The Impact of Expanding Pre-Deductible Coverage in HSA-Eligible Health Plans on Premiums

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 limited evidence on the impact of expanding pre-deductible coverage on insurance premiums. In this Issue Brief, we use claims data to quantify the effect of expanded pre-deductible coverage of services and medications specified in IRS Notice 2019-45 on premiums.

Key Findings:

The impact on premiums of expanding pre-deductible coverage for 14 services in HSA-eligible health plans as allowed in IRS Notice 2019-45 is small. Estimated premium increases range from virtually zero to 1.5 percent.
There is no expected premium increase when deductibles are replaced by coinsurance, use of health care services is assumed not to increase due to lower cost sharing, and enrollees’ related diagnoses are required.
We found a 0.9 percent increase in premiums when use of health care services was assumed to increase because of the lower cost sharing and when employers did not impose any cost sharing.
If all 14 services were excluded from pre-deductible coverage with no cost sharing, there was increased use of health care services, and the services were covered whether or not an enrollee had a related diagnosed condition, premiums would increase by 1.5 percent.

Several factors explain the relatively small increases in premiums. The percentage of enrollees with any of the diagnoses mentioned in the IRS notice is low. As a result, use of the 14 services allowed to be covered pre-deductible is also relatively low, especially among enrollees with a related diagnosis. The cost for nearly all the 14 services allowed to be covered pre-deductible is relatively low when spread across the entire population. Users of the 14 health care services are commonly high users of health care more generally because of their health conditions and often meet their deductible. As a result, even when coverage for services is provided pre-deductible, these users are likely to continue to meet their deductible. Employers could easily recoup the forgone cost sharing by imposing a pre-deductible copayment or coinsurance.

Even before there was evidence that expanding pre-deductible coverage had a negligible impact on premiums, there was an appetite among employers for adding more services if allowed by the IRS. There is also support for expanding pre-deductible coverage 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 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, National Pharmaceutical Council, Pfizer, and PhRMA.

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This Issue Brief was written IRS Notice 2019-45 lists 14 health services that may be afforded pre-deductible coverage in an HSA-eligible health plan, deductible that met the deductible requirements to be HSA eligible. However, we do not know how many of these enrollees Percentage of Users of Health Care Services Meeting Deductible May 19, 2022 • No. 558 $1 bec ,390 ome H . e A su W d as a oi:10.1 ra b t sh j f a eric le ingt utsu r e t37 o lt on, , t7/ he tC ot hlt D h a d C r ha l o e : o dK n ff ut uc a i.2 c - is tof 01 ible e Dr -i7.06 p s Fa .oc e For m a k1 s e ily 0. te t his spe Founda M asc nding ne ana gte ion. r is m io, I0 9 e $4 .w A n 8,39 c 1 e tc ; S e s I1 um 0. ss e 1r . e 0 v m d ;i c Ie 1 Se e 3 ds . p 0 t ;he ti n e I1m 3 td .h b 2 ee e ;d r I uc 5 E 15 0x .tx ible p , xa 20 n field 21 de . d ht s fr S tp a om s:/ fe /ww H all c arw la b.k o im r ffs for .org /h indiv ealtidua h- ls and m ins Rx euli d Eco ic n b atnomics ions ut no atnd enoug LLC; servic h to b e an s ard ee aA. low dhe Ma c rost ent rk Fen a to mtS ong he tair dr t u em ick, nr to eolle d ry ic M. a H ets d ion r SD A i., a L g e Un nosed ig m im itiv e sn w ,e w 2 rs 0 it he 0 ity h4 n insu r– eof 2 la0 te 2Michiga d lin 2 c hr wa onic s su n c b ond jectit tions o a .d For educ etxa ible m.p W le, he on n an with assistance from the Institute’s research and editorial staffs. Any views expressed in this report are those of the e wa ec re h w in it ah n a HS re Aq -e uir ligeib dle m he edaic lth al p dla ian. gnos Some is. Se wevre en a enro rell p er de in scr ai phe tion d alth rpug lan tw he ith ra p ae he uta iclth cla re ss imb es, urs wit eme h th nt ose arra bng eing eme 1) nt (HRA). Appendix Figure 2, Coding of 14 Pharmacy and Medical Services ............................................................................ 16 The percentage of enrollees with any of the seven diagnoses mentioned in the IRS is notice is low. 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The authors, and should not be ascribed to the officers, trustees, or other sponsors of EBRI, EBRI-ERF, or their staffs. antiresorptive therapy for osteoporosis and/or osteopenia; 2) angiotensin-converting enzyme (ACE) Pe inh r-Pe ibitrs oros for n Maximum Out-of- B t N he row ot 14 - G le old tser 's a bve ss ic rg e um s a , Zea llow rte ha ke tC donly ., to Am b ie ns it a culi b ov h C n w ere ha a ds c ndr prov ea-, d eB e re d ed uc nj on a tible m F4 a in R. 3 p .is 2r1 e a ;- H ls d F4 a e o nde 3 d.ruc 2 e3 la t l, ible tiv an e d ly b a Jona low sis. tiThe ha n m n T. ost ave K c ra olst ag ses. ea a d llow The . 20e 17 p de . a r" c m W eount nt ha atg e D for oe of ins s a the uli n is Percentage of Users of Health Care Preventive Care Service For Individuals Diagnosed With t han that dictated by the benefit design, then we flagged the member as having met the deductible. 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Services Meeting Diagnosis Meeting coronary artery disease; 4) inhaled corticosteroids for asthma; 5) insulin and other glucose-lowering agents for Eli g Dibl iabete es Health Pla ns on Pr E0e 8.xm x-Eiums 11.xx; E13 .xx; O24.xx the plan. disease $3 us car ing ,600 e ser a ny in ins vQua Iic ns of eur s in HSA ruli tthe a enc n. r ly seve eThey w Jour D-e e n me si ligib na gn: Q oul l le d of ic dhe ua E a tc l se he a onomi lit ltn y h p r vI m ic m la e e c p e ns s r srt ov 13 , tahe e e nge 2 ( m m irp e 3) s fr $3 loy nt : ,000 12 om B er ut s w 61 0.0 N d -e o 1 er2 p 31 d C euc ost g 8. ht e tuide ible r cSa etnt .p d v : ings. A b // tft o yw e 28 trw he " tw .3 p he H .nb Ient a d e lt e e e rh Af rr d cn .o e uc a nt rl Re g tfa ible /pa (ir Fiv sg e p is 32 ur nue e rm e s/ ( e 7 5) w Se t), :.21 $1 r12 A v63 m ic 0,30 51 e ong 2.p -(12 I0 in d RS) tf. 57 hose . he safe aus lt h ca ha ing rbror e 14 services. We ass Ind um ivid eu da tlhe maF xim amum ily poteInt nd ia ivl d idu ea dluctible F a re m coup ily ment In d wiv ould idua e l qual th Fa em m ily ean of this overspending Limit Deductible Deductible sharing. 