The Impact of Expanding Pre-Deductible Coverage in HSA-Eligible Health Plans on Use of Health Care Services

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. In this Issue Brief, we use claims data to quantify the effect of expanding pre-deductible coverage on use of health care services.

Key Findings:

Overall, we found that between 2018 and 2021, the IRS notice increased the use of 3 of the 7 medical services by more in HSA-eligible plans compared with non-HSA-eligible plans. Use of low-density lipoprotein (LDL) testing, hemoglobin A1C (HbA1C) testing, and retinopathy screening increased by a larger percentage among enrollees in HSA-eligible plans compared with those health plans not targeted by this policy change, suggesting that the IRS contributed to increased use of these services.
In addition, use of selective serotonin reuptake inhibitors (SSRIs), statins, and angiotensin-converting enzyme (ACE) inhibitors increased by a larger percentage among enrollees in HSA-eligible plans compared with those health plans not targeted by this policy change, suggesting that the IRS also contributed to increased use of these prescription drugs.

Use of health services may not have changed for all targeted services and prescription drugs because many employers substituted copayments and/or coinsurance for deductibles. Past EBRI research found that the percentage of employers that eliminated cost sharing for the preventive services identified in the IRS notice ranged from a low of 25 percent to a high of 40 percent depending on the service examined. In other words, 59 percent to 75 percent of employers substituted either copayments or coinsurance for the deductible, depending on the service or drug.

Employers would exclude additional preventive services if allowed by the IRS, according to past EBRI research. If employers’ goal is to increase use of those services, they should consider their approach to cost sharing.

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.

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" he c he bov st alle Plt ietrh o r ut e a M. sc g eut e d rD ipti t c e ot o om iton y he m . e e r 20 s, a D d cric 15 op ug a nd, t. aions C y The ost m in som e t nt P Sha o rs or m ob e raling: e na cc m aoins g ses, of e A ss c ur Und hr roc e aonic d nc ia e uc te rions ins e for c ond eur xpe W ta he it nc it ndit ion h e s aur nd ha es s P Cao ul Fr ngr onst esin is D sional irectE or ff of or Htes a lt th B o 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). 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Building on the momentum of Executive Order 13877 and IRS Notice 2019-45, Sens. John Thune (R-SD) and Conditions Using Service, by Type of Health Plan classes us Sur edv e to y, tr20 ea14 t 11 . N c ehr w onic Yor kc, ond NY:it ions The C (VB om Im D onw Heae lta h n.d lth Fund. .). It found Accessteha d tA c ugus overting 15, a20 ll t2 he 3. se drug classes pre- 4 2018 2021 research and editorial staffs. Any views expressed in this report are those of the author and should not be ascribed Heart disease 1,630,186 1,034,939 e nr Seolle e the es b lite et ra wture een 2018 review a s nd in Bund 2021o . rf Use (2012) of SSRI ands inc Agra rw ea ased l, M afr zom ure nko, 11 p a end rce Me nt na to c13 he mi pe( r2017) cent of ast he we sa ll am s p re les e (a Fi rc gh urin e 9) Brot . Use - Figure 9, Percentage of Plan Enrollees With Prescription Drug Fill, by Type of Health Plan ........................................ 14 35% Congestive heart failure, diabetes, and/or coronary artery 20 W I The nt ite h I r • fa na RS N cl Re t SSRI tha ot vte ic s nue e.e m 20 p loy S1 e9 re v -r45 ic s m e. in p ov 20e 04 la dc . e tow ", PH aa SA rrtd I- Ie cIov ligib - e Ard le ing m he ini se a st lt rv rh p a icte iv la s on en , s Pa ra oc r e pe rno d eur -w da e a l, db uc ale nd t ible to Misc a b da oesi plla ts onc a ne m oor us e e t: he H flexib y e aw lte h Sa le re b a evllow ne ings A fite d d e ctc si o oun g cn om ,t s e- s a t Tom Ang C ioa te rn ps eir n -( cD on -D veE rt)i nint g ern od zyuc me e d (A tC he E) C inhr hib onic itors Disease Management Act of 2019 in the Senate (S. 1948), followed By Paul Fronstin, Ph.D., and Eden Volkov, Ph.D., Employee Benefit Research Institute d eductible ht tw ps:/ ith a /ww 31% com w.c bom inam tion o onwf c eaop lthf aund.o yment rs a g/snd ites/ coins defa ur ult 20a 18 /f nc ile e20 sw /do 21 ould cum inc ent res/ ase ___ pr m ee m dium ia_fs b iles_ y 1.7 p public ea rc tions ent._is Mor sue e _br recie ent f_ly 20 , to the De poffic resse iorn s, trustees, or other sponsors of E A Bp RI pe , n Ed mix p loy F 5 ig eu er e B e 1nefit Resea2 r5 c,1 h I 26 ns t 3 itute-Education and 74,5 Re 25sea rch Goldberg, Chandra, Handel, and Kolstad (2017); Cha HSAnd -Eligib ra, le GHeal rube thr, P a lan nd E n Mc rolle Knig es ht (2010); Chernew et al. (2008); Collins, of statins increased from 8 percent to 9 percent of the sample dis . eA and se use of ACE inhibitors increased from 5 percent to 6 29% August 17, 2023 • No. 588 a offe crit r • 18 ing 30 ic a %l p m S Atd e or ad rtiod e it ins iona p .rof otl Q e tim cts & A ion for e. Ws, N he cn th e ot rtia cee in m A 20 CA 04 e d pic -a 50 a ss l se ." ed A rin 201 c vc iceess s t e0, it hr d oug Augus inc h a lude t v 15 adlue , p 20 r-ov b 23 ais sed . ions ht tins p s:/ re ur q/ww uir anc ing e w .ir d te ha s.go sig t n (V evm /ppub/ir -loy BID er ) ss a -p dla rnd op n st /n he r-uc a 04 ltth p -ur 50 ela .p . ns A ds f. Figur bey 10 the , 30 int-rD od a 16.8 y uc Atd ion o juste f d the Pr e csc om ripti panion b on Drug ill in t Fills he , A H m ouse ong E of nrRe olle prees Using sentativSe es (H rvic.R. e, b37 y Ty 09p ) e b y of Re He pa s. lth P Earla l B nlum ............... enauer 15 an EBRI 15 study _m aus y_e18 d 17 cla_ im collin s das_ tap tro ob ele stm im _of_ ate unde the erff ins ecur t of anc ee xpa _ib.p ndd ing f. pre-deductible coverage beyond IRS Notice 2019- R asmussD ein, ab e Be teute s l, and Doty (2015); Fronstin and Roebuck (2019) 7 ; Fronstin and Ro2 e8b,2 uc 39 k (2013) 4 ; Fronstin and 7 8R ,1 o2 e8 b uck Fund (EBRI-ERF), or their staffs. Neither EBRI nor EBRI-ERF lobbies or takes positions on specific policy proposals. Antires 16.1 orptive therapy Osteoporosis and/or osteopenia percent of the sample. We did not see increases HS in use A-Eligib of le ins Heal uli thn a Plan nd Enot rolle he es r glucose-lowering agents, beta blockers, Statutory HSA Limits, 2004–2023 t che ov em • r a crekrB e ta e t in p tfor a b rloc H eSA vk ee nt -e rs iv lig . eible ser h vic ea elt s in full h plans . These grows, it inc lude is im p ser orv ta icnt es su thac t h a thes sc se p re laens nin us gs for e this c a flexib ncer ili atnd y to ota he llow r he for alt h effective 16 (D-OR) and Tom Reed (R-NY). This bipartisan, bicameral legislation would give HSA-eligible health plans (2020) 25;% Fronstin and Roebuck (2014); Fronstin and Roebuck (2016); Fronstin, Sepúlveda, and Roebuck (2013a); Fronstin, 45 to 116 As c th la msa ses of medications. The impact on premiums of e 3 xpanding pre-ded 92 uc ,6t5ible 7 2 coverage to 116 d 08 rug ,874c lasses EB BRI et ainv bloit ce ks c ersomment on this research. Congestive heart failure and/or coronary artery disease Fi ant gur ireesor 11p, tiv Pe er c the ent ra ag pe y , of orP inh lan Enr aled olle core tic s Wi oste th roid Pre s.sc ription Drug Fill, Among Enrollees With Health Conditions, by Type of Internal Revenue Service. 