrick, "Employer Uptak 17% e of Pre-Deductible Coverage for Preventive Services in HSA- Paul Fronstin, Ph.D., and Eden Volkov, Ph.D., Employe 30% e Benefit Research Institute 16% HSA-Eligible Health Plan 40r% easons, including: 30% 2006 1,050 2,100 2,700 5,450 5,250 10,525% 00 700 r ee nr bound olle H ees in HSA e m do g in 202 lobin- A e1, th ligib 1c tee le s t p ihe ne gra cle tnt h p ag laens of wpitla hn me condm ition bers su s wit ch r h aes he D leiv ab aa e nt r tt e s he disaelt ah condit se, hype ions rtens inc ion, read sed epr e com ssion, mens dia ur ba ette ely s, . and Copyright Information: This report is copyrighted by the Em 40p % loyee Benefit Research Institute (EBRI). You may (SSRIs). 27% 9 in more detail below, HDHPs 26% may provide coverage of certain prev2e 5nt %ive services prior to the satisfaction of the health 30N % ewhousE eligib , J. le an H d eta he lth P Ins la ur ns a,nc " e E BERI xpe Iss rim ue e nt Br ie G26% r f, oup no. . 19 5493 2 (. EFr me pe loy Fo ee r A Bll? ene Le fit ss Re ons fr searom ch I tns het it RA utN e, D20 He 21 alt ).h I nsurance Also see https://ahiporg-production.s3.amazonaws.com/documents/202109-AHIP_HDHP-Survey.pdf and 30 R %esults 15% 24% Inter 2007 national no 14% rm1 a,l1 iz 0e 0d ratio (INR 2), 2 te 0s 0ting 2,850 Li5 ve ,6 r 5 d0 isease and5 /o ,5 r 0 b0 leeding dis1 o1 rd ,0 e0 rs 0 800 C B ast eo chm a nc us alus e t ha of ion n in pent t-he up p daest m, aand, nd it w he is p the oss r ible few e tha r su t c som h enr e p olle la2 n me e 0s a 18 rm e b 2 de 0 is r 2s w e 1nrollin ere st g ill fr om una H bSA le t o pla gns et .he Se ac ltond h ca , rw e eser exvaic m eine s in the copy, print, or download this report solely for personal and nonc 30% ommercial use, provided that all hard copies retain plan deductible. Enrollees in plans that meet these and other requir 20 e% ments are allowed to open and contribute to a 1. E Em xpe ploy rim ee rnt s m . C aa y m not br idg waent ( MA to ) c: ut H b ar ev ne arfit d s d Univ ure ing rsita y t Pim ree ss w . hen unemployment is low 13% and recruitment a 20% nd 21% 18% https://www.irs.gov/pub/irs-d 19% rop/n-19-45.pdf. 16% 20I% n thisL sect ow2008 -dion, ensitw y e lip p op re 1 ro sent ,1 te 0i0 n (t Lhe DL )fin ted st2 ings o in ,2 g00 n the im 2p ,9a 0c 0t of expa Hnding e 5a ,8 rt0 0 di sp erae s- 13% eded5 uc ,6t0ible 0 covera 1g 1,e 2 0 in HSA 0 -eligib 900 le health plans 2020 im Fu %p r 21 ta he c , tw r m of hic or the h e, w tnot ould her ic ee ha is on v ae lre e ha nr ad olle dy ta he en a c e ost p ffp e e c sh ttit a of er ing, for low a e w 20% d rit ing dh th ing the e m or knu ee ym ser qb ue evrst ic of e ios, a n b enrs e e olle ing ve ide w s w he nc itt eh he he d b r y w a lt tehe h a c rC e ond hr see onic itions ing Dfe .is A w end a ese r w eMa nr e oll dna o eg not ee s i m n k enow nt In response to IRS Notice 2019-45, three-quarters of large employ2e0r% s and health plans offering HSA-eligible hea 37% lth Fr 40onst %any in, P and aul, a all c nd opM. yright Chr a isnd top ot he he r r Roe apb puc lica kb , le "D not o Aic cc eu s c mul ont ataing ined H SA the B re ain, lanc ae nd s A yff ou ecm t Us ay ec it of e H or e a qlt uot h C ea sm re a Sll p ervo icre tions s an d of 19% A T A G L A 1N 5%C E health sa10% vings account (HSA) on a tax-preferred basis. Thus, these plans are also commonly known as HSA-eligible 20% retainment of workers is of concern. 9% 8% 9% 34% 10 Selective serotonin reuptake inhibitors (SSRIs) Depression 10on % enrolle 2009 es. Specifica 1lly ,15 , 0we look a2t, 3 the 00 impact on 3,00 p0lan choice 5 ,a 9nd 50 cost sha5 r,ing. 800 11,600 1,000 A H if t c SA S this , e-w e e ligib a hi http ff ce h w c s le t:e / he a /d w s r H a wlt e S w h p int A .e -e b rla od ligib ri.o ns uc rg le w e/ d d it he o h d in t ca slt /ehe d h p deuc faul U. la tible n e S. t-sC o n s for ong ur rolle ce r/ ser e e fas ss s m v ta ic -facts or s r es su ee or c/e ff c nt -le h a 445 ly ss s ins a -tp s ha sMa sn it uli urve 10 rn a c % h 2023 ayff nd -27o ect inh e cd .t22. a Thi ot lep he ds b d c fr.or ip he ta ic a rost tlt is h p aen, rla oid b n e ic sa .nr molle erae l s. le gH isow late ion ver, we 35% plans the expa rep nd ore t dp rpov reide -ded d uc tha tible t you cov do erso ve age for rba m tim ed a icnd ations with p and rop ser erv c ic 1it 0 ea % s t tion. hatA pny re v us ent e b the eyond exa c the erb sc atop ion o e of f cthr heonic for egoing Roebuck, Sp M. ending Chris? top ," he EBrRI . 20 Iss 12 ue . T Bhr rie efe, E no.482 ssays on (Em the plo E yc eo enom Bene icfit s of Re Psea resc rc rh I iptins on tit Dut rugs. e, 2019 Disser ). tation, Baltimore, MD: 15% health plans. In 2023, these plans must have a deductible of at least $1,500 for individual coverage and $3,000 for 10% 14% 28% Statins Heart disease and/or diabetes 10% 27% 2010 1,200 2,400 3,050 6,150 5,950 11,900 1,000 0% d w 3id 0 ould %fin d p rtov haide t the H SA pe-re cligib entale g eh e cha altnge h pla in e ns w nrit olle h aeds w ditiona ith va l fl rie ous he xibilitya tlto h condit 0% provideion prs w e-da es highe ductible r in HSA covera- ge eligib for le ser hv eic alt eh p s tha lans t 12% 12% conditions (Fronstin and Fendrick 2021). The impact on premiums of 5%expanding pre-deductible coverage for 9% 14 serv 1 ices 11 r 2. e quir E Univ m es E p. loy B of RI eMa rs m ’s p ryra la ior ynd c e on xpress Btainu ltim e or p to e er oC m ff ount is er si c on. y ov . eFor rag e p efor rm is the sions, se se p rle vic ae se s in full conta cif t t Ehe BRI y b ae t lie pe vrem tis ha sitons@e incentb ivrizi i.or ng g.t heir use 11% 11% fa m Se ily e http cove s:r/a/g wew . w E.nr na ollm tional ent all in ianc He DhH eP as lth.o acc rg oun /netw s s for /immuniz over one ation -ha -re lf of mains those -critiw ca itl/ h p . rivate health coverage (Figure 1). 