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At the time, these plans had to have a deductible Sug( gb es B ) eVolum ted ta bl ci oce k tatio : erL sow ne : rFr ponst atient in, P out a- ul, of-M. pocCkhr etis cto op sthe s tre Roe nd tb o uc inC k c, o re n ag a nd e se stA iut v. e ili Ma he za arrtk tion. fFe ailu ndr re a ic nk d, /o“rThe coroI nm arp y a ac rt te of ry d Eixpa seasnding e Pre- diabete H s. y pThe ertenrse io m naining 7 health services consist H of 35 m .0e 3d xi;c Ia 1l d 0.xe xv -Iic 15 e.s a xx; nd I67.d 4i;a N g2 nost 6.2 ic tests: 1) blood pressure monitor for Bundorf, M. Kate. 2012. "Consumer-Directed Health Plans: Do They Deliver?" Research Synthesis Report No. 24 (Robert 4 ser for Cost vtic he se ha s p er nt ing rir ior efa p to lls o p t he ula by tsa $360 ion tis , fa r or e cg t ion o a 0.2 p rdlef th ss er c of e e nt p wla .he I n d n o the etd rhe uc ar td ible w iaor g:nos d s, is e m wp aloy s perre sent costs in . Use cr e is a se slight by ly 0.2 p lowe errc w ent he . n restricting claims to See https://ahiporg-production.s3.amazonaws.com/documents/202109-AHIP_HDHP-Survey.pdf. Rx The thaEco n th IRS noti is nomics assc ue m spe pA LLC tion if vce ifi re a ;s t an g the eha S d ot tp p he A. ern e r- d Ma ser die nd g v rk Fen uc ic o e tn ible s now H e cdr a ov lsu ick, te hrb a C jg ea e c M. r t is e tD o S o. tnly e he , rU v a d iniv c llow ee ds uc e e P rs tdible e ity for rta w ieof n ould nr in olle Michiga g ha te os w vIe R ho S ot n he N ha o rw v tie is c e e b e2 ha e0 n d d 1 9 cia -op 4 g5 nosed ayment w s or ith the 2005 1,000 2,000 2,600 5,150 5,000 10,000 600 28% 30% Antiresorptive therapy of Dea dtuc le B tO a ible lo st so t e d $1 o C p pov r,000 o ers o es s ru ia s rg for e ; e o m s in HSA o indiv te no itp oe ridua ni- aEligib l cov lee r H ae gaelt a h P nd la$2 ns,000 on M80 P .for r xe xm ; fa M ium m 81 H ily .s y x,” p x c e ; o E rM tv e B 8 e n RI 5r s.a i8 og I x nss e ; M ue (se 85 e B .9 rx A iepfp , e no. ndix Figur 558 (Ma e y1) 19 . A , s w 2022 ill ). b e discussed hy Triv pe erdti, ens A W m ion; ood al N 2) Johns ., p Heus aon k e in Mo flow Founda m loo, ett eion) a r nd for . Vi ht anc st tp hm e:// nta w Mor ; w 3) w . .r g20 luc wj10 f.or om . g " eI/c tnc eont rr for ea esed nt dia /da b Ae m m te b /f s; 4) ula arm tor /r ry e e tp C inop or arte s/ a C r thy e op p o a sry ctm rs/ ee 2 ent nin 01s a 2/ g rnd for wjf4 H dospit 02 iab40 eta 5. eliz s; 5 atio ) ns only those enrollees with a diagnosis, because most enrollees will not use the services listed in the IRS notice if they 5 c aoins ssocur iaa te nc d e c.hr onic condition specified in the notice, as shown in Figure 4. All the premium effect estimates presented so See( cKa ) Off iser sets Famil : Iy n som Found e action linic( a2015) l scena and rios, g Interrna eatl eR r eut ve ili nu zaet ion o Servic f hig e (2013) h-value . therapies can decrease spending on other 2006 1,050 2,100 2,700 5,450 19%5,250 10,500 25% 700 Angiotensin-converting enzyme (ACE) inhibitors in morIe n L h iv d a ee lre td d ai il b s ce oa re ts ic low eost, erH oD idH s Ps may provide coveragK e7 of 0.xc xe -K rt 7a 7in p .A xx str he m va entive services prior to the satisfaction of the health hemoglobin A1c testing for diabetes; 6) international normalized ratio (INR) testing for liver disease and/or bleeding Emp • loy erPs c rev ould entiv e ae a m si ser ong ly vric etc e he ou s r E p elde ctom he rly m c." ost e nde N e sh w d a E rb ing ngla y the bnd y U. im Jour S. posi Pnra ng el o vea f M nt piv re e ed - Se ic de ine r dvuc ic 36 e tible s Ta 2 (4 csk )op : 32 For ay0 m c-e 32 e nt (8. USP or STF coins ), ur the anc Aed v on isor ins y ulin. To are not diagnosed with a related condition. However, notable exceptions are HbA1C (hemoglobin A1c) and LDL testing, far assume that the diagnosis associated with the chronic condition exists in the patient medical claims. It is reasonable C 6 opser yrig v2007 ic he t In s (e. form g., hospit 1 a ,1 ti0 o0na:liz Ta his tion r2 es) ,p 2. or 0 0 t is copyr2 ight ,85e 0d by the 5E ,6 m 5p 0loyee25% Be5 ne ,5fit 00 Researc1 h I 1,ns 00t0 37% itu St pe e nd (EB ing RI 800 ) pe . Y r ou may copy, Beta blockers Chandr In B a sl, e ue A lin d m in ait g na d db io s h, to hre d Jona re g rs luc tha ose n -lo Gw rube eringr , aa ge nd nt sRobin McK D65 night .xx-D.6 20 8.D x10 x iab . e"tP es atient Cost-Sharing and Hospitalization Offsets in the p la Se n d e Inte educ rna tible l Re . vEenr nu olle e Se es in p rvice ( la 2004) ns tha . t meet these and other requirements are allowed to open and contribute to a r de is cor oup de r$3 s; Com 60 and , m eit 7) mtp e dlow loy e oi:1 on e -d 0.10 rs c I em ns ould m 56 ituni y/N lipop rza E eJM q tion uir rb ot e e e P t a a in (L r a sa $2 ct 09 ic 0/ De 0 L fil s (A 45 ) l c te 33 op st C.Iing a Py ), m for te he nt he , Ha e ass a rtlt um h dis Re ing easour se. insu ce lin s a is nd reSe fille rvdic onc es A ed p m eini r m stont ration' h. The s (H$2 RSA 0 's) R as t ehose sults ar e used more in the general populatA ion. T A G L A N C E Spending per Proportion of Enrollee With to assume that enrollees with claims for insulin have been diagnosed with diabetes. However, a claim for LDL testing print, or downloadI nth his ale d re cp oo rtrit c o solely for steroids personal and noncommercial use 21% , provided that all ha 29% rd copies retain any and 2008 1,100 2,200 2,900 5,800 5,600 11,200 900 R H eeE tia n lde ro t p dr a is ly th e." y a s sA e cm ree er nic ina gn Economic Review 100 (1 I00) .x : x19 -I92 9- .x 21 xD3. d iabeoi:10.1 tes 257/aer.100.1.193. health savings account (HSA) on a tax-preferred basis. Thus, these plans are also commonly known as HSA-eligible 7 copaymeB nt right would Fu tb ur ee le Pss roje tha ctn th , and e $3 HRSA 5/m a on nd tht he cap I ns on tit out ute- of of -p Me ocd kic etine spe (I nding OM) c tom hatm w itats r ee eon cent wly om inc en' lude s clin d iin t cal p her eventive See Internal Revenue Service (2004). Enrollee Total Spending Diagnosis Health Service There is already an appetite for adding more services, as evidenced by 24% The Chronic Disease 26% Management Act, which cannot be assumeId n stu o lin b e a nlim d oit th eed r g to lu cp oe sop e-lo le w e w riit nh he g ageanrtts disease, and diagnosis codes do not appear on every claim. all copP ye right 2009 ak fl oa wnd me ot te1 he r,1r5 a 0pplicable2 ,not 300 ices conta 3ine ,00d 0 therein, a 5A ,9 nd s5 th 0 m you a may5 c ,8 it0 e0 or quote 1 1 sm ,60 a0 ll portions1 of ,00 the 0 report Using p Prre esc scrripti iption on d Drrug ugsand medical claims data on AH aFS ll in Th div eridua apels ut iin t c Che las sfin esal analytical sample, we flagged each of the I VB RS N ID ot He ic ae lt h. 20n.d 19-. 