2013. "Preventive health services required under Public Health Service Act section 2713 and he c I Cond ong nt alt • r it h ma r o e ion ss duc A s, v iona nt nair g t ae l B e ion csor c m iudg na ep nt ttiv ions e for te Offi t , he aa ll c nd re b a. p eb 20 ne yir . 12 fic th cont ia . Offs ries. rol. e A tt ing P ta la rg n sp Eeff te ed onsor ct s of stras tP eha rgeysc v e erxplor ipti bee on n ing p Drrohib cug ove Use it re ad g e on f rfor om Me cim d er ic p ta aosin r in hig e’s Sp g a hny e -v nding a for luem , for cof lin c M icost a elly d ic sh al aring Sepúlv a 14 deddit aiona , and l fle Roxibilit ebuck y (t2013 o prov b)ide , Fron cov stin, erag Re o efor buc se k,r Buxb vices t aum, hat a m nd ana Fegnd e ric chr konic (2020) Ma x cond im ;u Go m it ions ld Ou ma t- op n, f-r ior J o y tc o e ,m a e nd P e e t ring Zhe - P ertng she on ( p 2007) lan ; r elated tLo ive crhr donic iseas d e is ease management medications in HSA-eligib 1 le health plans9 w 5,1 oul 95d b 1 e relatively small, r 39,7 anging 54 from Blood pressure monitor Figure Hyp 6ertension 20% The Im Heap lth P ala c nt ................................ of Expandin ................................ g Pre-Dedu ................................ ctible Cov................................ erage in HSA ........... - 16 17% preventive care for purposes of Health Savings Accounts." Accessed August 15, 2023. Minimum Deductible Maximum Contribution Pocket Limit Catch-up ( indic Triv i.e., e • a d d ti, e eMo d dI Se uc nha he loo rtv ible aic le lt , e h se a d, s. nd c c or op C r Mo ong v ta ic icr yost em (rs p 2010) ee e ss nt r roid iona io s,r; s or tW .o l B ha c m udg oins e ra em te ur ing te a Offi t nc a the l. e c( ) e 2017) d . on e ht dt uc ppa ;:/ t rible a t/ww ic nd ipa Figure 7 w W w nt ill ha .c s r p b ra ro.g e od m ce ov uc eiv t e /s ing a l. im te (or t2018) s/ he e d se e efa ff .s e ult ecrtv /f iv ic ile ee , s sc/c .lin bic ofile allys /nua atta nc chm ed edn etsi s/g4ns 37 w 41 it-hout The d Me 12 edduc ica tible re P . rThe escripti bill on waD s rrug, eint Qu Irm od an puc rti ov ty ed e m o in t f eM nt he ed , aSe ind cal na Mod Serv te in J eriniz ces anaua t ion Ac Ursed y 20 ,t20 A of mo (2 S. 00 n32 g 3 (MM En 00)r,o A A llp )ees riil 202 nclude 1 (S. 1424 d a provis)ion th , and a Ma t crrc eh ated Bleeding disorder 10.9 44,725 262,398 Sim 1.3 ila to r I4.7 p n ly h, aw led e e r ccc o onc e rtnt ico lude . s ter otiha dst the IRS notice increased theF us igure e A of s10 tSSRI hma s, statins, and ACE inhibitors because we observed 10.6 Suggested Citation: Fronstin, Paul, and Eden Volkov, “The Impact of Expanding Pre-Deductible Coverage in 10.4 10.4 15% 13% Eli gibl httpe s:/ Hea /www.irs.go lth v/pub Pl/ia rsn -ds rop on /n-13 -Us 57.pde f. of Health Care Service Cos nt ribution Percentage of Plan Enrollees Using Medical Service, Among Enrollees With Using Service, by Typ 9.5 e of Health Plan Fi fun gur d • ae m 12 eMe A nt , Ca 30 E d lly ic in -D aa hibit lOff a ltye rA sets ing or djsus .- t he 11 ted -or 29 Pigina r-e 1sc 2.p rl int ipti df.on e ntD arnd ug spir Fillsit , A of mton heg se Enr pla olle ns.e s Wi Adop th He tion o af volu lth Cond ntait ry ions , clin Using ically Se nua rvn icce e, db e yxpa Typ nd e eof d 5 2023 O s(tS. eop 65 or5 os ), is a /o nd steit o pw en ai30 s r a -e D int ay rod Ad uc ju este d in t d Prescri he House ptiof o 9.3 nRe D 4 p ru re gsent Filla s, tiv A e 9.3 mo s in Ma n 9.3 g En y ,2 20 5 ro 4 21 ll 1 ees (HR. 3563), building ,16on 6 the what10 are commonly known as high-deductible health plans (HDHPs). At the time, these plans had to have a deductible Insulin and other glucose-lowering agents Diabetes la S rg ee e rhttp persc:e // nt wa w gw e. e inc bri.o rea rg ses /pub am licong ations HSA /re sp ela arc n h e-nr pub olle lice as tions tha/ n a fasm t-facts ong / ot co he nte r he nt/a ma lth p ny-la ha nv e enr -aolle -cho eic s.e - of-health-plans-during- Figure 11 HSA-Eligible HIe na dilt vih P duala l ns on Fa Use mi ly of HealtIh C ndiva idruea lServiceFa s,” mE ily BRI Issue Ind iB virdie ua f, l no. 58 Fa 8 m (E ilm y ployee Benefit Research Figure 8 Limit Health Conditions, by Type of Health Plan On September 7, 2022, Judge Reed O’Connor of the U.S. District Court for the Northern Distric 7.9 t of Texas found a key 10% 7.8 Using Service, by Type of Health Plan H W SA e r-e ec ligib entH ly le e a st he ltah P a rlt teh p la d n tla o ................................ n exa bem ne ine fit t dhe esi ig m ns p aha ct s t of ................................ he the p ot IRS N entia ot l to mi ice on tiga p................................ latn e e cos nrolle t-ree las. te Fr d onst non-in a................................ d ahe nd reVolk nce, ov e nha (20nc 23e ) p ea xa ........... tie mnt ine - d 17 of atI 20 RS g le Ra est tin uida o $1 pa ,000 tnc hye s a for crnd ee ind np in rg e ivvidua iousl c ve ov rsi eons t rage o and fur$2 the ,000 r inc for rea 20 se fa 18 m p D ily re i20 a -b c d 21 e o e tv e de suc ratg ible e ( se cov e e Arp ap ge end for ix cFi hg ronic ure 1) dis . e Aa s w se ill m b ana e d gis ec m us ent sed . open-e 8nrollment. Percentage of Plan Enrollees With Prescription Drug Fill, Among Enrollees With By Paul Fronstin, Ph.D., and Eden Volkov, Ph.D., Employee Benefit Research Institute 6 Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. Institute, August Qu 1 an 7, ti20 ty 23 of )M . edical Services Used, Among Enrollees With Health Conditions KFF. 2015. Preventive Services Covered by Private Health Plans under the Affordable Care Act. Washington, DC: KFF. 2004 $1,000 $2,000 $2,600 $5,150 $5,000 $10,000 $500 p Fr aonst rt of in, P the apul re , v"e Cnt an " iveC ser onsu vicm e eprris ov mis " ion unc Slow the onst Ra ittu et iona of Hl. eaSp lth B ecifi ene cally fit, Ctost he d Ie nc cis reion asein s?" B,r a Eidw BRIoo Iss d ue Ma B nraie gfe, m no. ent 247 Inc. v. 2018 2021 Use of Medical Services HSA-Eligible Health Plan Enrollees t che ent im e 10 re p 0% d a cout t of com thee not s, aic llow e on for enr low ollm ere p nt rH e fr eal mom ium th H s t C SA o ha n -e d n mo ligib ition le st s, 20 he P 18 b Pa y Os a lt T 20 h y21 p p nd la e ns o Hf MOs, a Hnd eal found a th nd Pl su an tb ha stta w nte ia a lly re r e not duc see e aing ggr m egor atee ehe nra ollle th es 185% Peak flow meter 3% Asthma in more detail below, HDHPs may provide coverage of certain preventive services prior to the satisfaction of the health 92% Using Service, by Type of Health Plan 6 6 2% Figure 9 2% 2% Appendix AFi ccg eur sse e d 1, ASt ugust atut or 15, y 89% H 2023 SA L. im htit tp s, 2 s:/00 /ww 4–w 2.k 02ff 3.or ................................ g/health-reform/fact................................ -sheet/preventive-serv ............................. ices-covered-by- 20 Also see 2005 https://ahip 1,o 00 rg 0-production. 2,00 s3. 