10% 23% 23% IRS Notice 2019-45 allows health savings account (HSA)-eligible health plans the flexibility to cover 14 medications and Deductible Copay Coinsurance Deductible Copay Coinsurance Plan Choice 9% 9% 22% 9% 9% 25% 2011 1,200 2,400 3,050 6,150 5,950 11,900 1,000 Fronstin, Paul, and M. Christopher Roebuck, "Health Care Spending after Adopting a Full-Replacement, High-Deductible 0% b pe re tw ve ent e Sn 2020 o tuhe rce e : xa h ta tc p nd e sr :/b /20 v a bti21 ion o dce tnha tf ern in c .o hr rgonic /iot nithe i ac trond iv e ty sp /ih te s ions s of a-hi.g he h-da elt dh p uctila ble ns -h e (a Fi ltg hur -ple a 0% n5) s-2 . / 10% 8% in HSA-eligible health plans as allowed in IRS Notice 2019-45 is small (Fronstin, Roebuck, and Fendrick 2022). Further reduces aggregate health spending in the long term. 7% ot 12 her health services used to prevent the exacerbation of chronic conditions prior to meeting the plan deductible. There 17% B 20ac % kgr Do edund uctible Copay Coinsurance Deductible Copay Coinsurance See Figure 8.3 in https://www.kff.org/report-section/ehbs-2022-section-8 5% -hig 5% h-deductible-health-plans-with-savings- Repo 2012 rt Availabili 1,2 ty 00 : This rep2 or ,4t0 is 0 available 3, 1 on 00the interne 6,2t5 a 0t www.eb 6,r0 i.or 50g 12,100 1,000 Roebuck, HM. ealt Ch P hris la tn Wit opherh a , J. H Sa ea m lta h Sa ntha v ings A Doughe ccr oun ty, tRob : A e Firv t eK-a Ye est arne Srt, udy and ," L Ea Bu RI ra IM. ssue Mille Brr ie . f20 , no. 15. 38 "I8 (E ncrem ase ploy d Use ee B Of enefit 15% I eRS N xpanding otice p 20 re19 -d-e4d5uc atllow iblee cdov ee m ra pg loy e e to rs a 11nd 6 dhe rug altch p lass laens s t 14% t ha o te xpa are nd usepdr em -d ost edly uc for tible chr cov onic er ad gis ee ta o se ser mveic de ic s r ate ion lated to the Figure 1 Muc is 15 c % ur h w rent orly k ha no s b resea een rc dh on on e tto he e 12% xa imm pa ine ct of the e xpa response nding p to re t-h dee d IRS uctible notic ce ov be yr a eg m ep on loy e prla s a n nd mem hebaeltrh p s. Ila n th ns, isa I s ss wue ell a Brs t iefh , ewe option/ 5% . 2013 1,250 2,500 3,250 6,450 6,250 12,500 1,000 Until I 3.RS N Ther Pre ot sc ic er e ipti is 20 p on r19 ecD -e45 rd ugs e nt wa Re for s rd euc cle ov e ae s Me sed ring on dtic he July al C se ost ser 17s I , v20 ic n M e19 s w e , d w itic hout he aid n it P co ocp st aula m sh et a ions tro ing p." rov in t Hiding ehe alt h Af a p br senc e fa -d ire s ed 34 of uc tt(ible he 9): A 15 cC ov A 86 em r-a 1 ag 59 nda e 3. of tehe . W alt he h n ResearcS h I tans tints itut foe r , H 20 ea 13 rt ).D isease Beta Blockers for Heart Disease treatment of heart disease, hypertens 9% ion, depression, diabetes, asthma, osteoporosis/osteopenia, liver disease, and management also ha Percent s a small im age paof ct on Person premium s Enro s (Frons lled tin, Roe in a Hig buck h , -a Ded nd Fe uc ndr tib icle k 20 Healt 22). h Plan 10% use cla 0% ims data to quantify the effect of expanding pre-deductible coverage on enrollee choice of health plan and cost impact of the notice on premiums. A 2021 EBRI survey found that 76 percent of employers with 200 or more Data and Study Sample c Tabl are ser e vo ic 2014 f es in HSA Conte-nt e 1ligib ,2s 50 le health p 2,5 la 0ns 0 , employ 3,e 3r0s w 0 ere guide 6,5d 5 0by the IRS sa 6,350 fe harbor1 sect 2,70ion 223( 0 c)( 12 ,0 )0 (C 0) of the he doi:0.13 alth re 77 im/h bur ltha seme ff.20 nt 15 a.033 rrang 5e . ments (HRAs) were introduced in the early 2000s, some employers provided bleeding disordeS (HDHP), rs. ta tA in s a s f o re r su by Hlt e , a Emplo w rt eD w ise ould y aer se exp Con ecttribu to see tio an inc n tor e HSA ase in or the HRA peB rc ,* A eetnt a a B mo g lo ecke n of g p rs Th lan me foose r Hm ea W bre tith rD s w i se ith th asee se SSRIs Insulin Beta Blockers Statins Antiresorptive Therapy Inhaled Corticosteroids 5% 2018 2021 2018 2021 sh em ap ring loye . es increased the number of drugs and services covered p ® re-deductible in HSA-eligible health plans as a result Fronstin, Paul, and M. Christopher Roebuck, "Managing Use of Health Care Services After People Satisfy Their Our analy2015 sis confirms t 1,he 300 findings fr 2,om 600 the 20213 ,E 3B 5RI 0 survey 6of ,65 e0mployers. 6,C 4ost 50 sharing 12 for ,90 ser 0 vices aff 1e ,0 c0 te 0d by the For Inte trhe na l Re pfir rest sent ve -d nue olla st udy, w C r od cov ee (rI e a RC g ut e)ili .for ze Em d p p rte loy he ve e 20 nt rs c iv 18 eould a ser nd vonly ic 20 e21 s p ( Fr rMa ov ons ird ke e tin tc sc ov 20 ae n0 ra 2) g C. e om C of om m the e prac ria follow ab l le Da g ting a eb ne aser se. rous c v D ica eo ts p a v efrr rior a om g et o 20 w ta 18 he s im w sa e ptrle is efa m us c etnt eion de d Introduction .......................................................................................................................................................... 4 conditions. For exa Pr m iv ple ate , d-iSector abetics m Health ight find Cov HSAerage -eligibleand hea ltEmplo h plans y to ee b- eO m nl ory e Cov attraerage, ctive if ins 2016 ulin a –nd retinopathy 0% 2018 2021 2018 2021 Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. 80 % 73% 100% of Triv IRS N ed 0% i, A ot Dm e icd ael N uc 20 t., ible 19 H-us : 45 W e in Mo ha (Frtons Dloo, o tin a Cop and nd aym Vi Fe e nc ndr ntes a nt ic k nd Mor 20 C21 . oins 20 ). 