45 "Fi ana llow ncs iahe l Im altph sa act v of ings a HSA-cH count DHP Re (HS for A)m -e ligib to Im lep he rov ae lt h p Accla ens ss tto heC hr flexib onic ili D tyis te o ac se ovMa er na 14g m em ed eic nt a tions and health plans. In 2022, these plans must have a deductible of at least $1,400 for individual coverage and $2,800 for The Afforim dap ba le ser c tI v ns on iculi ep s (r r n N em eow q ium uir A s ec d of t b pe y a xpa ss Se ecd nding t ion by t27 he pr 13 eU. - d of S. edtH uc he ouse t ible Patie of cnt ov Re e Pr p ra ot rg ee e sent c fo tion ra 14 tiv and eser s. A vff icor es in HSA dable Ca -r eeligib Actle of he 20 alt 10 h p (A laC ns A) a a s a nd llo IRS wed 8 See InternaM l R edi evce anu tion e S service (2004). was reintroduced in the U.S. Congress as recently as May 2021. This b 23% ipartisan, bicameral le30% gislation would provide Ther Chere ne for we , ,Mic em ha ploy el, S eTe e rs a lercetnd sa ive B he se . ra G olt tibson, oh p nin la rens uK p rtm is akta e ina y i n e hY rir b u ion t-o Irsenb st he (SS e si R r F d g Is ie ,g ) Mic u of rec ha 5 ov ee l C ring . Sok all L ol, DA Llli te son B sting . a Rose s it m n, aa ynd beA m . or Ma er k c ost Fely ndr to ick tr. y to provide Gd lu 2010 c tha omte y teou r d1 o ,2 so ve 00 rbatim2 ,a 4nd 00with prop 3,e 0r 5 0 citation. A 6D ny ,1 ia 5 b us 0 ete e sbeyond 5,9 t5 he 0 scope 1 of 1,t9he 00 foregoing 1 ,r 0e 0q 0uires EBRI’s Antiresorptive therapy 92:24:00 14 servicMe es us dicing ations the." c A od cc ee s li ssst ed e d A p in ril 7, App20 endix 22. ht Fig tp ur s:/ e /2v.b P idhe atiea nt lts w h.com ere/do clacss s/H ifie Sd A -w Hit Dh a HP -d Re ise for ase m-if t Brie he f.p y d ha f.d at least one fa otm heily r he coavlt eh raser ge.v ic Enr es us ollm ee d 5nt to in HSA preve- nt eligib the le e xa he ca elt rb h p ation o lans m f cahr y onic accoun cond t for itions ove p r rone ior t-o ha m lf eof eting those thew p itla h p n d riv ed at uc e the ible alt . h There in IRS Not Not ice ic e 20 20 1913 -45 -57 is) .su mmarized in Figure 3. In general, the effects vary in several ways but are relatively small, $0.68 0.01% $634 Antiresorptive therapy 9 20% 26% HSA-eligib 20 le 08 he . " aE ltff h p S etc at la ts of in ns s U a Id nc sd e rit eo iona afsed Hl fle e a Pa lxibilit tth ie C nta yC r t e os o S tp e Sha rov rvide irc ing e s p r on P e- ed Soc re ta diuc ioe nitn ible conomi g t o cov IR ce S rD a is g Np eo afor triit cie e se s in He 2r0 vic 19 es t -4 a5 lt ha h C t p arre ev ." e nt Jou the rna l of determ Hine em ow glhic obih cl n A1 acim 1 tes for sting LDL testing are related to enrolleD es w iabeit te h he s art disease. If we relax the diagnosis p rSior ee e the xpress An 2011 g lite iotra e n p ture sein rm -c re o is 1 nsi v ,v 2 ie e on. 0 rw t0 in sg For in enBund zp ye m r2 e m o , 4 (rf is A 0si C ( 02012) ons, p E) inhi b a le ind to a 3 rse s ,0 Ag 5 2 c0 r4 ont a:w 08 a a .l, 4 c4 tM .E 0a 4 B 6 z ;RI ure ,2 14 5 :a nko, 0 3t2 .p 0e 4 & rm Me issi 5 na ons@e ,9c5 h0 emi b(r2017) i.or1 g1 ., , 9 a0 s0 well as re1 se ,0 a0 rc 0h in Brot- inpatient or two outpatient (on different dates) claims during the year (using ICD10 codes). The prescription drug is Ins lim uliit ne a dnd evot ide he nc r eg luc on ose the- lo im w pe arcing t of ae gxpa ents nding are tp he re c -d ost edlie ucst tible of tc he ov e 14 ra g ser e v on iceins s tur haatnc ca en p b re em cium over s. e d I n th pre- is d e Iss duc ue tible Brie in t f, we he coverage (Figure 1). regardless. The estimated premium increases range from virtually nothing to 1.5 percent. $0.50 0.01% $37 Angiotensin-converting enzyme (ACE) inhibitors Medical Services e Go xa ld cb ee rb rg a,t ion o Chand f c rahr , H onic and c eond l, & it Kols ions ta . d (2017); Chandra 11, Gruber, & McKnight (2010); Chernew, et al. (2008); Collins, r W eq ha uir rae Im nm te , G e rJ. n e nt a ne tFr sio , ra n a pa nk l I rle n , m nt oFa rium e m rng a nla is zl M Zh e inc d a e rr a ng, d e tic ia ose ine (E IN m b R 23 e m ) ttw a e( se 8) M. te in : n 0. gE 11 gg 31 2le p -st 11 er on, c36 ent . C d hr aoi:10.1 n ist d ine 1. Li5 v e 00 Yp r. e d7 L irs /s u, cee 11 ant St se 60 .e a p6 nhe d -008 /o n B r b-l. e 06 e Soum d14 ing - 0. d ei s ra oi, rde arnd s Dennis Ross-Degnan. Be 2012 ta blockers 1,200 2,400 3,10 20 4:24; 24:08 6.,0 28 50 6,050 12,100 1,000 t Ihe RS noti ra •p eut cP eic e . r H iod cla enc ss ic e e he , s w if oth alt eh e ree v id ra e ser lua ntifi v tions ic ee ds w us su ing ecrh a e tche s a ov e A nnu rH eFS da on l p . hy a The p sircea m -ls dee d a dic nd uc al d tsele ible ev c ic b te ap s a si rs w ev nd eit nt d h no iv iae g nost sc co re st ic e nin sh tea st grs not ing s w, et rhe lis e t c e c aha d te a g nge b oov rize e in c d us ost ing use claims data to quantify the effect of expanded pre-deductible coverage of services and medications specified in IRS Beta blockers $0.49 0.01% $126 Rasmussen, Beutel, & Doty (2015); Fronstin & Roebuck (2019); Fronstin & 41% Roebuck (2013); Fron46% stin & Roebuck (2020); Report availabilit Bly o: o d Thi pre s r sse up re or m t ois n ita ov railable on the internet at www.ebri.org L 12 Io nw h 20 a -d le 18 ed n s . cio " ty rE t iff l13 c ip o eo s cp tte r o rof o te id iH n s igh (LD-LD ) e te dsuc tintg ible Insuranc5e 2 :on 08 .0 H 8igh ; 48 -H :A 1 e c 0 a uit .r 0 t8 y d is Out easc eomes in Diabetes: A Natural Experiment for 2013 1,250 2,500 6 3,250 6,450 6,250 12,500 1,000 Figure 1 HCPCS and CPT codes. It is worth noting that IRS Notice 2019-45 is not particularly precise in its specification of the P N sh rot e am r ic ing e ium 20 a(s inc nd 19 op- tsu iona 45 reb aon seq se l, p p u te he ree rnt m Ile RS N ium im ast ps a ot (.c 0. ic t 03 on e 20 p ee m 04 rc p-e loy 23) nt) e. rin t cost hes w follow ouldin b ge c m irc ini um ms atl. a nc For e: example, enrollee cost sharing would fall by Percentage of Fronstin & Roebuck (2014); Fronstin & Roebuck (2016); Fronstin, Sepúlveda, & Roebuck (2013); Fronstin, Sepúlveda, & $7.25 0.1% $960 Inhaled corticosteroids This Collin w s, Sa ork rgar eR a., tly P e im trp ar W ov. eRa s usm pon usp sen, rior Sop relahie ted B re esea utel, rca h. nd A H Mic IPhe cond lle M. uct21% D ed ot a y . st 20 udy o 15. The f heaPltrh p oble la 27% m ns of in 202 Unde 1 t rins o ur ass anc ess e t ahe nd Peak flow meter Selective serotonin reuptake inhibitors (SSRIs) Depression Insulin and oth Percen er glucotag se-lo e wo ef rin Perso g agenn tss Enrol6 led 8:2 0 in :0 0 a High-Deductible Health Plan (HDHP), by Translation in Diabetes (NEXT-D) Study." Diabetes Care 41 (5): 940-948. doi:10.2337/dc17-1183. 