0 amazona 2w ,6s0.0 com/docume 5,1nts 50 /202109-5AH ,00IP 0 _HDHP-S 1urve 0,000 y.pdf and 600 Bece5rra r(e Efe mrp s t loy o ete he B e pne artfit of Re the sea ArC ch I A tha nsttit ru etq euir , 20 es c 02ov ). erage of preventiv0.11% e services without cost sharing to which the HSA-Eligible Health Plan Enrollees 0.07% 0.06% 0.06% 0.02% 0.06% 90% in HSA care exp -ee ligib ndit le ur he es. a lth plans with conditions such as heart disease, hypertension, depression, diabetes, and asthma than 16Glucometer Diabetes 3.6 plan deductible. Enrollees in plans that meet these and ot 20he 18 r r20 eq 21 uirements are allowed to open and cont 3.5 ribute to a IRS N Cot op icyer ig 20h 19 t In -Percen 45 form allow a tag e tid o e n em o : f T pPlan his loy erre s a En por nd rto is lhe lees ca op HS lt h p y W Ar-ight E ith la ligib ns e Prescri le d t o Heal by e xpa t th he p Pti lan nd E om n Ep n p D r rloy e or lle -u d e es g e e d F B uc ie lltne ,ible bfit y T cRe ov yp sea e e ra o rg f ce h I H tealth o ns ser titu v Plan t ic ee ( s r EB eRI lat)e . d Y ou to tm he a y 0% 4 2018 2021 https90 :// % www.irs.g 14.3 ov/pub/irs-drop/n-19-45.pdf. priv 14.1 ate-health-plans/. 6 18% 2006 76% 1,050 2,100 2,700 5,450 5,250 10,500 700 M U.S. etPho 8r0e %vds ent ive Services Task Force (USPSTF) — a group the Agency for Healthcare Research and Quality has been 73%80% Lo 79% w-Density Hemoglobin A1c Retinopathy International Peak Flow Meter Glucometer Blood Pressure C in t ohe nc H plus e am sto .ion g W lob e in a A ls1 o c e te xa stm ing ined the impact of Athe T not ic Ae onG enr D Liolle abA ee te N s cost C sh E aring, with the key question being whether 14 he trea alt tc 4 m h sa op ent y, v ings a p of rint he , ac or rctoun d dow ise t a nloa (H se, SA d hy ) ton his per a tre etns p ao xion, r-tp r solely for ed fe erp rr ee dss b ion, p ae sirs. T sona diahus bl a et, e ns, a tdhe nonc se sthm pom laans , m ost e arrc e eia op al use ls or o osis c, om p/rost m ovonl ide eop yd e ktnia now ha, t liv n a all ha es H r dris d SA eca -op e se ligib ie , s an r le e d t ain HSA-Eligible Health Plan Enrollees 2018 2021 80 2% Fr onstin, Paul, and A. Mark Fendrick, "Employer HS Up At -a Eligib ke of le Heal Pret- hD Pe lan duc Entrible ollees Coverage for Preventive Services in HSA- 7 2007 Lipoprotein (L 1,DL) 100 (HbA1C) Te 2,2 sti 0ng 0 Scree 2,ni 8ng 50 Normal 5, iz 6 ed 50 Ratio 5,500 11,000 800 Monitor 70% 16% a A ut c Sc ehor or e d http ize ing d s:t / b o /y w N t w ot he w ic .e U. eb 20 S. ri.o 19 C rg ong -/45 pub r,e tli ss he ca t tions o lisc t onv of /rep e sr e ne e av rc e si h nt n -p c iv e ub e 19 li ser c98 ations vic — es t /a fas ss ha igns a t-tfacts can b /rca e ot nte ing cov nt/ e of rw e“d ilA l -” p e ror mp e- d “loy B e” de .uc rst -ible introd wuc ill e b-e c orsetv -s ie ha wring ed on -fo ra - 3.2 To cap In tur tere n atthe ion a im l np oa rm cta of lizeIdRS N ratioot (IN icR e) 20 tes19 tin- g45, we examined ov Live er r a dll use iseasea and nd/a ols r b o lec eom ding p a dr is eo d r dus ers e of health care services we are seeing fewer enrollees in HSA-eligible health plans with deductibles for services such as insulin and inhaled 12 5 Testing (INR) Testing he In r alt esponse h plans . to In 202 IRS N 3ot , tic he e se 20p 19 la-ns 45 , mtus hre t e ha -qvua e r at HS e drA e s of -d Euc ligib la tible le rg Heal e of etm ha P p t lan loy lea E e st nrrs o$1, lle and es 500 he for alth p indiv lan idua s offe l crov ing era Hg SA e -aend ligib $3 le, 0he 00a lt for h b Le leee, d aJoy L ing ny adnd ., isor Ma ad ll c tetrhe op s. w y Ar s a L ight . Ma r e asu c nd ie lt j, e ot w w he sk e rw i, aould Shv pplic e e t aa xp b le S. e cnot Ra t to jic u, e see s c W ill ont ain am a inc in H r e. e da Shr se the ain rnk e in, t, he aa nd p nd eN rc y it e ou e nt ea sh m ga eK y . of cC itp houd ela or n me hr quot ym . 20 e b e sm 13 rs a . us ll p "Va ing olue rthe ions -B alt a h sed of 65% 65% 70% 0 60% 2008 Eligible Hea 1lt ,1h P 00 lans," EB 2RI ,20 I 0ssue Brie2 f,, 9no. 00 542 (Em 5p ,8loy 00ee Benefi 5t ,6 Re 00search I1 ns 1,t2 it0ut 0e, 2021). 900 3 9.9 9.9 10.0 preventive-services-findings-from-ebri-s-first-employer-pulse-survey. p eriod 14ic % basis. In fact, the guidance specifically states that the periodic review is expected to occur approximately every 13% 9.5 among L o ew nr -dolle ense its y w lipit oh he protea inlt (h condit L 9.4 DL) testion ings impacted by the not 9.3ic He e ain HS rt dise A a-seeligible health plans and other health plans Insulin and Other Selective Serotonin Statins Angiote 2.4 nsin-Converting Beta Blockers Antiresorptive Therapy Inhaled Corticosteriods cortic 10 osteroids, and found that cost sharing shifted from deductibles to copayments and coinsurance among enrollees fa p ca la m rns eily tser he e cxpa o v rv e ice p e nd ror s r ae g t d e e pl .a rp ov E tre nr ed ide -d ollm te o d d tuc te he ha nt tse ible t in HSA y c ou ond cov do e it -r e ions so ve a ligib ge. for le For rb he a m te im a e xa lt d h p a m icnd a ptla le ions w ns , it d h p ia a acb nd ce roun o tic p ser e s in trsv c ic for itH eas t SA tov ion. ha -e erligib t 8.7 A one pny re le v -us ha e he nt elf of a b tlt he eh p ytond hose ela xa ns c the e w m rb it ight sc a h p top ion o rinc e iv a of f c rte eta hr he he se onic a for tlt he h eir g oing use of Insurance Design: Quality Improvement But No Cost Sa 2.2vings." Health Af 8.6 fairs 32 (7): 1251-1257. 60 50 % % IRS Notice 2019-45 allows health savings account (HSA)-e3.7 ligible health plans the flexibility to cover 14 medications and If this 4 court decision is upheld, employers and health plans could impose some form of cost sharing for these 2009 Glucose-Loweri1 n, g150 Reuptake Inh2 ib,i3 to0 rs0 3,000 Enzy5 m,e9 (ACE) 50 5,800 11,600 2.0 1,000 35% 3.5 fiv 8 e to 10 years. For 33% patients and employers alike, 10 years may be a long time to wait for such coverage decisions, 12S %elective serotonin reuptake inhibitors (SS 1.8 RIs) Other Health D e Pp la re n s Es nroll ion ees 7.4 b etween 2018 and 20 1 21. Spe 11% cifically, we focused on enrollees with diabetes, depression, 7.2 heart disease, hypertension, in HSA See2 http -eligib s://le w 32% w he w.ana lth p tional lans all ia for nc a e hnum ealth.o berrg of /ne ser w1.7 sv/ic immuniz es impa ac tion ted- re 3.3 by ma IRS N ins-criti otic ca el/ 20 . 19-45. The same shift was not observed 8 Agents (SSRIs) Inhibitors c cond overitaion ge s( Fi (Fr gur onst e 1) in a . nd Fendrick 2021). The impact on premiums of expanding pre-deductible coverage for 14 services Fr ins onst uli r50 n a e 40 in, P q % % uir nd doi:10.1 eas E rul, a etinop BRI nd 37 ’s p a7/ M. thy hlt rior C sc ha hr e ris ff e xpress t e .2 op nin 01 he g 2.09 s rp Roe onc er0 m 2. e b is uc tsi he on. k,y "w D For e o re Ap cno e cru m m lon is ul si g a ons, e ting r su p H ble jSA eacse tB ta o cla ont tnc he 1.5 a e c p s A tla En’ ff Be s RI cd t e a Us d t uc p ee tof r ible mH is.e si Sim aons@e lth C ilar aly rb e , r i.or e Snr erg olle v.ic ee s a s w nit dh other health services used 1.4 to pr1.4 event the exacerbation of chronic conditions prior to meeting the plan deductible. In preventiv 2010 e ser 1.3 vic 1.3 es. Y 1,2e 0t0, employe2r,s m 400ay continu 3,0 e5 0 to provide6 ,t1 he 50se service 5s a ,95t0 no or low 11 c ,9 ost 00 to memb 1e ,0 rs for 00 at least a 1.2 1.2 1.2 given the pace of research on plan design and medical innovation. There are already examples of services that may Statins 39% Heart disease and/or diabetes asthm 3 a, liver disease, bleeding disorders, and osteoporosis26% /osteopenia, because IRS Notice 2019-45 gave employers 10% 37% 9% 25% for e30 nr 6 30 % olle % es in other types of health plans. Yet, the IRS Notice appears