10 ur Pr. a enc " -I dnc e e dD ruc eo? atsed ible ," E A B cm RI ovb eI ula rss ag ue tor e w y B ra C ie s oft afr,e no. C en a op 51 ady 9 d m e (e d Ent m for s a ploy h nd eeaelt H h ca B ospit ene re fit a liz ser atv io icns es 71% b I of RS ec the an us ot p eic la te 2016 n d he sh ye ift r de e uc p drt e ible frsent om 1:, 3 d 0 the e 0d uc lat st ible ful s t l 2,yo 6e 0a c 0op r pa re ym cee dnt ing 3s a ,35I0 nd RS c N oot ins icur e6 a 20 ,7 nc 519 0 e -a 4m 5.ong Da t6 e a,nr 5fr 5olle om 0 e 20 s in HSA 18 1 w 3e ,1 r-0 e e0 ligib comle p ahe rea d1 lt ,w h p 00 it0 h th lansos . Ien when HSA-eligible health plans were introduced ( 2020 Fronstin, Sepulveda, and Roebuck 2013). And of course, the SSRIs for Insulin & Other Statins for Heart Beta Blockers for Inhaled Antiresorptive screenings were no longer subject to the plan’s deductible. Any Condition Heart Disease HypertensFi iongure 4 Depression Diabetes Asthma B Key ack Fin ground din ................................ gs: ........................................................................................................................... 6 70% 43% related to heart disease and diabetes care. Two-thirds of employers added pre-deductible coverag 77% e for blood pressure 60% Re amsea ong rc th I hens Elde titut rly e." , 20 Ne 20 w). E ngland Journal of Medicine 362 (4 45% ): 320-328. doi:10.1056/NEJMsa0904533. Depression Glucose-Lowering Disease Heart Disease Corticos75% teroids Therapy other hea2017 lth plans, we 1 ,3 d0 id 0 not see 2 the ,60 0 shift in co3 st ,4 sh 00aring. Em 6p ,7loy 50ers would 6, 5 a5d 0d additiona 13,l se 100rvices if a1 llow ,000 ed by the from 2021 20 for 21 E seve BRIr su al rrv ee ay son me s.nt For ione one d a, b20 ov21 e found was the tha fir t w sthe ye n th ar in w e IRS a 8hic 0%h w llow ee o db e ser mp vloy ed ear s laa rnd gerh p ee arlt ch p entla ag ns e of to e cm ovpeloy r ers 80% Source: EmployPercent ee Benefit Resag earce h Inof stitu te Plan estimateEnro s based llees on adminiW straith tive e nHealt rollment ah nd Co claimnd s data iti . on, by Plan Type, 60% Agents for Diabetes 49% 40% 36% D ma onit ta • a or nd s a P St rnd eudy Sa veins ntiv uli em n/ ser p gle lu v ................................ ic cose es r-e low com erm ing ende age dnt bs, 61 p y................................ the U. erS. ceP nt re a vd ed nt eiv d ec ov Se ................................ e rr va ic gees Ta for sk gluc For om cee t(e USP rs, a ................................ STF nd )54 , the pe A rc de vnt isor ad y de .......... d 7 On the one hand, we did find that the percentage of plan enrollees with any of these conditions increased. Between 50a I% RS, dopa ting ccor 2018 som ding e tfor o E m B RI of 1,’3 s su p 5r0e-rd ve ed yuc retsu ible 2,lt 70 s. c 0 ov And eratg he e.r3 e Fu ,4 is 5r0 tb he ipa rm rtor isa en, ,6 a ,9 b 0 cic 0 ruc am iael c raom l le 6p g ,6 one is 5la 0tnt ion th of this at1 3 ha a ,3na s b 00lyesi es is n int ursi od 1ng ,uc 00d 0 eia d g in t nos he is certain preventive services outside HSA-eligible health plan deductibles, about three-qua 33% rters of them chose to • Cost sha2015 ring sh -2021: ifted from HSA de d Enrollees uctibles to cLess opaymHealth ents and y, cO oins thur er anc Enrollees e among eMore nrolleeHealth s in HSAy -eligible health 50% 35 60 % % Fr VB onst ID H in, P ealta h. ul, M n.d. . C "Fi hr na istnc op ia he l Irm Roe pacb tuc of kH , a SA nd -HA D . H Ma P r Re k for Fend m rtic o kI,m "P pr re ov meium Acc Iem ss p a to ctC of hrE onic xpa D nding isease PrMa e-Dna edguc em tible ent 31% Cov 31% erage coverageC for om m be itttae e b loc on kIem rs. Hea muniza lth ca tion rP er a ser ctic vic es (A es le Ca Ist P) , lik the ely H to eaha lth ve Re psour re-dc ee ds a uctnd ible Se cr ovvic ee ra s A ged w me ini rest pre aa tion' k flow s (H m RSA ete'r s) s a nd HDHP Only HDHP With Employer Contribution 9 to HSA or HRA 20 U.S. 18C aong nd 702019 % r20 ess 21 t, ha the t w pould 1 e,r 3c 5e 0 nt pra ov ge ide of ap 2d ,la 7 d0 it n0 iona enrolle l flee xibi s w 3,5 lit 0 it0 y h a to ny ext of end t7 he ,0p se 0r0ec -d ond educ itions tible 6,7 in 5 c 0c ov ree arsed age fr 1 t3 o om ,5 ser 0 0 16 vic .3 p es t eha rce t1 nt ,m 0 0 a t0 o na16 ge.6 Dis codecu s tos ide sion ntif y enrollees with conditions affected by the IRS notice, namely diabetes, depression, heart disease, 40Me % thods d ................................ o so, often without cos ................................ t sharing (Fronstin and ................................ Fendrick 2021). ............................................................... 7 plans for a number of services impacted by IRS Notice 2019-45. The same shift was not observed for enrollees 40% 35% 30% 26% HSA-Eligible Health Plan Other Health Plan t Me o C dhr ica onic tions D." is e Aa cse cess Ma ed na Ag perm il 7, ent20 Me 22 d. icht attions ps:/ /in HSA vbidhe-aE ltligib h.com le H /do eacltsh P /HS la Ans -H,D " H EB P- RI Re Ifor ssue m- B Br rie ief.p f, no. df. 563 32% 32% int ernationa Bright l nor Fu m ta ur liz ee P dr oje ratio ct, (a IN nd R)H tRSA esting and (25 the pe Irns cetnt itut ee a cof h)Me . Most dicine 4 e 0m % ’sp (loy IOM er’s s d ) id com not m it etlim ee ina on te w om cost e n' sh s c arlin ing ica for l the p C e ost rce nt Shari , a 2 p ng er cent increase (Figure 3). In ot30% her h O eta hlt eh p r H la ens alt, ht he Pl a pn es rcentage of plan enrollees with any of these 30c a % hr sthm onic a , ca ond 2020 nd iost tions eop . E or m 1osis ,p 4loy 00/os ers te a op nd enia p 2,olic 8. 00 Iy ndivi makd eua rs ha ls 3, 5 w v 5e e 0r e a n lea ss p plik e7 te it ,ly 1e0 0 t for o see mor k eout flexib 6, 9t0 r0 ele at m pla ent n d in inp 1e 3si ,8g 0ns 0 at ie ornt “ sm and a1 rout t ,0 e0 r” 0 p atient 25% Our analysis confirms the findings from the 2021 EBRI survey of employers. Cost sharing for services affected by the in other types of health plans. 18% 60.1% 30Re %sults ................................................................................................................................................................. 8 (Employee Benefit Research Institute, 2022 17% ). 