2014 1,250 2,500 3,300 6,550 6,350 12,700 1,000 Figure 4 Enrolled 14 $100 ser /y ve ic ae rs. for Thu inh s, w aled e c aor dop tictost ed ear oid rela s ta ivnd ely$1 br0 for oad int SSRI erps. re These tation o re f th pre esent list. 0.02 For e p xa erm ce pn le t , aw nd e inc 0.01 lude pedr ca ess ntoc of iae te m dp p loy are ts r Roebuck (2013); Fronstin, Roebuck, Buxbaum, & Fendrick (2020); Goldman, Joyce, & Zheng (2007); Trivedi, Moloo, & Mor $98.33 2% $3,627 Insulin and other glucose-lowering agents impact of expandeG dl u p cro em -d ee ted ructible coverage in HSA-eligible health pla 34% ns on premiums. It found 33% that about one-half of How Ris Emp ing D lo ey der uc tC ible ons Wi tribu ll ti Ma on k e to I tH W SA or se: or H FiR nding A,* A s fr mo on m g t T he h o Cse omW mionw th Pr ea iv ltate h Fund -Secto Biernni Heal al He th alth I 7 nsurance Statins Heart disease and/or diabetes Selective serotonin reuptake inhibitors (SSRIs) P 2e 8:r1 c6 e.nt 04a .2 ge 0 of Population Using Average Use • Employers impose coinsurance. Key • Fi nding 2015 Obe s: si ty we1 ight ,30- 0loss prog 2r,a 6m 00 s and tob3 a,c 3c 5o 0cessation p 6,65 rog 0 rams (opti 6,45 on 0al, per 1 IRS N 2,900 otice 2004 1-,23) 000. (2010); Wharam, et al. (2017) Prev ; alen and W ce hara ofm, Diag et al. no (2018) ses .Pertain ing to IRS Notice 2019-45 he and altsu h sp ppe lie nding s for, tr he espe me cd tiv ice aly l su . pplies (e.g., test strips for glucometers). Selective serotonin reuptake inhibitors (SSRIs) $1.85 0.04% $104 Coverage and Employee-Only Coverage, 2016–2020 Retinopathy screening 22% 28% he Wha altrh p amla , Sur J. nsv Fr e expe a ynk , 20 r , ie Fa 14 nc ng . eN de Zh a w a p Y ng, ror em k E ium , m Nm Y :inc a The M. reaE C se gom gof lem st le onw on, ssE te nrol C ha a hr lt n 1 ih Fund. lst ed ine pe rY c. e A L nt u, c, ce a St ss nd eep d 8 he – Se 19 n So p tp ee um m rc be e ent H r ra e 15 i, a elxpe a t, h nd 20 C ra i21 D ernc e e. nni eds Ross no Amp on re -g D me E ium g nrol na n. led Table S to atf insContents 24:06.1 • Enrollees are diagnosed with the requisite conditions. So2016 urce: https://1 v,b3 id 0c 0enter.org/i2 n,i6 tia 0t0 ives/hsa-hi3 g,h 3 -5 de 0ductible-h6 e, a7 lt5 h0 -plans-2/ 6,550 13,100 1,000 10 See Lee, Maciejewski, Raju, Shrank, & Choudhry (2013). $4.65 0.1% $126 Statins Population Using Ave 20% rage Use Service W 25% hen Population When Hemoglobin A1c (HbA1C) testing change. Yet, this survey also found that there is great deal of remaining uncertainty regarding the effect of Notice • • 20 D The htrtugs 17 ps:/ im . "t/ww p D aa k ia c etb n b w e on .c te y om s Out p a rsy e m m m oium p nw p attom ie e s of a nt lt a hf tC ie cund.o a xpa r indiv e nding and ridua g/s A it cp ls ut e r s/ e te o - d d C p e eom r fa d euc ult vp etlic nt /f ible ile a tthe io sc/do ns ov m e c B arum nif e afor ge e est nt e for aa s/ tnd ion o _ 14 __ A ser m ft f d e ev rd is ic H ia e eigh _f a s in HSA se ile -D s_ (op ep dtub uc iona -e tlic ible ligib a l, tions p le Ie ns rhe ur _is IRS N a alt su nc h p e eot _br la icns e ie f_ as 20 Devic He eart Di s sease HCPCS Codes 7% Introd • uc2017 tU ion se ................................ of hea1 lt,h ca 300re servic2e,s d 6 ................................ 00 oes not inc 3,4 re 0a 0se be................................ caus 6,e 7 5of 0 lower cost 6,5 5sh 0................................ aring. 13,100 .......................... 1,000 4 Impac Cotngr Ana elys ssis ional of Pre E-ff Ded ort uct s tio ble Fur Cov the erarg E e xpand Pre-Deductible Coverage Health Care Among Enrolled Diagnosis Is Diagnosis Is 11 Medical Services 8 39% 42% International normalized ratio (INR) testing AHFS® Pharmacologic/Therapeutic Classification© used with permission. © 2022, the American Society of Health-System 2019-45 2004 E a 15 on llow nr _m ollm pr-e a e 50 d y m e _ ) in nt ium .18 : I17 RS N A s. I _ Nc n th aollin ot tur ice a e s_ l Ex A 20 p HrI 19 p ob Pe -rle su 45 im m r v e_of_ is e nt ysm , for 15 unde a ll. Tr p e E a rrs ins ns c te im la ur nt t aion in a tof e nc d ful e p _ib.p rly D e m ia ins b ium de f. ur t e e s (NEXT inc d p rla ea ns ses -aD nd r)a St nge 29 udy." pfr eom r cJA e nt v M ir A of tua Iself nt lly e r- ze na ins rl M o urte o ed d1.5 ic pine lap ns e 177 r n ce ot nt e.d Blood pressure monitor A4660; A4663; A4670 80% 2018 1,350 2,700 3,450 6,900 6,650 13,300 1,000 Service Population Indicated Indicated Health Service $0.004 0.0001% $71 B To ace kst grim ound ate ................................ the B lim ood p a pc re t sof surp er e m-o dne itd o................................ uc r tible coverage for th ................................ e 14 services, we first................................ summed the following ........................... fields from all 6 Low-density lipoprotein (LDL) testing 17% 25% Pharmacists, Inc. (ASHP). The Data is a part of the AHFS Drug Information®; ASHP is not responsible for the accuracy of that it is too early to know what impact the Notice had on premiums. Another 7 percent of fully insured plans and 17 If em • ploy PeTher (a 3) ekr s c : flo 35 ew hoose is 8 m -no e 36 te8. d re to xpnot oi:10.1 ect e im d p p00 ose re1 m /j a iu a ny m m a c inc int ost ree rsh a nm se ar eing w d Ahe .201 4, 6n d p 14 r6.84 e ; e m Ad 4 ium uc 6 11 2t7ible .s inc ; S8 s0 rare 9e 6a ; se S re 80 0. p9 la 3 7c ; p e Se d 8r 1c b 0 e y 0nt ;c S oins . 810ur 1; a Snc 81e 1, 0use of health care Building Hy on pert tehe nsi om n omentum of Executive Order 13877 and IRS Notice 2019-45, Se 5% nators John Thune (R-SD) and A 2021 EBRI survey found that 76 percent of employers with 200 or more employees increased the number of drugs 2019 1,350 2,700 3,500 7,000 6,750 13,500 1,000 Medications Peak flow meter $0.01 0.0003% $38 transpositions from the original context. flagged claims: deductible, coinsurance, copayment, plan paid amount, and total allowed amount. These aggregate I Fr nc onst reain, P ses in c aul, a onsu nd m Ae . rMa out rk- of Fe -p ndr ocic ke kt. c 20 os21 ts for . "E m he pa loy lth ca er Up ret a ha ke v eof be Pe re n -D ass edoc ucia tible ted C wov ith d eraeg le et e fo rious r Pre c vonseq entiveue Se nc rveic s.e s in These Source: Employee HDH Bene Pf O it nl R yesearch In HDH sA ti4 tP u 2 W t3 e3 ite ;h E s At4 imp m 23 a loy 4 te ;er Co sA b 4a 2ntri s 3e 5d b ; uti A oon 4 n2 a 3 to d 6m HS ; A in A 4 i or HRA s 2t4 ra 5t;i v A e4 e 2n 5r3 o;l lm A4 e2 n5 t 6 a;n A d 4257; A4258; D p e artc ae a nt nd of ser St self v udy Sa ice -ins s is ur m ae p ss d le um p ................................ lae ns d not rep o tr o te in dc “ re ot ahe se r” d ................................ ue whe ton low aske erd c a ost bout sh a the ring, ................................ ima pnd act eof nrolle the eN sot ’ rie cla e. ................................ te Ndo dciont agnoses ext wa as g re r iv ee qn for uir .......... ed t . he 7 70% Tom Carper (D-DE) introduced the Chronic Disease Management Act of 2019 in the Senate (S. 1948), followed a nd services covered pre-deductible in HSA-eligible health plans as a result of IRS Notice 2019-45 (Fronstin and 2020 1,400 2,800 3,550 7,100 6,900 13,800 1,000 Glucometer 1.7% $0.40 7.1 0.01% 0.1% $310 7.7 AntiresorptiG ve lu tcho em rae pty er figures were div cide laim ds b dya tta he . total sample size to derive mean values. The average annual deductible amount (per inc 12 lude fin HSA anc -E ialigib l strle ess H, ew alt or h P se la dns ise ." a se EBc RI ont Iss rol, ueinc Brrie Ae4 f, no. a 2ses 59; E in hosp 54 062 07 ( ;E E it m 0a 6 p liz 2 loy 0a ; te E ions e 2 1B 0, e 0ne ;a E nd fit 21 e 0 Re xa 1 se cea rr bcah I tion o nstit f he utea ).lt h disparities, Figure 3 “ot Th he er ”H r ee asponse lthcDe are pr e s, b Commo ssiout n wn e P cro an conc cedurelude Cod ing tha tS y 22 ste p m er(cH eCP nt CS of fully ) is a c ins ollur ece tion d pla of ns sta and nd ard 46 iz p ed e rc co ed nt es of tha self t re -ins preur seent d p me lad ns ic a sl till • We found a 0.9 percent increase in premiums when use4% of health care services was assumed to increase by the introduction of the companion bill in the House of Representatives (H.R. 3709) by Representatives Earl Fendrick 2021). Pre-deductible coverage was often added for health care services related to heart disease and diabetes Methods2021 ................................ 