to have had a negligible impact on overall cost 9 2.5 in HSA 40% -eligible health plans as allowed in IRS Notice 2019-45 is small (Fronstin, Roebuck, and Fendrick 2022). Further heart disSp eae se nding might ?," inc EBrRI ea se Isstue he ir B rus iefe, of no.482 LDL t(e 2.4 Est m ing ploa ye nd e B st 34% eane tins fit. Research Institute, 2019). See Figure 8.3 in https://www.kff.org/report-section/ehbs-2022-section-8-high-deductible-health-plans-with-savings-option/. this Issue Brief, we use claims data to quantify the effect of expanding pre-deductible coverage on use of health care few r 1easons, including: 8% 2011 1,200 2,400 3,050 6,150 5,950 11,900 1,000 30% 2.1 2.1 2.1 meet the criteria for pre-deductible coverage that were omitted from Notice 2019-45. For example, the notice identifies 15% 28% the op R20 ep tion to e %ort Availabili xpand cov tye :r Thi ages r of ep por retsc is r ipti ava on 14% ilad br le ugs on atnd he ser inte vric ne es us t at e w dw bw y.e the br27% se i.ore gnr ollees outside of their plan sh Nea w ring hous 8% Soa ue s a rc , eJ. :p he a ttr n p cd s e :nt t //he va bg i d Ie c ns eof n ur teta rot .nc oa rg e l sp / iE nixpe te ianding tiv re im s/e h nt on sa -G ha ir g oup num h-de. d b19 ue crt93 ib olf se e . -h Fr ere avle tic h Fo e -ps im la r nA sll? p -2a / c Lteess d ons fr by the om not the ice RA . Thi ND s m He aa ylt b h I e b ns eur caa us nc ee 4 expa30 nding % pre-deductible coverage to 116 drug classes that are used mostly for chronic disease medication Figure 1 2.7 2.7 2 23% 23% services. 25% 2012 1.5 1.5 1,200 2,400 3,100 6,250 6 1.5 ,050 12,100 1,000 6% 20% 19% ACE in 10 hibit % ors to prevent exacerbations for individuals diagnosed with congestive heart failure (CHF), diabetes, and/or Other Health Plan Enrollees deduc 0 tible. Fr Wonst e exa in, P mine aul, a d allnd 14M. ser Cvhr icis es in t tophe he r Roe IRS bn uc ot kic , e "H to easee lth C if a are nd Sp how ending use aof ftehe r A a 2% d ltop h ca 1 2% t.2 ing re a se F rull vic-e Re s w pla as a cem ffe ent cte , d H igh by -tD he e d nuc ottic ible e. employ 2 erEs w xpe errim e m ent or Percen .e C lik am eb ly tag r idg to e e sh o (f ift MA Perso c) o: st H sh a nrs v aa r En ing rd rUniv o fr llom ed e rid si ne t y d a uc P Hrtie ible gss h. -s t Ded o u cop ctib aylm e e H nt ealth s and Plan coins 1% (H ur D a 1% H nc P), e ins byt ead of eliminating 20 6% % 5% 0.1% 1.1 0.4% management also has a small impact on premiums (Fronstin, Roebuck, and Fendrick 2022). Enrollment into HSA- 1. Employers may not want 20% to cut benefits during a time when unemployment is low and recruitment and 1.0 20 2013 Low-Density 1,250Hemoglobin A 2,1 5c00 Retinop 3 a,thy 250 Internat 6,4i5 on 0al Pea6 k Fl ,25 ow M 0 eter 12 G ,5 lu0 c0 ometer 1B ,0 loo 00 d Pressure 0% 1 4% 4% 4% 4% corona 20% ry artery disease. Patients who either do not respond to or who have an adverse reaction to ACE inhibitors are Employer Contribution to HSA or HRA,* Among Those With Private-Sector Health Ov Tabl erall, w e oe f found Continc ent reas se s in use of 3 of the 7 medical services among HSA-eligible health plan enrollees that it . 0 Health Plan With a Health Savings Account: A Five-Year Study," EBRI Issue Brief, no. 388 (Employee Benefit 10% Lipoprotein (LDL) (HbA1C) 17% Testing Screening Normalized Ratio Monitor e Kligib ey Fi le 4% nding healt s: h p lans has been unaffected, but enrollees are paying a smaller share of the total cost of services as cost retent Loion w- 17.4 Dens of ity workeHe rs is mog of lobic n A onc 1c ern. Re tinopathy International Peak Flow Meter Glucometer Blood Pressure Muc h w 18 ork has been done to examine the impact of the IRS notice on the response of employers and health plans, as 2014 Insulin and Oth1 e, r250Selective Sero 2t,o5 n0 in0 Stat3 in,s300 Angiotens6 in,-Con 550verting Be 6 ta ,3 Bl 5o 0 ckers An1 tire 2s ,7 orp 00 tive Therapy Inh1 a,le 0d0 Co 0 rticosteriods 16.6 In our analyT si es s, ti ng we studied the cC ha ong ver eag in t e he an d us Emp e of lhe oy aee lt (INR) h ca -On Tes rle y ti ng se Co rvvic er es ag for e, t 2016 he ent –2022 ire population and among those Roe usua blly uc k swit , Mc . he Chr d is to top angio her. t20 ens 12 in r . Thr ecee pet or Ess ba loc ys on kers (A theRB Ec s) o nom to pic res of ventP r the esc sa ripti mon e eD xa rc ugs. erba D tions is2% ser . tH a 2% tow ion, evB ea r, ltA im 2% RB ors a e2% , rMD e not : Lipoprotein (LDL) (HbA1C) Testing Screening Normalized Ratio Monitor excee0% ded the percentage increase in the use of these services among enrollees without HSA-eligible plans. Among IntroductRe ion sea ................................ rch Institute, 2013)................................. .......................................................................................... 4 15% Glucose-Lowering Reuptake Inhibitors Enzyme (ACE) sharing 0 has shifted from deductibles to copayments and/or coinsurance (Fronstin and Volkov 2023). 2. 2% Employers may believe that incentivizing the use of these services reduces aggregate health spending in the w ell a 16s the impT aes ctti ng on premiums. A 2021 EBRI survey found (INR) tha Tes t ti76 ng percent of employers with 200 or more employees 2015 1,300 2,600 3,350 6,650 6,450 12,900 1,000 Insulin Selective Statins Angiotensin- Beta Antiresorptive Inhaled with these aff Ag ec entts ed health cond (SSRit Ision ) s from 2018 to 2021 to Ine hiv bia tolua rs te whether the IRS notice led to a change in health Univ. of Maryland Baltimore County. inc In th lude is d Iss in t ue Low- he B Dens r ie lisft i, ty of we14 ex He ser am mo v ine gic lob e s in N itnhe A1 cim ot pa icce Re t 20 of tin1 op I9 RS N a- thy 45, ot aic nd e 20 In thus ternat 19 - tihe 45 onal y on caus nno Pe ea tof kb Fle he ow M ca ov lt ete h ca er redr e p rser e G- lud v ce oic me deuc s a tertible mong in HSA B le oonr d P olle - re esligib se us i rele n • Overall, we found that between 2018 and 2021, the IRS notice increased the use of 3 of the 7 medical services enrollees in HSA-eligible plans, use of LDL testing increased from 29 percent to 31 percent of the sample (Figure 4). and Serotonin Converting Blockers Therapy Corticosteriods long term. HDHP Only HDHP With Employer Contribution to HSA or HRA 0% Background Lipoprotei ................................ n (LDL) (HbA1C) Testi................................ ng Screening No ................................ rmalized Ratio ........................................................... Monitor 6 incre14 ased 2016 the numb1 e,r 3 0 of 0 drugs and 2,60 ser 0 vices cov 3,e 3r 5e 0d pre-ded 6uc ,75t0 ible in HSA 6,-5e 5ligib 0 le hea1 lt 3h p ,10la 0 ns as a r1 e,su 00lt 0 of IRS 10% Other Reuptake Enzyme (ACE) c are use. We compared use of health care services among enrollees in HSA-eligible health plans vs. other health plans he H FrSA onst alt -h p eligib in, P lans le aul, a .he Sim and ltila h p r M. ly la, ns Cser hr . is Mo ot tonin op rehe spe -rnor Roe cifi ep cb a ine uc llyp k , ,hr w "ine e Ma e na xa rem g upta ing inek U w ese he inh of the ibit Hre or ta he s (SNRI lth C not aic ree s) Se a m ff re v ac ic yt e ed bs A e us afn e te e rof ff Pe eins c otp iv uli le e n a Sa tretnd a istfy m ot eTheir he nt rfor g luc paose tient - s Our analy bsi y s mc In or onfir sue lin in HSA am nds tha -e t ligib use Sele lof e cp tivhe la e n as c lth ca omp re a Sta rser ed tin v sw icit eh s ha non s -so fa An HSA giote-r ne sb ligi ine - ebn una le pla Be ff ns ta e Bl .c t o Use e ckd e rs b of y tlow he An - Id RS tie rens sn orp it ot tiy vic elipop e. Thi rot s m eIn in ( a hay leL db DeL ) Use of HbA1C Tes t tie ng sting increased from 13 percent to 17 pe (INR) rcent Tes of tingthe sample, and use of retinopathy screening 80% Glucose-Lowering Inhibitors (SSRIs) Inhibitors 3. There is precedent for covering these services without cost sharing in the absence of the ACA mandate. When Notice 2019-45O ( thFr eronstin andSe Fe ro 11.1 to ndr nin ick 2021). Pre-deductible Con c vov ertine grage was often added for Th he erapa ylth care Cort ser icv oic stee ris r odselated Roeb12 uck2017 , M. Christop 1,3 he 00r, J. Sama 2nt ,60 ha 0 Doughe3 r,t4 y0 , 0Robert Ka 6e ,7 st 5ne 0 r, and L6a,u 55 ra 0 M. Mille1 r. 3,20 1015 0 . "Increa 1se ,00 d0 Use Of between 2018 Ag and ents2021. W 10.7 e also evaluated changes in health care use among enrollees with the relevant health Data andD St ed udy Sa uctiblem : p W le ha ................................ t Do Copayments and ................................ Coinsurance Do?" EB ................................ RI Issue Brief, no. 519 ................................ (Employee Benefit Re .......... searc h 7 low with d ering epra eg ss eion w nts, se ho lec dto iv not e ser re ot spond onin r teo upta SSRI 10.4 ke s. inh 10.5 ibitors (SSRIs), statins, beta blockers, antiresorptive therapy, inhaled 5% testing, hemoglobin A1C (HbA1C) t3% esting, 3% and retinop 3% a 3% thy screening increased by a larger percentage among b inc ecra eus ased e t he fr Gom lum coa s e 2 p j-L or owe it ey rric nof e gnt e m to p3 p loy Reue e pta r rs su c keentb of stittu he te d sa cm op pa ley.m W ee nt d En s a id zynd/or m not e (ACE) see coins an inc uranc rea ese for in us dede uc of tible INs ins R test teing ad or of e glim lucom inateing ters. health reimbursement arrangements (HRAs) were introd 9.6uced in the early 2000s, some employers provided 9.4 9.4 9.3 to heart 2018 P dr is ee sc ase rAg ipe ta n ion D nd ts1,d 35 ia r0 ugs beIn te Re his c bito drs a uc (SSRIs r2 e e ,. 7 s Me 0 Tw 0 ) od -ic thir al C ds ost 3a ,4 d 5 s I d 0en M d pr ee d-ic da e In 6id d h ,9 iuc b0 ito P 0t rs oible pula ctov ions e6 r,a ." 6g 5H e 0 e for alt h Af bloofa 1 d3 ir p ,3 sr0 e34 0 ss 9.1 ur (9) e : m 15 onit 86 1,0 or -0 10 s a 593. nd 10 0.35% 0.07% conditions to see if the IRS notice had impacted use of health care differ0.11% ently by type of health plan. 0.03% We specifically corticoste Ins roid tits, a ute, ngio 2020 tens ). in-converting enzyme (ACE) inhibitors, blood pressur 0.07% e monitors, pe0.18% ak flow meters, c ost 6 sha70 re ing nr % olle com es in HSA pletely. - Ie t ligib mayle a ls pla o n bs c e d om uep ta o re la dc k w O it of th her etnr hose Heolle althhe e P la ka n now lt Eh p nroll le la d ens eg se not about tar g pe la tn edd b esi y g this n ch pa olic nge y s t cha ha nge t w, esu re ggesting Use of peak flow meters fell, and use of blood pressure monitors increased, but in both cases, very few enrollees filed Methods ................................................................................................................................ 7.9 ............................... 8 0% first-dollar coverage for preventive services (Fronstin 2002). Comparable generous coverage was implemented insulin/glucose-lowering agents, 61 percent added coverage for glucometers, and 54 percent added coverage for beta Furthe 8rm 2019 dor oi:0.13 e, the77 re /h 1 is ,3 lta 5ha lr 0eff a.20 dy 15 an a .033 2,p 7p 05 0 e.t ite for a3 d,d 50 ing 0 more ser 7,0 v0 ic 0es, as evide 6,75 nc 0ed by The 13 ,C 50 hr 0onic Dise1 a,se 000 Management 5.3 focused on changes in use of health care for all 14 classes of medication and services specified as the prescription hemoglobin A Lo1c w-D ( ens Hb ity A1C) He tes mo ting, globinint A1e crnationa Retinl nor opathymalized In ternat ratio ion (I alNR) t Pe ea st king, Flow M low ete- rdensit Gy lu clipop ometerrotein (L BlooD d P L) res te su srt eing, that the IRS contributed to increased use of these services. c int larim ods for uced t hose to incser entviv icize es. us Thi e s m of pary e v beent div ue e ser to tvhe ice fa s.c E t m tha ploy t the ers w cost ould of t eho xcse lude ser av dic de its is iona rl ep la re tiv ve ent ly iv low e ser , and vicets if a hey allow re ed Other Health Plan Enrollees 20 when health savings account (HSA)-eligible health plans were introduced (Fronstin, Sepúlveda, and Roebuck 60.1% Resu10 lts 0% ................................ Lipoprotein (LDL) (HbA1C) ................................ Testing Screening ................................ Normalized Ratio ................................................................ Monitor . 8 Fr bloc onst kein, P rs. Hea 2020 aul, M lth ca . Cr1 hr e, 4is ser 0t 0op vic he es le r Roe a2 st ,b 8 uc lik 00k e, lya tnd o ha A. 3 v,Ma e 5 5p 0 rrk e -Fe de nd duc rict7 k ible ,,1 0 "0 P crov em eium rage I 6 m w ,9p e 00 r ae c tp of eaE k xfp low 1a 3nding ,8 m 00et ePrrs a e-D nd e1 dI,uc N 00 R te t0iblest C ing ove (r 25 ag e Act, w 6hich was reintroduced in the U.S. Congress as recently as March 2023. This bipartisan, bicameral legislation 5 Other Health Plan Enrollees drugs and services that could now be covered pre-deductible by the IRS notice. The medications are ins 57.9% ulin and other 6 57.7% glucome60 te% rs, and retinopathy screening. by the IRS, according to EBRI’s su 90% rvey results. However, if their goal is to increase use of those services, they should available over Ttes he ting counter. When examining claims data for (INR) t Tes hese tingservices, the average spending per enrollee with a 5.5 88% Other Health Plan Enrollees 4.4 Trive18 di, Amal N., Husein Moloo, and Vincent Mor. 2010. "Incr 5e 5.3 ased % Ambulatory Care Copayments and Hospitalizations 2013a). And of course, the 2021 EBRI survey mentioned above found that when the IRS allowed em 3.6 ployers Other Health Plan Enrollees percent 90% e 2021 ach). Most1 ,e 4m 00ployers did 2,8not 00 eliminat 3e ,6 c 0ost 0 sharing 7,2 for 00 the pre-d 7,e 0d 0uc 0 tible serv 14ic ,0e 0s t 0 hat were 1 ,a 03.4 d 00 ded. The would giv to e C Hhr SA onic -eligib Dis le e a he se alt Ma h na pla gns em aednt dit Me iona dic l fle 53.6% ations xibilit in HSA y to p-rE ov ligib idele p rH ee -d ae ltd h P ucla tible ns, " cov EBe RI ra g Iss e ue for B ser riev fic , no. es tha 56t3 prevent 18 4% glucose-lowering agents, SSRIs, 53.0% statins, beta blockers, antiresorptive therapy, inhaled corticosteroids, and ACE Use of Medical Services ............................................................................................................................................9 • In addition, use of selective serotonin reuptake inhibitors (SSRIs), statins, and angiotensin-converting enzyme c re onsi leva dnt er d the iag irnosi app s w roa acs $71 h tow for ard bclood ost sh praerss ing. ur e monitors and $38 for peak flow meters in 2019 (Figure 5). However, 16% 4 a and mong he atlt he h p Ellde ans rly to ." cN ov ew er E cngla ertain p nd Jour revennt al o ivef M ser ev dic ice ine s out 36si 2 (4 de )H : SA 32-0e-ligib 328. d le he oi:10.1 alth p 05 la6 n d /Ne Ed JMsa uctible 0904 s, a 53 b3. out three- 5 16 90% Other Health Plan Enrollees 4.7 Source: Em 15p .0 loyee Benefit Research Institute estimates based on administrative enrollment and claims data. perce 16 nt 80 % % a2022 ( gE em ep lim loy ina ee 75% t 1 ing B ,4 e0 ne 0 cost fit Re sha sea ring 2r,c 8h I 0r0 ans nge titdu tfr eom , 320 ,6 5 25 22 0 ). p ercent 7t,o 3040 0 percent 7, ,0 d5e 0pending 1 on 4,1t0 he 0 service. 