18% pre-deduc prte ible vent ser ive v ic ser es t vic ha es (r t we er qe uir ae dd d ebdy. Se The ct ion 2713 percenta g of e tehe lim P ina atie ting nt P cr ost ote sh ction a aring nd ran Ag ffe or d dfr aom ble 25 Ca rp ee A rc ce t nt of t20 o 40 10 (ACA) 20Tw % o recent surveys find support among employers for the continua 20 tion o % f providing p57.7% reventive services without cost 60% 22% 15% c dond educ itt ion ible s a 2021 s, ls bo ec inc aus reea 1 sed ris ,4ing 0 00.3 h epaeltrh ca ce2 nt ,8 r. e 0B 0 spe ecan us ding e the 3ha ,6r0 e s c 0 wre eraet efe d w ser 7e ,2 r ious 0H 0SA fis pla can e l c7ha n ,0 r0 olle lle 0nge es s. w ith a 14ny ,00 0 of these cond 1,00it 0ions than settings d 11% ue to the COVID-19 pandemic, the exact settings that issue the diagnosis codes needed by this analysis to 30% 10% 20% W IRS e e nxa otm ice ine sh dift ee ight d fr om of t he de d 14 uc t ser ible vic s t eo s in t cophe ay m IRS entn s a otnd ice c to o ins see ur if a ancnd e a how mong cost enr sh olle areing s in HSA was a-ff ee ligib cted le b he y a the lth p not laic ns e. . In Wharam, J. Frank, Fang Zhang, Emma M. Eggleston, Chr 20 ist 18 ine Y 2. 02 L1 u, 55.3% Stephen B. Soumerai, and Dennis Ross-Degnan. 8% 9% 5 53.6% 15% 1 20 0% % 53.0% sh pea rPc rla ing. ent n C , a A d hoic nd e20 pe e I22 nding RS N ................................ EBot RI on ic su et he 20 rve 13 s ye - found r57) vice .. The tha ................................ t 20 8021 pe E rc Be RI nt su of rv HeR d y a ................................ e lsco ision ma found tk ha erts sa mos id t te he ................................ my p loy would ers w cont ould inu ae d d to p....................... r ce o-vd ee rd p uc retv ible ent iv e8 othe • r hea I2022 RS N lth pla otn ic e enr 20 olle 119 ,40e -045 s, ta he pp p ee arr 2c s ,e 8tnt 0o 0a ha gev e c ha hange d 3 ,a 65 ne in 0 g enr ligib olle lee 7 im s w ,3p 0it a 0c h a t on ny ov of e 7 tr,he a 0ll c 5se 0 ost he a sh lth condit ar1 ing 4,10 a0 s a ions pe in oth rcent 1,a e 0g 0 r e 0he of alt tot h al identify affected enrollees. Thus, we used the 2021 data to measure the impacts of the 2019 IRS policy change. Using ot Ov he erra ll he , t aot lth al c pla ost ns , sh waer ing did ans ot a see per cte he nt a sh gift e of in c tot oa st l sp she andi ring ng . H for ow e ea vc eh o r, ov f th ere a ll c serost vic e sh s e arxa ing mine for dser wv aic s m es a ost ffly ec c ton ed st ba yn tthe Fronstin, P 20a 18 ul, M . "E. ffC ehr ct is of top Hh igh er- D Roe edb uc uc tik b, lea nd Insur A. aMa nce rk on Fe H nd igh ric-kA,c "uit The y Out Imp com act eof s in D Expa ianding betes: A Pre N -D ae tur duc al Ex tible p eCrov ime ernt ag for e in 10% 0% 0% 35% 10 3 31% c Sm ova e • rrt aeg re 50 P d for e % er diod uc ad tic ible d it he iona s a altc h e l he com va am lt lua h ca od tions atring e se su ser rc vh ic ve ic as if a s a es p nnu rllow ev ae l p e nt d hy ing bsi y c tla a he ls w .e axa nd A c20 e sele rb 21 act tA ion o p HrIe Pv f c su ent hr rv iv onic eey sc of c rond e he enin ait ltions h p gs not la m ns igh lis als tte o b de found a a b ov naett ur ha atl services in full. Sim 47.1% ilarly, a 2023 survey found that 72 percent of employers expect to continue providing coverage for 10p % lans incspe r2023 eased nding only on 1 p 1 a, 5num 0 e0 rcebnt er. of serv 3,00ic 0es impac 3t,e 8d 50 by the not 7,ic 75 e0 . Thi 30% s may 7 ,b 50 e0 due to the 15 ,fa 00c 0t that emp 1loy ,000 ers were diaC gost nos Sha is cod ring es fr ................................ om the inpatient and ................................ outpatient service fil................................ es, we defined health con ................................ dition indicators. W ..................... e also used 10 b IRS etwneot en 2018 ice was m and ost 20 ly2 un 1. cThi has is nge d not . Thi a s is sur pnot rising a su fin rp dring. ise, Ian th s the e 20 ma 21 jor E itB yRI of su e D m rev d p e u loy y c tof ie br le s int empe loy rve ierC w s, o ep w d a e y in 202 found 1 r tC ha e op it n or sthe u te ra d n ce D He SA du-c Etligib ible le Health P Cla ons pa yon Premium Co si,n " sE urB aRI nc e Issue Brief, 5% no. 558 (Employee Benefit Research Institute, Translation in Diabetes (NEXT-D) Study." Diabetes Care 41 (5): 940-948. doi:10.2337/dc17-1183. 28.0% 30% 11 4 evolution o 25% f health plans. Value-based reimbursement promotes the delivery of evidence-based, high-quality care that t ahr ll p ee re -q ve ua nt (op riv tete riona s of serl, vhe ic pe e as w rlt h p Int itho e la rn na ut s e l Re cxpa osv t e nde sh nue ad ring. Se pre rv -d ic e ed (uc 20 tible 04)) c . overage as a result of the IRS noti 25.7% ce. procedurm e or and e lik m 25% eely d ic to atc ion ha nge cod e cs fr ost om sha trhe ing inpa instte ie ant d ,of out elim paina tient tin , g a nd it. prescription drug files to identify the medication 0% 24.4% 0% m t ha ajtor the ityy of did em not ploy elim ers w inae te re c rost ep la sh cing aring dew duc hetn th ibles w ey a itd h copa ded pryem -d ee nt ds or uctible coins cov ur ea ra nc ge e .a Is a nst e re asu d, ltt he of yt he su bIst RS itut not edic e. Discussion 2022 ................................ ). ............................................................................................................................ 