1,400 ................................ 2,800 3,600 ................................ 7,200 7,0 ................................ 00 14,000 ............................... 1,000 8 5.2% $1.23 9.4 0.02% 1.3% $262 9.7 Angiotensin R -c eo tin nv oe pra titn hg y e sn cz re ye m ne in (g ACE) inhibitors 9 covered P rlif oc ee ) du for re t she 14 services represents the expe CPc T te &d H cC ost PC S tha Cod t w eill s be shifted from the member to the plan sponsor p p ro arc tic ed ula ure rly s, tshose uppliew s,it p h ch roduc roni ts,c am Im nd e dpa sic erv act l c ic e ond of s. Expan itions and ding low e Pre r hous -Ded ehold uc tib incle omCo es.v I erage n fact, there is a body of peer- 57.7% d o not k60 now b% eca w us ha e tof im the pa clow t theer N cost otic sh e ha aring d on and prew mhe ium n s. em ployers did not impose any cost sharing. Blumenauer (D-OR) and Tom Reed (R-NY). This bipartisan, bicameral legislation would provide HSA-eligible care. Two-thirds added pre-deductible coverage for blood Fi g pu rr ee ss 8 ure monitors and insulin/glucose-lowering agents, 61 2022 1,400 2,800 3,650 7,300 7,050 14,100 1,000 Beta blocke Hre smoglobin A1c (HbA1C) testing 4.1% $1.12 8.7 0 55.3% .02% 0.4% $38 9.8 Fronstin, Paul, and M. Christopher Roebuck. 2020. "Managing Use of Health Care Services After People Satisfy Their 67028; 67030; 67031; 67036; 67039; 67040; 92134; 92227; 92228; because of the forgone member cost share in the form of de53.6% ductible contributions. In this case, we assume that the r evM iew easur ed lit em eraent tureo d f e 1m 4onst Health rating Serv in tha ic HSA tes sele ................................ -c Eligibl tively low e Health ering cost Plans ................................ sharing on for Pr high emiu -vams lue ................................ chronic disease m...................... anagement 8 13 53.0% Diabetes 3% Curre • nt If a Pro ll 14 se cedurarl vTe ice rmino s welog re e y xc (CP lud T) e d re fr feom rs to p rae - me ded dic uc at l ible cod e c ov see t,r a cr geea te wit d,h no and c ma ost inta shin areing d b, yt he ther e Ame waric s inc an rMe eased dica l use of health plans additional flexibility to provide coverage for services that manage chronic conditions prior to meeting percent added coverage for glucom Im ep te arc s, a t ond f A54 dd p in eg rc P ent re a -D dd ee ddu c cov tib elre a g C eo for ve r ba eg tae b o lo n ckers. Health care services least 8.7% 2.7 0.8% 4.9 Inhaled cortIn icto es rn te ar to ioid ns al normalized ratio (INR) testing $0.16 0.003% $82 Retinopathy screening 92229; 92230; 92235; 92240; 92250; 92260; 2022F; 2024F; 2026F; Deductible: What Do Copayments and Coinsurance Do?" EBRI Issue Brief (Employee Benefit Research VB emIp D loy He era lt ph ha rovide s q s fir uant stifi -de olla d tr he c ov pot ere ant ge ia fo l fina r the nc ia 14 l im ser pv aic cte s t on hr eou nrolle ghout e out the -of y-e pa oc r.k W ete sp meanding ke this a nd asse um mp ploy tion b er spe ecandi use ng it of is m edications can meaningfully improve adherence; reduce the risk of adverse health outcomes; and, in some cases, Association 50% . It is used by providers oUs f he e Fl aat, lth No O care ther Cos servic t Se ha s rto ing tracUs k the e Hi gh se er, No rvice O sthe and r C os pro t Sc he arin dure g s they perform for purposes of 47.1% health care services, and the services were covered whether or not an enrollee had a related diagnosed Im the pact plaAn n d al ey dsis ucto ible f P.re The -Ded bill u ctibl waC s r e oes C int to S v rod erag ha uc rie n ed g ................................ 2 in t 0f2 o 3rhe F; E 2 m Se 02p na 5lF; ot y e 2 e 0in Ja 3 e3-F; O nua n S................................ l0 y 6 r 2 C y 0 o ;20 S v0 20 e 6r2a 1 (g ;S. S e3 32 0000 0 ) a ................................ nd April 2021 (S. 1424 ......... ) 8 likely to have pre-deductible coverage were peak flow3 m .8e %ters a$ nd 1.7I8 NR te 14st .3ing (25 0.0 p 4% ercent 2.7 e %ach). Most $34 emp 1loy 6.7ers did Insulin and L oo th we -d r e gn lu sc ito ys le ip -lo op w re or tie nig n a (L gD eL n)t stesting Institute). 10 unl billiik ng e ly and tha cla t a ims n e p m ro pcloy ess eing r w . ill provide pre-deductible coverage with no cost sharing and then impose cost sharing once r ee xpa duc nding e exp e pndit re-dur ed euc s.tible coverage Us te Fl o 57 at, A dvrerag ug e Co class inse ura s nc us eed to Us tr e H ea igh t 11 er, A c vhr eraonic ge Coi c ns ond uranc itieons (VBID Health n.d.). It found Asthma 1% 25.7% Hecm ond oglit ob ion, in Ap 1c re (m Hbium A1C s w ) teould sting increase by 1.85 3 0 p3e 6r;c 8 e3 nt 03 . 7 a1. nd 6%in the House of Representatives in May 2021 (HR. 3563), building on the IRS guidance and previous versions not eliminate cost sharing for the pre-deductible servic 7e .4 s t %hat$ w 4,e 94 re 7 .2 a8 dde 8d .1. The p 24.4% ercenta1g .8 e% eliminating cost8 sh .0 aring SelectivTo e ste arlotonin reuptake inhibitors (SSRIs) Re sults ................................................................................................ 24.8% ................................ 1.5% ................................. 9 t aha n e t nr cov olle ere ing me ae ll t ts his hese or d rhe ug r cd la ess duc es p tible re.- d Ie n p duc rior tible w ow rk it, h a we cfound ombina tha tion o t the f c m op aja or ym itye nt of e s a m nd ploy coins ers ur im ap nc ose e w d ould som e inc for rem ase of 40% 25.8% International normalized ratio (INR) testing 85610; 85611; 93792; 93793; 99363; 99364; G0248; G0249; G0250 to Stfur atints her increase pre-deductible coverage for chr 7onic .5% disease mana 9.g 3ement. 3.7% 9.5 Fr r aonst nged in, P from aul, a 25 p nd erM. cent C hr to is40 top p he errc e Roe nt, bduc ep ke . nding 2019. on "Do the Ac ser cum vic ula e.t ing The H20 SA 21 B a Ela Bnc RI esu s A rvff ee yc a t ls Use o found of Hetaha lth C t maost re Services Insulin and Other Coronary Artery With IRS Notice 2019 22.4% -45 in place, HSA-eligible health plans are now able to adopt a more flexible benefit design, c ost sharing in lieu of a deductible, ranging from 60 percent to 75 percent, depending on the service (Fronstin and premiums by 1.7 percent. 0.5% Several factors explain the relatively small increases in premiums. The percentage of enrollees with any of the Discuss Lion ow- ................................ density lipoprotein (LDL) ................................ testing 80061................................ ; 82465; 83700; 83701; 8................................ 3704; 83718; 83719; 837........................... 21; 83722 10 Disease Glucose- Inhaled Selective Me1. di 4% cal Services employers w S ould ourc ea :d E dm p prlo ey -e de e d Buc enteible fit R e cs ov ea err ca hg In es for titu ta e d ed sit tim ioa na tel he s baa slt ed h ca on r ae d m ser iniv stic ra ets if a ive enll ro ow llme ed n tb ay n d la cw la.i ms data. and Spending?" EBRI Issue Brief, no.482 (Employee Benefit Research Institute). offering more protection for certain medical services through a value-based insurance design (V-BID) plan structure. As 30% Fendrick 2021). d iagnoses mentioned in the IRS notice is low. As a result, use of the 14 services allowed to be covered pre-deductible is Lowering Agents Cortisteroid Serotonin C onclusion 0.02% 1.2 0.01% 1.1 Blood pressure monitor Conclusion .......................................................................................................................................................... 14 Data and Study Sample the market for HSA-eligible health plans grows, it is important that these plans use this flexibility to allow for effective Overall, 8 pLi er vc er Dis ent ea of seenrolle0.3% es with individua No l c S ov ere vria ce gs e met tC he ov ir e rd ee d dP uc re tible - , and Cov 7 p eree d rc Pernt e- with faR m eil up y tc aov kee rage did so. also relatively low, especially among enrollees with a related diagnosis. The cost for nearly all the 14 services allowed to Fr Ther onst e in, P are seve aul, a ra nd l wM. ays in w Christhic ophe h e rxpa Roe nding buck . p20 re13 -de . d"uc H0 et.a ibl 1lt 2e % h C cov are er a Sp ge e nding may 1 .5 im aft pe arc tA p dr op em ting ium 0.0 as. 4 Fu % Ellxpa -Rending place m the ent 1 g ., 7eH ne igh ro-sity Peak flow meter 1.2% When enrollees face reductions in cost sharing for health care, they are likely to increase utilization. Nonusers may health management for all beneficiaries. A C ta ov rg ee re te d dP st rer-ategyD e explor ductiing ble c for overag De e du forc tcie bl re ta fin hig or Ih nh -via bi lue tors , c (lin SSic Ra Is lly ) Appendix 20 ................................ % ............................................................................................................................ 15 I The n rep sponse ercent atg o eI RS N of usot eric s of e 20 the 19 -14 45 , he thr alt eh ca e-qua rer t se errs of vices la lis rgtee d e m in t ploy hee IrRS noti s offering ce m HSA eet-ing eligib the leir he de ad ltuc h p tible lans w ea xpa s m nd uc eh d pre- be covered pre-deductible is relatively low when spread across the entire population. Users of the 14 health care of cov G elu ra cg om e e sh teift r s spending from enrollees to the plan. 0 .E 1% nrollees may inc 3r .2 ease services ut 0.ili 1% zation when the3 ir. 7cost-share Deductible Health Plan With a Health Savings Account: A Five-Year Study." EBRI Issue Brief, no. 388 For the present Osteo pst oros udy, w is; e utilized the IBM® Marketscan® Commercial Claims and Encounters (CCAE) Database and Deductible Diabetics Asthmatics for De 32.0% pression d ecide to initiate use of health care (i.e., the extensive margin) and existing user30.9% s may increase their level of utilization indicated health services prior to meeting the deductible will produce more effective clinically nuanced designs, without 0.3% 28.9% higher. Depending on the health care service, the percentage of users meeting their deductible ranged from 17 percent d eductible coverage for medications and 27.1% services that prevent the exacerbation of chronic conditions. The impact on services are O csom teop m enonly ia high users of health care more2 g .2e % nerally because 1 .of 8 their health condit 0.5% ions and 1.0% ofte2 n me .5 et their ReferR enc etin eo sp ................................ athy screening .......................................................................................................................... 17 declines, (le Em ad ping loyete o B highe 24.8% enefit r h Re easea lth ca rch I re ns cost titu s a te) nd . — as a result — higher premiums. However, there might be cost 1.0% IBM® Marketscan® Benefit Plan Design (BPD) Database. Data from 2018 were used — the last full year preceding IRS (i.e., the 10 P int % lae n ns Div es ei gn margin). To model this scenario, we repeated the analysis described above but included a utilization- fundamentally altering the original intent and spirit of these plans. Adoption of voluntary, clinically nuanced, expanded p for re m LD ium L te s of sting expa use nding rs to 41 pre p -d ee rc de uc ntt ible for tchose overarg ee ce fo ivr ing 14a ser blood vice s in HSA pressure- e m ligib onit le or he (Fi ag ltur h p ela 7) ns . A am s a ong llow te hose d in us IRS N ers w otit ich a e deductible. As a result, even when coverage for servic 1e 3s .3is % provided pre- 1d .4 eductible, these 2.9us %ers are likely to 2.3 continue to Hemoglobin A1c (HbA1C) testing offsets from increased use of 0.9% other services. Despite these theories, there is limited empirical evidence on the impact of N Endno otice t20 es 19 ................................ -45. Member health insu ................................ rance eligibility inf................................ ormation, as well as m ................................ edical (inpatient and ............................ outpatient) and 19 Deductible $3,000 $3,000 $3,000 $3,000 inc rease Ba lee ssdi um ng D pit sion. order Using 0.1% the often cited -0.2 elasticity of demand estimate for outpatient medical care from the H SA-eligible health plan benefit designs has the potential to mitigate cost-related non-adherence, enhance patient- related diagnosis, the percentage reaching their deductible was even higher — ranging 4 from 25 percent to 46 percent. Fr 2019 onst -45 in, P is asul, M mall.. P Crhr em isium tophe inc r rRoe eases bucrk a, nge Jason B fromuxba virtua um 2lly .2 , % a not nd hin A. gMa to rk 1.5 Fe 2p ndr .4 erc iceknt . 