1 The ,0002021 EBRI the exacerba 14.7 tion of chronic conditions. 2 inhibitor50 s. % The 73% me 82% dical services are blood pressure monitors, peak flow meters, HbA1C testing, INR testing, LDL 47.1% (ACE) inhibitors incr14% eased by a larger percentage among enrollees in HSA-eligible plans compared with those these services c 79%an often be found over the counter for as little as $20. Use of Pharmacy Services ................................................................................................................................ 6 ...... 14 quarters of them chose to do so, often without cost sharing (Fronstin and Fendrick 2021). 14 80% % surve 14 y 70 a %2023 lso found tha 1,5t0 m 0 ost employ 3,00 e0 rs would a 3d ,8d 5 0pre-deduc 7t,ible 750 coverag7 e, 5 for 00 additiona 15l he ,000 alth care ser 1,0v 0ic 0es if allowed 28.0% Background Employ 0 ers and policymakers have an appetite for more flexible plan designs or “smarter” deductibles be 25.6% cause rising testing, glucometers, and retinopathy screening. 25.7% 12% health plans not targeted by this policy change, su 3.7 ggesting that the IRS also contributed to increased use of VBID4 3 Health. n.d. "Financial Impact of HSA-HDHP Reform to Improve Access to Chronic Disease Management 24.4% Insulin and Other Selective Serotonin Statins Angiotensin-Converting Beta Blockers Antiresorptive Therapy Inhaled Corticosteriods Fr onstin, Paul, M. Christophe 66% r Roe 66% buck, and 11% A. Mark Fendrick, "The Impact of Expanding Pre-Deductible Coverage in 12% Discus 70s %ion ................................................................ 24.8% ............................................................................................ 17 by law 60 ( % Fronstin and Fendrick 2021). A 2021 AHIP survey of health plans also found that three-quarters of health plans 12 40% 25.8% Unt he We a il I lt ch ca onc RS N lude rG elot u spe co ic s te ha e -L nding o20 twe the 19 ring -ha I45 RS s c Reu w n ra po e ta sa t kic r t ee e Ie nd le hinc ib a ser ito sed r rse ious a se on d fis July us cae l c 17 of ha , L20 lle DL nge 19 te , st En s. w 2.3 ing, zhe Sm ymn it e (ACE) a 3.2 Hrb tc e Aa r1 m d c e etd etuc st o ip tng, ible rov a s a iding nd ccr om eptr inop e m -d od e ad t ahy uc ting tsc ible ser re e cv nin ov ice e g s p r a ag m re eong vof ent he H ing a SA lth t-he these prescription drugs. Two receMe nt d su icravte ions ys fin ." A d csu cep ss pe or dt A augu mong st 15 em , p 20 loy 23 e. rs ht for tp s:/ the /v c bont idhe 2.1 inu ala th.c tion o om/do f prc ov s/H iding SA- HD preHP vent -Re ivfeor ser m-vBic rie es w f.pd itf. hout cost 10.1 10% HSA-Ag Eligib ents le Health P (SSRIs lans ) on Premiums 10.0 ," EBRI Issue Inhi bB itorrs ie 3 f, no. 558 (Employee Benefit Research Institute, Data and Study Sample 9.9 60% 22.4% We evaluated changes over9.7 time among enrollees without the relevant conditions in HSA-eligible health plans, but we expa3 nde 50%d pre-deductible coverage as a resu 1.8lt of 1.8the IRS notice9.5 . 9.4 8% exace 2rbation of chronic conditions might be a natural evolution of health p 1.7 lans. Value-based reimbursement promotes c e Ca ligib onc re 10 lu ser lesi he v on icae ................................ lt s in HSA h plan e-n erligib ollee les ,he as w alt................................ h p e o la bn ser s, e vem dp la loy rge errs w pee r ................................ c re e nt guide age d inc brye t ahe ses Int in use e................................ rna l Re among venue HSA Se p rv la icn e e ( ........................... nr IRS) olle sa es a fe s harbor 19 2.5 2.5 9.0 8.9 sh aring. A 2022 EBRI surve 1.5 y found 1.5 that 80 percent of HR d7% ecision makers said they would continue to cover preventive 8% 1.4 2022). 2.2 2.2 References also us 50% ed the com 1.3parison group of the unaffected enrollees (those in other health plans) to show how use of health For the p 30 r% esent Sou 6% rce : st Em udy, w 6% ployee Be en e ut fit ili Res ze ea d rc t hhe Ins ti20 tute18 esti m a and tes b20 ase21 d on Ma admr ink ise tra tsc tivea en n® rollm C en om t anm d c6% e lar im csia d6% a l ta D . atabase. Da 7.8 ta from 2018 were used 40% 1.2 Use of health services may not have changed for all targeted services and prescription drugs because many employers c sect t W he om ha d ion 22 p re a aliv m re, e dr J. 3( y w Fr c it of )h a (e 2 nk ot v )(ide he , CFa )r nc of ng he et- a he b Zh ltah p se a Ing, nt d la e , n e rhigh E na m nr l Re m -olle q aua vM. e elit nue s.E y g c g a Cle rod e st e ton, ha (ItRC C ehr nc ).i st our Eine ma pg loy Y e. s us e Lru, s c eSt ould of ep — he only rn B at 1.1 he . pr Soum r ov tha ide n cr e r ca 7.4 ov e i, ae a tring nd age D b a of er nni rtie he s Ross rs t follow o — -1.1 D ing high egna - n. 7 41% 8 40% 1.8 servic6% es in full. Similarly, a 2023 survey found that 72 percent of employers expect to continue providing coverage for Refer 2ences ........................................................................................................................................................... 20 When it com 1.6 es to the impact of expanding pre-deductible coverage on premiums, three studies have been conducted. 1 40% 1.5 c ba erce a us ser ev it ic e re sp w re ould sent ha s tv he e lik last ely ful trl ye ende ard p in t reche ed ing absenc IRS e N of otic the e 26% 20 IRS int 19 26% -45. e rD ve ant taion. from 2018 were compared with 2021 for Agraw 30 a% l, Rajender, Olena Mazurenko, and Nir Menachemi. 2017. "High-Deductible Health Plans Reduce Health Care 33% v su ab lue sti tser ute vd ic e cop s. I ant ym er evnetnt s a ions nd/or tha ctoins imp ur rov anc e e p a for tie nt de-d ce uc nt tible ered s. P out ast com EBeRI s w re hil sea e m rca h found intainin g tha aff t or the da p be ili rtcy e nt ma ag ye b of e found emploin yers ser vices p 20 rior 18 . to "E tff he ec sa t of tisH faigh ction o -Dedf th ucte ib p lela In d ns 8ur ed auc ncteible on: High-Acuity Outcomes in Diabetes: A Natural Experiment for 31% 3% 4% Figure 5 30% 1.2 Fronst 6in, Paul, M. Christopher Roebuck, Jason Buxbaum, and A. Mark Fendrick, "Do People Choose Wisely After all preventive services without cost sharing. 29% 1.1 1.1 The 2021 AHIP survey of insurers mentioned above noted that most reported either no premium increase or premium 2% 2% 2% Endno 30t % e20 s ................................ % ............................................................................................................................. 