14 24.8% Figure 3 25% 22% 22% 40% 25.8% encour • agOb es us esite y of we— ight ra-tloss her tpha rog n cr ram ea s a ting nd bta ob rrie acrc s t o o ce— ss a hi tion p gh-va rlue ogr a ser ms (opti vices. I on ntal e, rvpeent r ions Inte rtna halt Re imvpernue ove Se p 21.9% ar tie vic nt e- (2004)). Deductible Copay Coinsurance Deductible Copay Coinsurance 21.6% 21.4% 21.4% a W nd haser ram v, icJ. es ut Fraili nk ze , d Fa bng y eZh nrol ang, lee 21.3% s t Em hr m oug a M. h th Eg eg 21.3% p lela st n ye on, a Crhr . istine Y. Lu, Stephen Soumerai, and Dennis Ross-Degnan. H cop ow ae yv m ee r, nt the s arnd e isc oins a slight uranc ly e d iff for er e dnt ed uc pic tt ible ures. w W ith r hile e spe enrc olle t to es m type a yo f he not a spe lth p nd lale n. ss A m mone ongy H ov SA e-re aligib ll on lehe he alt alt h ca h prla en services, Referenc Per es cent age of Plan Enrollees With Health Condition, and Change in Enrollment 22.4% When it comes to the impact of expanding pre-deductible coverage on premiums, three studies have been conducted. N 20 e% arly 20 years after passage of the MMA, only one-quarter of smaller employers and one-half of larger employers Conclusion ........................................................................................................................................................... 16% 16 cente • redE out nrollm com ee nt s w in hil He S A m -e aligib intaini le ng hea alt ffh p ordla ans bili taym m ong ay16% b indiv e found iduals in t whe ith he fora m lt h condit of a clinion ically s im nua panc cte ed d b HySA the -e ligib IRS le n ot he icaelt h • Drugs taken by asymptomatic individuals to prevent the manifestation of disease (optional, per IRS Notice Fronstin, P 20a 17 ul, M . "D. ia Cb hr etis ets Out ophep r a Roe tient buc Ck a, re Ja ason B nd Acuxba ute C um om , p alic nd atA io . ns Ma B rk e for Fee ndr and ick,A " ftD eo r H Pe igh op 15% -le D eC dhoose uctible W Ins iseur lya A nft ce e r e the nr olle imp ea s, ctc of ostc ha sha nging ring ats he a c pom ercp eosit ntaion o ge of f tc ot ost al sp sha ending ring m fe ay ll for cha n SSRI ge us s, ins e of uli he n a altnd h ca otrhe e ser r g 19.2% v luc ic 14% e ose s a-nd lowim erp ing rovaeg p ea nt tie s, nt 14% 20% 12 Agrawal, Rajender, Olena Mazurenko, and Nir Menachemi. 2017. "High-Deductible Health Plans Reduce Health Care The offe 15%r20 an HSA 21 30 % AH-Ie Pligib sur 6le ve y h eof altins h p ur lae n. rs t ha Em t pw loy as enot rs m ed a ya b be ov hold e found ing b ta ha ckt fr mom ost a re dp op or tt ing ed H eit SA he -e r ligib no p le re he mium alth p inc larns ea se becor aus e of does not appear to have changed, as it was already trending in the direction of higher enrollment among The plan th dat aa t2004 b b ae se tt- ec 50 rom m ).e p e ris ts w ed or mk ee m rs’ becrlin he ica alt l h insu and fin ra anc nce ia e l ne ligie bd ilis. ty information as well as medical (inpatient and outpatient) References ........................................................................................................................................................... 17 Sa Enr tis ollm fying entH : e Aa lt Nh P atur laan D l Exep deuc rim tible ents? for Ev Tr ide ans ncla e tFr ion in om the Dia Use bete of s (NEXT Low-Va -Dlue ) St H udy." ealth C JAa MrA e Se Intre vric na es." l Me Ed Bic RI ine Iss 177 ue out statcins om , e as. nd ISp ninh hra ela a ele d ding d C c or o out rttic ico os cos st te te rsh roid oia d s ( rs ing Fi fog rov ur Aee st r 6) h the m . a C cost our sh se aof ring the w y ae s unc ar ins ha tenge ad d of fo re r qb A uir en ta ing ti rb elso oc par k tp ie etrint s v e s t a nd T o hp e inc a ra yrp e ay a la sed fo rg r e for am ount at Inhaled Corticoster 8% oids for Asthma Antiresorptive Therapy for 30% HSA-Eligible Health Plan Other Health Plan premiumC inc ostr e Aand ses Uti of liz le ass tion, thaIn nc 1 ludin percge nt Use . A Of N lthoug eeh e ded st P im reavte ent s a ivre e Se rep rv or icte es." d, a H g ea re lta h Af t defa al o irs f unc 36 (10 ert)a : int 17y62 re -g 1a 76 rd 8. ing the e 1v 0ide % nce that they may be associate7% d with a reduction in appropriate preventive care and medication adherence individuals with health conditions prior to the issue of the notice. and pharmacy claims. Our sample in both years included policyholders, spouses, and dependents, all under age 65, B (3) rie : f35 , no. 8-36 51 8. d 6 (E oi:10.1 mploy00 ee1 B /jeane mfit aint Re ersea nmrecd h I .201 nst6.84 itute11 , 20 . 20). Osteoporosis/Osteopenia t ahe nt irbeesor ginn pting ive t of hetrhe ap y y.e a In cont r may rra est su , lt a m in ong highe othe r us r e he of althigh h pla -v n ty alue pd e ser enrv olle icee s e s, c arost ly in O sh st ta he ero i ng y pe oa a rr o s a , si w s/ p hic O erh coul st ceent oa pg d ee n p iof a rev tot ent al Endnotes ............................................................................................................................................................. 19 20 doi:10.1 % 377/hlthaff.2017.0610. e I (nc A ff 5% g errc e ata w of ses al, NM in c ota ic zur onsu e 20 enk 1 m 9 o, e -r 45 aout nd on -M of p e-rna p eoc m cium he kem t s r c i 2017 os etm s for ains ). The .he In th alt sa h ca v eing ArH e s or I ha P su vm er e v bd eeic ye, a n 15 l c ass ost poc e roffs c ia etnt ee d tof s fr wit pom h d rov e ide ple rov tre s r idin of ious ful g c inc ly onseq ins entur iv ue e ed s t nc po e la s. g ns e These t and 2 20 01 18 8 2 20 02 21 1 who were enrollees in their health plan for the full year. We also required that an individual’s claim data 16.6% have full 15% 16.3% 16.2% spe comnding plicat ions incre d aue sed t o for nona SSRI dhe s, rst enc atins e of , b tr ee ta at b mloc ent k erres, a gim nd ens a.nt iresorptive therapy, and it 32.0% fell for insulin a 32.1% nd other 15.6% 30.9% 1% Employers would add additiona15.4% l services if a 1% llow 15.3% ed by the IRS. There is also bipartisan, b2 ic 0a 1m 8 era 2l le 021 gislation that has 29 inc lude perc e fin nta of ncia pr l st ovr ide ess rs of , wor se se lf-d ins ise ur ase ed cpont lans rol, not inc ed re ta ha 28.9% ses t iti n hosp was too italiz eaa rly tions to , know and e w xa ha ce t rim bap 2 ta ion o 0c 1t 8 the f he 2 0 n2 a ot 1 ltih d ce ha ispd a ron ities, pr 0% eventive care are often difficult to quantify. Yet employers often invest in such care in the absence of evidence. 