20 . E20 mp . l" oy D0e o .r 2P s c % eo ap n lem C ini hoose mize W the 4is .6 em lyino Afrt er meet In the terir na d tio en dauc l nto ible rma.l iE ze m dp rloy atioe (rIs c NRould ) test ie ng asily recoup the forgone cost sharing by imposing a pre-deductible copayment e xpanding pre-deductible coverage on insurance premiums. A recent AHIP survey of insurers found that most 0.8% pharmacy claims, comprised the CCAE files. The BPD database provided carrier-specific individual and family deductible 0% Coinsurance 10% 10% 10% 10% RAND Health Insurance Experiment (Newhouse 1993), we assumed a 20 percent increase in utilization for the 14 centered outcomes, allow for lower premiums than most PPOs and HMOs, and substantially reduce aggregate health Our cost s a fin Lod ss wing Sa -oc detia n is ts ha tfy ie ty d t ing lp iw pro it e H ph e m re oa ium te lt xpa ih P n s inc (L nding la DL n D )r e te a e s p sed d trin e uc g - d tvible e ed ry uc s? lit t ible tE le v ide dcue ov nc e te o r 2 aFr 8 tghe .e om 3 % bey xpa t he im ns p Use osin ion o of g f p c Lom ow 1r .3 em --Va don elue d uc cop t H ible a ey am lt c h C e ov 5nt .3 e a % le rra ev g e Se el s or is rv ic re e cla s." oins ted Eur B t1 o RI a.nc 6 t he Ie ss tue o p re- or coinsurance. respondents reported 20 e 16 ither no premium 20 inc 17rease or premium 20 in 18creases of less tha 2019 n 1 percent. Althoug 2020 h estimates are le vels. Although the 2018 CCAE contains over 27 million covered lives, we restricted our analysis to those continuously Heart Failure 0.1% services in this scenario. care expenditures. r d e ela duc tivteible lyB To high r ie ser taf, no. l v S p ic pe eer s c nd 51 .e nt i6 ng a(g Ee m of ploy use ee r s of Bene the fit 14 Re sea serrvcic h I $ e1 s m ns 6,9t0 e it0 e ut ting e). h the ttp irs:/ d$e /ww 1d 6uc ,9w 0 tible 0.eb.r i.o User rg/do s o$ c f th 1 s/ 6,d 9 ee 0 se fa 0 ult 14- sour healt ch ca e/e $1b 6 rr ,e 9 i- 0 ser is 0su ve ic-es r eported, a great deal of uncertainty regarding the effect of Notice 2019-45 on premiums remains. In the AHIP survey, Figures 0.6% 0.6% Sou 0r .c 6% e: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. enrolled (i.e., 365 days) in an employment-based, HSA-eligible health plan. We also required that the policyholders Even before * HSA = therhe e aw ltha ss ave inv gside accnc oune t, HR tha A t = he expa alth re nding imburse m perne t - ad rrae nd geu mcetnible t. coverage had a negligible impact on premiums, there are generally P rhigh e-dedu us cte ib rls of e cov h ee ra ag lt eh more generally becaus $0e of their hea $lt 3h condit ,600 ions. As$ a 1 ,r 0e 0su 0 lt, even when cov $100 erage brief/ebri_ib_516_lowvalhealth-22oct20.pdf?sfvrsn=56693a2f_6. 15 percent of fully ins0% ured plans a 1% nd 29 perc 2% ent of self-3% insured pla4% ns noted tha 5% t it is too e 6% arly to know 7% what imp 8% act the Next, we ass Sou um rce: e Md ed t icha al Ex t pe em ndip tuloy re Pa enres im l Survp eyose - Insd ura som nce Com e for ponm ent (M of EPS cost -IC). sharing on the 14 services. This cost sharing is imposed were full-time employees, and we included their spouses and dependents. These exclusions resulted in an initial sample According to Notice 2019-45, the list of preventive services that can be covered pre-deductible will be reviewed on a E wa ves a n in n a the pp e atb itsenc e am eong of eevm ide ploy nce e rts for hat e a xpa dding nding mor pe re ser -dev dic ue cs if a tible llow cove erd a g be y w the ill inc IRS re . a The se p re re is m a ium lso supp s by only ort for a sm exp all anding Figure 1, Percentage of Persons Enrolled in a High-Deductible Health Plan (HDHP), by Employer Contribution to HSA or Deductible $3,000 $3,000 $3,000 $3,000 for services is provided pre-deductible, these users are likely to continue to meet their deductible. Services that would Notice had on premiums. Another 7 percent of fully insured plans and 17 percent of self-insured plans reported “other” 0.4% of reg2.1 m ardless illion of w mhe em the berr s. a n Ne enr xtolle , we e m me eregte s his d indiv or idua her ld a end ducftaible mily . Id n p edruc ior tible wor le k, ve wls e fr found om t he tha B t PbD e td w ae ta eb n 48 p ase. Thi ercs ent and 63 periodic basis. In fact, the guidance specifically states that the periodic review is expected to occur approximately every Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. a Fr m onst ount in, P , em aul, M ployearrs w tin J. ereSe alr pe úa lvdeyd a re , p aor nd ting M. tC ha hrtis tthe opyhe wrould Roe b auc ddk a . d 20 dit 13 iona . "Me l se dric vic ate ion U s on ta ili za pre tion a -dednd uctible Adhe braesi nc s if a e in a llo wed pre-deducH tible RA Co, i nc A sov m ure a ong n ra ce g e Thos ame o ng Witph P olicry iv m aa te k-eSe rsc , ta or s e Hve $ ide a 1,lt 3nc h C 90eov d b ey ra tg he e a Cnd hr $1 onic E ,0m 30 p D loy ise ea ese -Only Ma na C $1 ov g ,2e e 9m r 0ae gnt e, A 20 ct16 , w –hic 2020 $1 h w ,3 8 ............. 0 as 4 While the IRS notice specifies that pre-deductible coverage is only allowed for enrollees who have been diagnosed with otherwise be subject to copayments or coinsurance once deductibles are met will be subject to the deductible when w hen asked about the impact of the Notice. No context was given for the “other” responses, but we can conclude that 0.3% percent of employers require a copayment from employees, depending on the health care service (Fronstin and information was generated by Marketscan® developers via a plan-specific statistical analysis of claims data and not five to 10 years. For patients and employers alike, 10 years may be a long time to wait for such coverage decisions to r be yint the rod IRS. uc He e a d T Ther lt oin t h Sa tal e he O u v is tings Ac U. - o bfipa S. -P oC r cton kis ce oun a tg n, (rO etO ss b -E ic P ligi a )as r m be e le rca e P l le nt laly n. gis "a la s Ma Atm ion th e$ ryic 4 20 ,a 3a n J 9t 21 0 ha our . s b Thi na e s b l eof n int ipa Ma r$ r t4 is od na ,a 0uc g 3 n, 0 ee d bd ic C in t a am rehe e 19 ra U l (le .S. 12 $g 4is ) ,C 2 : la ong 9e 0 t40 ion w r0 e-ss eould 40 w7. hic p h w r$ ov 4,ould ide 380 H p SrA ov - ide the associated chronic condition specified in the notice, it may be impractical for health plans to follow this rule. One of other services are no longer subject to the deductible. 0.2% 22 percent of fully insured plans and 46 percent of self-insured plans still do not know what impact the Notice had on Figure 2, Chronic Disease Management Services in the Expanded Safe Harbor ........................................................... 5 0.2% g Fe lendr ane icdk fr 20 om 21 p ). laThe n doc pe um rce ent nta s. g e A s a of e rm esu ploy lt, edre s r duc eqtuir ible ing lev coins els w ur ea re nc not e for av ta he ila b 14 le he fora lt ah ll m caerm e b ser erv s ic in t es r he a nge initia d l sa from m p 4 le. be made given the pace of research on plan design and medical innovation. There are already examples of services a Und ddit eiona r the l fle inixibilit tial IRS y to guida extenc nd e , punt re-d il t ed he uc t dible educ cov tible er ais g e m te ot ,ser cov vic er ea s t ge ha dtoe ms not anag e inc clude hronic "a c ny ond ser itio vic ns e. or Em bp elo ne yfit er s a inte nd nded to eligible health plans additional flexibility to provide pre-deductible coverage for services that manage chronic conditions. the issues is that diagnoses do not always appear on medical claims, and prescription drug claims do not have Change in OOP -$360 -$100 -$10 premiums. Dis p G Ae ft old re cre m cu nt re a q n, s tuir o sD ion 19 ing ana pindiv e P rc ., eG nt idua e.offr l/fa eym F. Jo ily de yd ce uc , taible nd s of Yuhu ai Zhe t least ng. $1 2,00 350/$2 7. "P,r700 escr ipti — ton he D 2 20 rug 18 C fe ost de r Sha al mi ring: nimA um sss for ociat ions HSA W eligib ith ility that may meet the criteria for pre-deduc 0.03% tible coverage that were omitted from Notice 2019-45. For example, the Notice D Fi ia gur gnosed e 3, Im up se arcs of t of tEhe xpa 14 ndin heg a lt Ph ca re-Dre ed se ucrtv ible ice s lis Covte erda g in t e in he H ISA RS noti -Eligib ce le a H re e a lik lte h P ly la to ns c oon ntinu Pre em to ium ms e e ............................. t their deductible. 