22 W seve hile ra us l re e C a ost of sons sele And . For ctUti ser one lizvaic t, ion, e20 s i21 nc Inc rw ela udin ased s the g , tUse he first num Of N yea bre 16% e e in w r dof edhic serv Prh w eic ve ee nt s ob e ivm e se p Se rloy vrev e dic d a e a s." la mrong g Heera p us lte h Af r ecre s d nt faa id irg s e not 36 of ( ce 10 ha m)nge p : loy 17 e b 62 res a t-w 176 d eop e8. n 201 ting 8 20% 15% 24% that eliminated cost sharing for the preventive services identified in the IRS notice ranged 23% from a low of 25 percent to a t he for 1 m Tr of ans a cla lin tion in ically nua Diab nc eteed s (NEX HSA-e Tligib -D) le St udy." health D p ia la bn th etes C at a br eet t4 e1 (5 r me)e : t94 s w 0or -94 ke 8. d rs’ oi:10.2 clinical a 33 nd 7 22% /d fin c17 anc -1183. ial ne eds. 2% Average Spending on Health Care Services per Enrollee Satisfying Health Plan Deductibles? Evidence From the Use of Low-Value Health Care Services," EBRI 19% Issue 0 4 32.0% 32.1% 32.3% increases of less than 1 percent. Although estimates are reported, a great deal of uncertainty regarding the effect of 30.9% 2.8 2.7 a som nd e • 20 20 for % 21 P m rae m of ve ong p nt re iv -H e d SA e ser d-uc e vligib ic tie bs r lele c e ov he com e arltm ah p geende .la Fu n dr a tnd b he y r 28.9% tot m he he or U. e r ,he S. a a P clt r ruc e h p via ela nt l c n e iv om enr Se poll one rv eic ent s e.s Ta of On tsk his av For earna ac ge ly e , si (USP us s is e STF w usi as v ng ), e td he ria y g low Anoses dv is am orong c yod e s to doi:10.1377/hlthaff.2017.0610. 10% 27.1% 5% high of 0%40 Lo pw- erDens cent ity depending Hemog lob on in A the 1c servRe ice ti ne op xa athy mined. In o Internat the ion r al words, 59 p Peak Flow M erce ete ntr to 75 G p lue corme cetnt er of em Bp loo loy d Pe res rs sure Nearly 20 years after passageW of ith the D iMMA, only agnosis P one ert- aq in ua in rtg e rt o of IR sm Sa N lleo r te ic m ep 2 loy 01 e9 rs -4a5 nd , 2 one 018-half of larger employers Discussion 24.8% 3% 2% 2% Brief, no. 516 (Employee Benefit Research Institute, 2020). 0.4% 0.1% R Not eic se ults 2019 -45 Ins uon lin anp dremiums Se re lem ctiva eins. In theSta AH tinI sP survey, An 15 gio te pne sir nc -ent of fully Be ta insured pla An ns tire s a ond rptive29 percent Inh aof ledself- 02 10 Lipo %protein (LDL) (HbA1C) Testing Screening Normalized Ratio Monitor 10% e ide W nr ha nt olle rif ay m e s e , Cnr us J. om olle ing Fr m ae it nk ts w the e, e Fa it ser on h condit ng vIic m Zh em s auni (ng, iFi ons a g za ur E 9tm ion eff m 6 ec ) a P . t r e M. Thi a dc tb E s is ic y ge g ts (A he le not st IC on, RS a IP su )n C , r ot hr tp he ic rist ise e H ine , ,e na a a s t Y lt m h . e he LRe ly u, se d sour St ia ser e bp e cv he e tic e s a s, d n So es a nd erum p e Se r e te r y ss v p ric a ion, ic i, e as A a lly nd he d not m a D rini e t us nni dst is ers Ross e d aa tm ion' se, or s (H e a - D st tha e hm RSA gn o na a, n. 'nc s) liv e e ror substit0% uted either copayments or coinsurance for the deductible, depending on the service or drug. Other Serotonin Converting Blockers Therapy Corticosteriods offer an HSA-eligible health plan. Employers may be holding back from adopting HSA-eligible health plans because of Low- Tes Dens tingity Hemoglobin A1c Retinopathy (In INR) ternat Tes ion ting al Peak Flow Meter Glucometer Blood Pressure The fact that we do not see a change in use of all targeted services and prescription drugs as a result of the IRS notice Figures ins Brot ur-e Gd old pla be G ns r lug c Lo o not , sw- Z e-L a Dens e ord we e k ri t ity ha nC g., t it A m He wa it Reu mo a s t b g ph C loo ta ob kie nha e Aa 1ndr r cly tao , Re B know e tinj nop a am w thy in R. hat im H En p a In a nde zternat ycm t et (ACE) l, he ion a n al ndot Jona ice P ea ha tha k Fl d n T. ow M on p ete K re olst rmium adG . s. l20 uc A o17 me no. ter the "Wrha 7 p tB D le oor oe d P ces a nt res sof urefully In this 0 section, we present the findings on the impact of expanding pre-deductible coverage in HSA-eligible health plans disease, 0% Li 20 B bpo rle ight 17 protei ed. ing "Fu n (L Dia td DL) ur b ise e or t e P ds Out re (oje HrbA s, c 1C a tp , nd )a T atnd e ie ost snt ting H eC RSA op aror e a osis a Snd nd cree /os tA ni he c ng tut eIop e ns C e tit om nia ut Noe p . rm lic Iof al ndivi a izM t ed ioe Rati ns d dua ic oB ine ls e for w (e Ie OM) c r ea nd lessA om ft lik e m erly itH t t e igh o e see - on Dek w d out uc om tible e tn' res c aItns m lin ur eic nt Mo a anc l p ni in inp tor er eve ant tie iv nt e twice per year when they are used. Medications Medical Services e Fr vonst idenc in, P e tha aul, M t theayr tm in J. ay b Se e p aulv ssoc edia at, ea dnd wit M. h a C hr reis duc top tion in her Roe apbpuc rok p. ria 20 te 13 par e"v Ceonsu ntive m cearr-e D ir and ecte m de H dic ea alt tion a h Plad ns he Re renc duc e e The So Lu ip rco ep Ag : rEm o ete np ts in lo (L yee DL Be ) nefi In ( t Hb h Re ibA is to e 1rs a C) T rc (SSRIs h In es sti titu n )g te estimaS tec sr b ea es n ein d g on adminNo istra rm In tiv h ae ilb i z e ito e nd ro rs Ra llme tin ot and claims data. Monitor Insulin and Other Selective Serotonin Statins Angiotensin-Converting Beta Blockers Antiresorptive Therapy Inhaled Corticosteriods is not surprising. Ins uT linhis may beSe d leue ctiv eto the reduc Stattion in ins use of Anghe iotea ns lt inh ca - re servBe icta es due to t An he tire C soOVI rptiveD-19 pande Inhale m dic. It Testing (INR) Testing insured pD 0% la ens duc atnd ible 17 D o? pe rThe centI m of pself act -o ins f C ur ost ed- Sha plans ring reon porH teeda lt “ot h C he arr”e w Phe ricn a es, Qua sked nt ab itout ies, a the nd im Sp pe anding ct of t he Dy na not mic ices." on The on use of health care services. Specifically, we look at the impact on use of the following medical and pharmacy Employers w Gluco ould se-L Tes o we e ting xc ringlude Reu ad pta dkit e I iona nhibito l p rs reventive services if a En(z INR) yllow me (ACE) Tes edti ng by the IRS, according to past EBRI research. If and outpser E anr tie v ollm nt ice sett s (r ae nnt d e ings d : qA uir Ne aue d tur b ty ao Se l Ex Se ro the tocp nt iion e nCrOVI im 27 eD nt 13 - 19 for of p Tr ta he n ad ns P ea m la tie ic tion in , nt t he PCon r ot e Dxa ve ia ec rtib c t nt ie gon tsett es (NEXT and ings th Aff Blor - oa c D kd te ) a rs iss St blue udy." e C tahe r eJA d A Th M ia ct eg A ra of noses pIynt 20 er 10 na c od ( l M A Cort e Ce sA d ine c)ic o saine te e nd ri d oe d 177 sd IRS by $634 $71 Antires So or up rcte iv : e Em th ple or ya ee p y Benefit Research Institute estimates based on administrative enroB llmlo en o t d a np dr c e la sis mu s r de a ta m . onitor Long-Term Use Of Outpatient Physician Visits And Prescription Drugs." Health Affairs 32 (6): 1126-1134. ( Fi Ag gur rae w 1, al, PM ea rczur ent ea nk 20 ge o, 16 of and Pe rM sons ena c 20 Ehe nr 17m olle i 2017 d in a ). H The 20 igh 18-sa De vd ing ucs or tible 20 m H 19 eed aic lta h P l cla ost n (H offs 20D 20e HtP s fr ), om by E p m rov 20 ploy 21 iding er Cinc ont ernt ibut iv 20 e22 io s t n to HS o get A or may also be d Ag ue en tsto other fac (SSRIs tors.) For instance, 2021 was the Inhib fir itors st year that many employers expanded pre-deductible Other Reuptake Enzyme (ACE) A pr m eong mium eQua s nr . olle Nro te e crs w ont ly Jour e itxt h th w na e al s g rof eliv e Ev e ca n for onomi nt he ta c he lt s h condit 13 “ot 2 ( he3) r”: ions r12 esponse 61 , w -e 1 31 fs, b ind 8. ht ut the tw p sa :e// m cw ae w n conc p wa .nb ttee lude rn w r.or it g tha h r /pa te p 22 spe er s/ p ce t w rt21 co ent t 63 he 2.p of pe ful drf. cly e nt ins ag ur ee of d plans Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. ser emv pic loy es: er s’ goal is to increase use of those services, they should consider their approach to cost sharing. this analy Nsi ot s ic to e ide 2013 ntify -57 a ) ff (e Kc atis ee dr eFa nrm ollily ee Founda s. Thust , ion 2015 we use 2 ; 02 Int 1 etro na m l Re easu vernue e the Se im rvp ica ec t20 s of 13) the . 