27.1% 25% 60 inf Fr %onst ormin, P ation o aul, M n praersc tin J. riptiSe on pd ulv rug eda and , a nd meM. nta C l he hris atltop h se herrv R icoe es spe bucknding . 2013 . . In "C 2018, onsum our er- D sa irm ec ptle ed inc He lude alth P d 2.1 m lans Re illion duce The 70% 24.8% 54% 63% g Bluc rotose -Gold -low bee rg ring , Zaa re gk e nt C., s a And mit inh abh C aled ha cndr ortic a, ost Be enj roid am s. in R. Handel, and Jonathan T. Kolsta7d. 2017. "What Does a 10%SSRIs for Insulin & Other Statins for Heart Beta Blockers for Inhaled Antiresorptive 13.5% been introduced in the U.S. Congress that would provide additional flexibility to extend pre-deductible coverage to p p Ba r ee r cm ta ic us ium ula e rs. of ly A c anot onst mong he rar int t7 p hose s a er rc ound w eit nt h ch of prr p eonic rvov ent ide m ivr e es of d cic aa re ful l c aond ly nd ins iH tions ur SAe-d e a ligib p nd lans le low he ae nd ra lt hous 17 h p p le a ehold ns rce , nt e m inc of pom loy pro e ev r ss ide . aP p reer s of pea -rrself e tv o ie -ha w ins e vd ur e lit m ed e ov rp ae ltad ur ns te ow ha as rd 21.9% 90% enrolleesL in HSA ong-Te-rem ligib Use le Of O he58% altut h p pa la tie nsnt a nd Phy11 sic.3 mi ian Vi llisi on ts A enr nd olle P 21.6% re es in scripti 6 ot 0on he % rD he rugs." alth p H la ens alt. h Af In 2021 fair55% s , 32 our (6) sa : m 11 p2 le 6 -inc 1134. lude d 1.7 The fact that we do not see 21.4% a change in enrollment patterns as a result of the IRS notice is not surprising. As 60% Depression Glucose-Lowering Disease Heart Disease Corticosteroids Therapy Figures Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics." The 77% 50% services that manage chronic conditions. Employers and policymakers have 76% an appetite for more flexible plan designs or r de ep m oonst rted r“ aot ted he trha ” w t he sele n c atsk ive ed ly alow bout er ing the cim ost p ash cta of ring the for n ot hiig ch e- on value pre cm hr ium onic s. d N is o ec aont se m ext ana wg ae s g miv ent en for med t ic he at ions “othe cr a”n higher 10 de %ductible 45%s in PPOs, while some have adopted HRA plans ins 80t% ead, possibly with flexible spending accounts million enrollees in HSA-eligib Agen le ts he fora D lth p iabe la tens s and 6.8 million enrollees in other health plans. W me he ntn e ione xadm aini bov ng e, the this c om map yos bit eion o due f c to os the t sh rea druc ing, tion in we fin usde tof hathe ita sh lth ca ifted re fr se om r2% v ic de ed s d ucue tible to s t the o cC op OVI aym D-e19 nt s a pand ndemic, 50% 20% 0% Quarterly Journal of Economics 13 4% 2 (3): 1261-1318. http://www.nber.org/papers/w21632.pdf. 50% 43% "smarter" deductibles, because rising health care spending has created serious fiscal challenges. Fr m rE (e FSA ndno e onst sponse anin s)in, P . gThe ful s, b te a ly ul, M s Iut RS im w pn a e rov ot r tcin J. ic a en conc e a m dSe he ay p r lude e ulv not nce e d only ; tha ar, eta d c nd 22 uc aus e p M. e tehe re C cm e hr rnt is p is loy k tof op of ep he ra r s off ov drv R ie dr e oe e se rring b s of he ucH k aful . SA lt20 h o 7 ly - 0e 13 % ins ut ligib . cur om "Me le e d ehe d sp ic ;a la a a ltt ns nd, h p ion U a la in som nd ns t ili 46 za to tp e a ion a e d crop a ce ses, nt nd t p of rA ree d -p d d he r uc eov d re e uc ide nc etxpe ible e rs of in a ndit self ur- es Figure 1, Percentage of Persons Enrolled in a High-37% Deductible Health Plan (HDHP), by Employer Contribution to HSA or 40% 2016 2017 2018 2019 2020 2021 c woins hich in uranc tur en a forff e enr ctolle ed our es in ab Hili SA ty- t eo ligib idele nt ihe fy aeltnr h p olle lae ns s w . Ait m h he onga H rtSA dis -e eligib ase,le hy he pe arlt te h p nsla ion, n e d nr eolle press esion, , thed ia pe bre cteent s, aa gst e hm of c aost , 37% 34% 16.6% 40% 16.3% 60% 40% ins c Lov ee ur e e rea td g a e p l. H ,la ( e b 20 ns a ut lt 13 h Sa st als ill ).o d vm id ings Ac ight not rke cnow oun sult tw in m -E ha ligi tor b im e le p eP a m la cp tn. loy the " A e r m ns offe ot eric icea rn J h in ag d our su on na ch p pl re of la mns Ma ium . na s.g ed Care 19 (12): e400-e407. HRA, Among Those With P rivate-Sector Health Coverage and Employee-Only Coverage, 2016–2020 ............. 4 15.6% Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. sh ost Bundo aerop ing ror f, M posis aid . K /os thr atte oug e. op 20 h d e12 nia e . d , "uc C liv onsu teib r le dm is s fe e ea rll for - se D,ir a e nd c SSRI ted b le s, ins He ed aing ltuli h P d n a la isn or ns: D d d e ot ro s. he They D It r g m luc ayose ealiv ls-o e low rb ?" ee Re rding use e a tao g rce o h Synt nt the s, st r fa he acttins si or s Re s. , b Ma eptor any b t loc N em o. kp e24 loy rs, a ( eRob rnd s ert 5% 30% 28% 50% 1 * HSA = health savings account, HRA = health reimbursement arrangement. Methods 30% 15% In 2021, 60.1 percent of individuals with health coverage through a private-sector establishment were in a plan with a 30% 24% e inh xpa ale nde d cd W or p ood So tr ic e uost rc - d eJohns : ee Md r euc oid dicaton lible s (F ExpFounda e igur nc dov iture e er Pa 7) a tnion) g e. e l Su C for ost . rve ht y t -sh the p In:// sa ufir r raing w nst cw e Com tw w im .r ap s unc e w o 23% njin ef.or nt 20 (M ha g EPS 21 /c nge ont . -IC). Id te m for nta/da ya t nt a m k ir/f e e a sor trim mp e /r t iv e for p eor te he tnr s/ro rae lle ppye o .s w rW ts/ eit 2 h th d 01 id 2/ not er w a b jfin f4 ov 02 d e t 40 he he5. a sa lt h ca me re 21% Fi gure 2, Chronic Disease Management Services in the Expanded Safe Harbor ........................................................... 