9 p trolic eaty a m n e akxis ers ha ting vill e ne an a ss, pinj peur tity e, for or cm ond ore it ion, flexib inc leluding plan d d ersi ugs gnsor or m "sm edic ar atte ions r" d." ed uc Thi tible s na s b rrow eca d us ee fin rit ision o ing he f th alteh ca "sarfe e diagnosis fields at all. Claims may be denied only to be appealed later, with the appeal resulting in a reversal of the 0.0% — the finMe al a dic na aly tion a tical sa nd m Me ple dic inc al U lude tiliza d 1 tion a .6 mind llion Sp m ending embe ra s. nd Health." JAMA 61-69. doi:10.1001/jama.298.1.61. identifies angiotensin-converting enzyme (ACE) inhibitors to prevent exacerbations for individuals diagnosed with The relat% iv e of ly S high amplus e e W of ith he Con altdi h ca tion re services in this population amounts 3% to an average of $16 1% ,900 in spending 4% per ha spe rb nding or" ha ha s lik s ce rly ea c te ad us ser ed ious som fis e p cla al c n me halle mnge bers. s to go without needed care, as it is well established that increases in cost EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 –137X/90 0887 –137X/90 $ .50+.50 denial when the enrollee provides documentation of the diagnosis. Employers and health plans might try to avoid such In this Issue Brief, we use cla Diim ags nos ded at a Enro to llee est s imate the effect of expanded pre-deduc Atllible Enro c llee ov serage of services and Fi Our Fina gur lly fin e , d 4, w ings a e P rceon va rsi e le d c nc e onsi re e d of st the e Dnt ia sa g w noses m ith r e four ela Pe t e rsc td a e ini rna esea ng rios tro ch in unde IRS N trhis ot w hi ic ar e ce h p 20 a. la 19 AH n sp -I45 P ................................ onsor conduc s d teo d not a st rudy o equirf he e ................................ the alt ah p ssoc laia nst ein 202 d diag1 noses to ........ ass for e ss 10 congestive heart failure (CHF), diabetes, and/or coronary artery disease. Patients who either do not respond to or who year. To understand how cost sharing might change for these users and their employers, consider the examples in sharing for health care have been associated with deleterious consequences. Thus, the U.S. Department of Treasury an admini Cst os ra t t Siv ha e rc eost Shi bfur t ad se an a s it appears that only 2 of the 14 services (HbA1C and LDL testing) are provided to the medications specified in IRS Notice 2019-45 on premiums. Our work greatly improves on past research, which found t W t Ihe he nt ee im 14 a rna lsp o ser l Re ac ca tv p v © ic of tee ur nue 2 e s lis 0 e xpa 2 d2 tS a ,e nde e g E dre m vin t ,ic dg plo ee p he . nd ry 20 e ee -e Id RS N 13 r e , B d . g enef uc e "P ot otrg ible e ic it rv a e e Resea p . nt c hic G ov iv iv e e e re r rc n th a he gg h In ion (N e aa ltin HSA th se sp tit ha oute rrt r vhe m - ic e –a e a ligib E c s r st du y , e cle ca Mid q laui im he tio rw e s d a n e dltst a h p und and , ta Sout la e Resea dns ro P h, not ublic on W rc p ce h F ont r st H em ) e, a un a ium irlt n d e d. h Se las. ia t All r ions g Thi rnosi vic hip r ig e ty h s inf A -tsi ts co x he tre or p sect olic sm er aa ion 2713 lt v yth p ed hold ion, lae a ns rnd ( s ae nd lf, This study was conducted through the EBRI Center for Research on Health Benefits Innovation have an adverse reaction to ACE inhibitors are usually switched to angiotensin receptor blockers (ARBs) to prevent the Figure 5, SoUse urce: Em of pH loye ea e lt Beh C nefit a Re re se Se archr v Inic stie tus P te ese tim rt aa teini s bng asedt oo n aIdRS N ministra otitvic e e en ro 2019 llment - a45 nd c ................................ laims data. ................................... 11 Figure 8. For all the examples, we assume that there is a $3,000 deductible and 10 percent coinsurance above the issued guida Perc nc ent e a 15 ge y of ea To rs la talt e Srpe in 201 nd 9 via IRS Notice 2019-45 to furthe0r. 2 inc %rease the flexib 0.02ili %ty of HSA-eligib 0.0le 1% health population more generally. Alternatively, health plans may choose to cover the 14 services where it is safe to assume there was still a great deal of uncertainty regarding the effect of Notice 2019-45 on premiums. Data from the 2018 IBM spe respond cific m epdr e e d tv o ic et a nt he l se iv su er v c ric a vr e ee y s d .fo The o r not pur su pa rose lw vea ys of y found s lis Hte rae tlt ha le h Sa v t aant b vout ings Ac dia g one nosis c -ount ha c lf od of s.e "s, p he Ac acla lt eh p n sp ssela donsor ns Se (p56 te s m m pb ear ey cr e w 15 nt a , nt a20 m to ong 21 a. v oid fully the in sured spouse, dependent), and household size (number of enrollees on the policy) for descriptive analysis. (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield same exacerbations. However, ARBs are not included in the list of 14 services in Notice 2019-45, and thus they cannot that an eS nr oolle urcee: E re m cp eliv oy ing ee B the en eser fit R ve ic se e aha rch s a In srte itlu att ee e ds d tim iaa gtn eosis s ba s(e i.de . o, nins aduli min n for istra tid ve ia e bn ert oe lls) m. e nt and claims data. MarketScan Commercial Claims and Encounters databases are used. This research is important because the EBRI Figure 6, Average Spending on Health Care Services Pertaining to IRS Notice 2019-45 ............................................. 12 https://www.irs.gov/pub/irs-drop/n-13-57.pdf. Association, ICUBA, JP Morgan Chase, National Pharmaceutical Council, Pfizer, and PhRMA. 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 br 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.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 rg g g g g g g g g g g g g g g g g g IIIIIIIIIIIIIIIIIIs 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 su 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 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 rief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief A re • • • • • • • • • • • • • • • • • • s e Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma Ma arc y y y y y y y y y y y y y y y y y y h 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 re ,,,,,,,,,,,,,,,,,, p 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 0r2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 t 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 fr o• • • • • • • • • • • • • • • • • •m N N N N N N N N N N N N N N N N N N to o o o o o o o o o o o o o o o o o h..................e 558 558 558 558 558 558 558 558 558 558 558 558 558 558 558 558 558 558 EB RI Education and R esearch Fund © 2022 Employee Benefit Research Institute 19 18 17 14 15 10 12 13 16 11 2 5 9 8 4 7 3 6