5 W G Y EB e ait tRI t, h I ww ood rRS N hil ese e , a Jus e r ot m ch usin ic tpin, Te e loy 20 eg 1 rs c r 9e c-la sa 45 ould im B in p s d . in Ga ibson, la ctec ant e a , iv nd H ize Mic SA a ss t-ha he eum ligib e us l E.F C ple e tions of hehe p aa rlte b rh p ne v out ew nt la , b iv nA e s eha m a ser a rve nda ior vno ic a 4 e w l M. 0 s in non r % e asponse Fa bler rt, o E -H a m s c d SA ily oonfir p 20% p t Vog la a m ns m te m , or dnot a e nn, t he flexib a ll e fin and d le m ings fr A p b. loy eMa ne eom r fit rs ha k Fe d tehe v nd sieg r A n d ic H on ,k I. P e so. 19% deductible that met the deductible requirements to be HSA eligible. However, we do not know how many of these enrollees To capture the impact of IRS Notice 2019-45, we compared the health plan enrollment and cost sharing of enrollees 20% 2 20 0c sh % % ond ift it aion mong s to ot ghe et rc om heafor lth p tab la le n e choosin nrollee gs (F a ne igur w e he 8) a.lt h p lan, and these medium-run effects can be identified once the 14% This study w 14% as conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), 30% su The offe rvre Iing RS y (Fr m 20 not onst or 14 ic ee . p i n, "m rP ot ra Roe ic e ye c m t ion for b Eov uc last e k ,ic su a i tc nd c ye h e r atFe nd am in m ndr p Me loy ic e de d k ic r ic a 20 s t a tion U l se 22 ow)a r.v rse: Id ic n g e c s t ha C eost ne hr ngi oug r a Sha ng l, h a ttr he he ing ir v im a A p lue p c la a ross n c -b td a on e sed Mul sig p n to inc rtins e iple mur ium C alin nc e s of nt ie c a iv d l C e e ize xpa siond g tn (V he nding it ions us -Be Ip ." D of r )eJour - p pd la re en st d v na e uc nt l o r tible uc iv f et ur e. As w Und eree r in the an H ini StA ia -e l I lig RS ible g uida health nc 12% ep, la unt n. S il t ome he d weed re uc e tible nroll e isd m in ea t, he cov alth erapgla en dw oe ith s not a he inc alth lude reimb "any urs e ser me vnt icea or rra ng bee nme efitnt int (H eR nde A).d to Fi Cha gur ndr e 3, a, P Ae m rc ite ant bh, agJona e of tPha lan n E Gnr rube ollere , s Wi and tRob h He in McK alth Cnight ondit.i on, 2010 and . "P Caha tienge nt C in En ost-Sha rollm ring enta ................................ nd Hospitalization Offset ............ s in the 8 with hea 0% lth conditions impacted by the notice in HSA-eligible health plans and other health plans17% between 2018 and 2022 data are made available. Similarly, they may not be aware of the change in plan design, despite employers’ best w 10it % h the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, ICUBA, JP 10% 2 10 0% % 13% c ser the ovv em ic ra e ag s for rk eMa e a t s a na for seve llow g H ed r SA a eC ld -a re e r in I lig e a so ible & RS N ns Sp . heFi e ot ca ia ric lt st lt h p e, y 20 t he P la ha 19 ns y r- m m 4 ga 5 a ro y cwa w yd s, it o 20 s sm so ( is 11 b a e im ll. )c . a p Eus or ste itm a tnt a he t e t ha d IRS p t rte n he m otse ium icep ha la inc ns s le re us ag ses e it im this rize ange flexib d it d. fr Se iliom tc yond t v o ira , tllow ua as he lly for ze alt rh p e o ffte o la ct 1. niv s 5 e 2015 2016 2017 2018 2019 2020 2021 11% 10% Others were in health plans that met the deductible requirement but may have not met other requirements, such as the A trnot eathe an e r wxis ayt ing to look a illness t , the inj ur im yp , a or ct cof ond IRS ition, notinc iceluding on cos dtr ugs sharor ing m is e d to ica etxa ions mine " (I tnt he e rp na erl cRe ent va eg nue e of Se enr rvic olle e 20 es p 04a)y . ing This 2021. SpE elde cifir cly ally ." , Aw mee rfoc icaus n Ec edonomi on enr c olle Rev eie s w w it 10 h 0 (1 diab)e : t19 es, d 2-21 ep3. d ressoi:10.1 ion, he25 ar7 t /a dis ee r.100 ase, .1.19 asthm 3.a , and 5% efforts to inform enrollees of a plan design change that is considered an improvement in benefits. In fact, EBRI Morgan Chase, Pfizer, and PhRMA. 10% Figure 4, Percentage of Plan Enrollees With Health Condition, by Plan Type, 2015-2021: HSA Enrollees Less Healthy, m p he ear ak clt e eh ma nt it .e Ther ana sie gre e tm w o e a offe nt s no for r p p ra re e ll vm b ee nt ium ne ive fic inc ser iarre ie vaic s. se e s on Ain t tahe ra g e p c tr e onser e d- d st erd v au a te c tiv tgible y e e sc xplor beana sis in HSA ring io w cov hee r e rp a la d ge e ns d for uc , itt ible c beerc ts w a om in hig e ers e jh us re -p v t a la alue s e ced , a c sy blin y for ic coins a lly em ur pa loy nce er, s 0% 0% restriction on preventive services. narrow definition of the "safe harbor" has likely caused some plan members to go without needed care, as it is well a nything toward their deductible by type of service. We find that among HSA-eligible health plan enrollees, the osteoporosis/osteopenia, because IRS Notice 2019-45 gave employers the option to expand coverage of prescription 0% r Geold sea m rc ah ind n, Da ic na at e Ps t ., ha Getoffr 63e p ye F. Jo rcenty c of e, ea nr nd olle Yuhu es w i Zhe ith ang. n HS 200 A-e 7. " ligib Prle esc 0% he ripti alth p on lD an rug spe Cost nd lS ess ha rting: han 3 A0 mi ssocnu iations tes c hoos With ing a DOt edhe uctri bE le nrollees More Co H paeyalthy ................................ Coinsurance ................................ Deductib................................ le Copay ................... Coinsurance 9 indic use of ate he d a he lth ca alth se re se rvic rveic s p es w rioe r rte o a m ss eum eting ed tnot he d inc edruc eatse ible d u w eill t o prlow oduc ere c ost mor -sh e e aff ring, ectivaend , clin enr icolle allye nua s’ re nc lae te dd d d eia sig gnoses ns, witw hout ere to adopt the strategy in other types of health plans. Chernew, SoMic urceha : Eme pl, loyTe ee Be re nsa efit Res B. eG arc ibson, h Institute K ersis tim tina ates bY au se- dI o senb n adme inr isg tra , tiMic ve enha rollm ee l C nt a. nSok d claim ol, s daA talli . son B. Rosen, and A. Mark Fendrick. 5% e p st era cb elis nthe agd e 8 p tha ayting inca re ny ases thinin c g tow ost a rsd ha the ring de for duc he tible alth ca for rte he ha ev ight e b e ser en va icss es e ocia xa te m dine wit dh d fell for elete r siious x of th conseq ose ser uenc vicees. Thus s betwe , en d 2 rugs and D eser ducvtic ibe les used by the Cose pay enrollees out Cosi ind se u rof ancte heir plan deductible. DThe educfir tibst le part of our Co pa ana y lysis com Cop ina sr ue ra dn ce he Sa elt e h p http lasn. :// w Fu wrw the .irsr.m go or v/ ep , ub the /irs e-m dro ploy p/n e-r19 s t-he 45.m pd selves f. may or may not have done a good job educating their employees Medication and Medical Utilization and Spending and Health." JAMA 61-69. doi:10.1001/jama.298.1.61. fun reqd uir am ed e.nt W ae lly found altering a 0.87 the or peigina rcent l int incernt ea se and in p spir reit m of ium the s w se he pn use lans. A of dop heta ion o lth ca f volu re ser ntv aic ry e, s cw lin aic s aally ss um nua en dc e to d, inc and rea se 2008. "Effects of Increased Patient Cost Sharing on Socioeconomic Disparities in Health Care." Journal of t Fi he gur U. eS. 5, DPeep ra ce rtnt ma eg nt e of Cha Tr ng ea esu in En ry isrsu olle ede s Wi guida th He nce a 15 lth C yea on rs la dition, ter in 201 by Typ 9e , v of ia H IRS N ealth P otic lae n, 20 20 19 20 -45 –20 , t21 o fur ........................ ther increase t 10 he 2018 and 2021; it increased for one (antiresorptive therapy) and remained constant for another (retinopathy enrollment in HSA-eligible health plans with other health plans between 2018 and 2021 among enrollees with these about the change. EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 –137X/90 0887 –137X/90 $ .50+.50 3 b expa ecaus nde e d of HtSA he- e low ligib erle c ost hea -sh lth p aring lan a bnd ene efit m p dloy esie grns s d ha id s t not he im pp ot ose ent ia any l to mi costt-iga sha te ring. cos tI-f re ala ll 14 se ted non rvic -aed s w hereernc e e exc , elude nhad nc fr eom See https://ahiporg-production.s3.amazonaws.com/documents/202109-AHIP_HDHP-Survey.pdf. General Internal Medicine 23 (8): 1131-1136. doi:10.1007/s11606-008-0614-0. Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. flexib screenin ilityg of s) H (Fi Sg Aur -ee ligib 9).le W he hean th lth p ela pns er cte o nt cov age er of spe enr cifi oll c elow es - pcaost ying pra e vdeent duc ivet ible ser vfe icll, it es t o fep ll b rev ee tw nte e the n 3 exa pec rc ee rb nt a ta ion o nd 30 f SouI he rce nta e :lt r Em na h c p l Re o londit yev ee ions Be nue ne ft iS to e Rr see ev sic ea eif t rch . 20 hi In04 s stn it. u ot " teP ic e ae sr ttiha m II ad Ite -induc s A ba dsm ee d ini d o st n e nr r aa dolle t m iv in ee i, ss w tP rartoc iv it eh th e ed nur ro ea l lm a l, ff ea n end tc atn eMisc d d clhe aie m alla lt s h p ne dato a la us . ns , N to oteic nr eoll in 2004H -2 SA 3." -e A ligib ccele ss ed 0% Fi gure 6, Cost © Sha 202r 3ing , Emp as a lo yP ee B erce enef ntait ge Resea of Tot rch I al Sp nse tit nding ute — , E bduca y Typ tio e n of aH nd ea Resea lth Pla rch Fund. n ................................ All rights reserv................... ed. 11 p pa re tie -dnt ed -c uc ent tible ere c dov out erc aom ge e ws, ith no allowc ost for low shae ring, r preus me ium of s t he ha alt n mos h care t p se re rv fe icre re s inc d prrov eaide sed r, oarn gd a niz the a tser ions vic (e Ps w POse)r e a nd covhe era elt dh 2 4 2015 2018 2021 p c The hr eronic ce fa nt c t.c t ond In ha c tiont te ions mrp aloy st on , e aa rm s m p ong reov -d ot e ed d he uc tow rt ible pa la rd n e b caov n si rs olle er(ing Fi eg s, t ur see he r v2) ic c.eha s on ngea in t prehe -d e pd euc rce tible nta gbea si of s onc enrolle e the es p y a wyeing re a allow ded euc d t to ible com wa es s at he Sa elt e h http pla Se sns :p // ta m ehip m orbo ee rg rso t -15 pro ha , d 20 n in uc21 tio . ot n. ht he st 3. pra s:/ he ma /ww a zlt oh p na ww .ir la ss.go ns .co.m v//pub docume /irsnts -dr/ op 20210 /n-04 9- -AH 23.p IPd _H f. DHP-Survey.pdf. C ollins, Sara R., Petra W. Rasmussen, Sophie Beutel, and Michelle M. Doty. 2015. The Problem of Underinsurance and m whe aint the ena r or nc e not or g an e aniz nr atoll ions ee h (H aMOs d a r)e, la atn ed d su dia bg stnosed antiall y c ond rediuc tion, e ag pg re rm egium ates inc healt re h ca ased re beyx p 1.5 p endit eur rce ent s. . Fi a m g ost cur ritle ic y a 7, unc l pCeha ost riod nge Sha of d rtb ing im ete w b . e y W e Ty n he 20 p n th e18 of e a H A nd e CaAlt 20 h C p21 ass a . r e e d Se in 201 rvice0, it , Am inc onlude g HSA d p -E rov ligib isions le H e ra elt qh P uiring lan Enr thatolle eme psloy ............................. ers and health pla ns 12 Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. How Rising Deductibles Will Make It Worse: Findings from the Commonwealth Fund Biennial Health Insurance cover certain preventive services in full. These include services such as screenings for cancer and other health 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 J J J J J J J J J J J J J J J J J J Ju u u u u u u u u u u u u u u u u u u aly ly ly ly ly ly ly ly ly ly ly ly ly ly ly ly ly ly ly rc h 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 re ,,,,,,,,,,,,,,,,,,, p 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0r2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 t 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 fr o• • • • • • • • • • • • • • • • • • •m N N N N N N N N N N N N N N N N N N N o o o o o o o o o o o o o o o o o o o th ................... e 587 587 587 587 587 587 587 587 587 587 587 587 587 587 587 587 587 587 587 EB RI Education and R esearch Fund © 2023 Employee Benefit Research Institute 20 19 16 17 11 15 12 14 10 13 18 4 3 6 8 5 2 9 7