2019 IRS policy change. Ang( io 3) tSo e G: n lu u35 s c rc o in e s8 : e -c Em -L -o 36 on we plv o8. d e ri yn r etg ein Be oi:10.1 g ne eIn n fit h z Res ib yim to00 e rs e a (SSRIs rc (1 h A/j In Ca sE tim )tu ) te ia n int e h siti b m e ita r o te nm rs s ba e sd ed.201 on ad $37 6.84 ministra 11 Intih vi. e b ito en rs rolP lme ea nk t a n fld o w cla im ms e d te ata r . $38 preventive H c RA ar, eA am reong oft e Thos n diff e ic W ult ith P to rqiv ua atnt e-ify Se.c Y tor et H em eapltloy h C eov rs oft erae gn inv e and est Em in suc ployeh ca e-Only re in t Cov he e ra ab gsenc e, 20 e16 of –e 202 vide 2 nc ............. e. 4 coverage. It may take time for enrollees with the above health care conditions to learn that their health plan has Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. Agents e anr nd olle 46e p s us erce ing nt m of eself dica -ins l seur rveic de p s a lans nd st the ill d qid ua not ntit yk now of ser w vha ice ts us impe ad c.t The the n m ot aiin d ce ha iffe dr e on ncp er e bm etium wees. n th e findings for all * HSA = health savings account, HRA = health reimbursement arra$126 ngement. $310 Fr Using onst • Bd in, P eia ta Pg e bnos a r lo ul, M iod ckis e ic rc s a he od rtin J. a elt s fr h e om Se vap lua tulv hete ions inpa da, su a tie nd cnt h a M. as a nd Chr nnu out istp a op a l p the ie hy nt r si R ser coe als b v ic uc ae nd k . filsele 20 e Gs lu 13 , cc w o tb m e. p e d r "te Me e ev rfin ed nt e icd iv a te he io sc n U alt re h condit teili nin zag tion a s not ion ind nd listA ic ed d ahe ta or b re s ov nc . W ee e in als a o Because of constraints around preventive care and HSA-eligible health plans, employers appear to have moved toward changed So cov u So rce u erc : rEm a e: g M pe le o d yfor ie ce a lBe Ex cne pe er fi nt t da Res itu in p re ea Pa rc rh e n e In v l e Su stint tu rvte eiv y e e -sIn ti m ser su ara tev s n cic be a e s Com esd. opT no he a nd em ny t in (M im sEPS tra a tiy v -e IC). not enro llb me en t a aw nda cr lae im of s dat tahe . change in plan design, despite Bundorf, M. Kate. 2012. "Consumer-Directed Health Plans: Do They Deliver?" Research Synthesis Report No. 24 (Robert Medical services: e Finr gur olle e e 2, s a Cn hr donic those Disw eit ah he se Ma alt na h g ce ond meit nt ions Se ris vic te ha s in t t the he sm Expa allende r sad m Sa plefe w H ita h he rbor a ................................ lth conditions is more ........................... likely to use health 5 $960 $262 used Ip nr ho a(c le op edd tc ur iona ore ti c al, on sd p te em rr o ie I dnt d sic ea rna tion l Re cod veens fr ue om Ser v the ice inpa (2004 tie)nt )., outpatieR nt e, tin ao nd patp hr ye s sc crre ipti enion ng drug files to identify the Health Savings Account-Eligible Plan." American Journal of Managed Care 19 (12): e400-e407. higher deductibles in PPOs, while some have adopted HRA plans instead, possibly with flexible spending accounts E em BRI ploy ree se rW s’ aood rb ce h usin st Johns effg or on c ts t laim Founda o s d infor atm a tion) aend nr. olle a ht ss te p um s of ://p w tions w a w pl.r a a w n d bjout f.or esi g g b/c n ch eha ont v ae ior nge nta/da l trha em sponse t/f is a rc m onsi /r s e cp onfir dor ert es/ d m re a ed n im p o the rts/ p rfin 2 ov 01 d eings fr 2/ me rw ntjf4 in b om 02 40 e the ne 5. fit A H s.I P In c E andno re servt ice es s (Figure 7), and the quantity used is slightly higher (Figure 8). $3,627 $38 Insulin and other glucose-lowering agents Hemoglobin A1c (HbA1C) testing m Am ed ong • ic a te ion Ob nrs olle e a sind te ys fil w ser elight ing vicep -s ut loss resc ili r p ze ipti rog dons, t r baym es a nr he oll nd num ee tob s t ba hr ecrc oug of o cd h erout ss ug at fil t ion p he ls inc prla og rn ye eraased m as (opti r. slight on ly al for , p ins er uli Int n a erna nd l ot Rehe vernue gluc Se ose rv-ic low e (e 2004) ring ). Fi gure 3, Sample Sizes for Enrollees With Health Conditions ..................................................................................... 8 (FSAs). The IRS notice may not only cause employers offering HSA-eligible health plans to adopt pre-deductible • Blood pressure monitors. fa sucrtv, eE yB (RI Fr onst resea in, rcRoe h ind buc ica kt,e a s t nd haFe t 63 ndr p icekr c20 ent 22 of ). e In g nrolle ene ersa w l, it the h a im n HSA pact- e on ligib prle em he ium alts of h pla en xpa spe nding nd le p ss re t-ha den duc 30 mi tiblenut es This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), Fronstin, Paul, and Eden Volkov, "The Impact of Expanding Pre-Deductible Coverage in HSA-Eligible Health Plans on Selective serotonin reuptake inhibitors (SSRIs) $104 International normalized ratio (INR) testing $82 agent • s, SSRI Drugs s, tst aa kteins n b , yA C asy E im nhi ptb om itor as ti, c aindiv nd aidua ntirels sor to pt piv re ev tehe ntr a the py m am anif ong est baot tion o h HSA f d -e isligib ease le( he opa tiona lth pl, lap n e er nr Int oll ee rn ea s a l nd 5 Chandra, Amitabh, Jonathan Gruber, and Robin McKnight. 2010. "Patient Cost-Sharing and Hospitalization Offsets in the cove • r ageP , ebaut k flow might m e at ls eo rsr.e sult in more employers offering such plans. c choosin overagg e a a s a hellow alth p edla in I n. RS N Furth ot eic rm e or 20 e19 , the -45 ewa mps sm loyerasll. t he Est m im selves ated p mra ey m or ium m inc ay rnot eases havre a nge done d fr aom good vir tjua oblly ed ze ucra o ting to 1. the 5 ir Und e w rit th th he ini e tfun ial I dRS ing g su uida ppor ncte of , unt the il t follow he deing ducor tible ganiz is a m tions et, c: ov Aon, eragBelue doe Cs not ross B inc lue lude Shie "ld any A sser socvia icte ion, or b IC eUB nefit A, int JPe nded to 1 $126 $34 Me Figm urb e Se t4, r a tE he in P m se a p rlt c loy h insu ent ee a gC e rhoi a of nc ce P e la e on lif He gE ibilit nraolle ltyh P inf es Using la or n a mand tion, Me Cost d aic s w Sha al Se ell a ring," rvs m ice , e Ed b Bic y R I a Ty l I Lss ( o pinpa w e ue - d of e B tnie H r sie int e ty a f , lt la ino. p h P nd op rla out o 58 tn e7 (E i................................ p n a (L tie D m L nt p ) loy ) te a se nd tie n gB pe ha ne rm fita Re cy ............... sea claim rch s, 10 In 2021, 60.1 percent of individuals with health coverage through a private-sector establishment were in a plan with a other hea Re lth p venue lan e Se nrrolle vicee s ( (20 Fi 04 gur )).e 10). Elderly." American Economic Review 100 (1): 192-213. doi:10.1257/aer.100.1.193. • HbA1C testing. e pm erp ce loy nte . eTher s abe out w ats no he cha prnge emi.um increase in the conservative scenario where deductibles were replaced by coinsurance, Morgan Chase, Pfizer, and PhRMA. treat an existing illness, injury, or condition, including drugs or medications" (Internal Revenue Service 2004). This c dom ed Suc o pu rtib ris ce e le I :d ns E tha tm he tit p t u l o me d ty e a e , tt e a 20 the b Ba e 23 se n d e ). fe .i td Our R uc etib s e sa a le rm c re hp le Iq nuire s in b titume te ot e nts h ye sti m to a a trb e s inc e s b Ha S s lude A ed e li o g n pib olic ale dm .y iH hold nio sw tra e etv r iv e s, spo er, e w nre ous lld m o e e s, a no nt a t n nd kd no cd lw a ei p m ho e snd w d ae ma tnt a.ny s, a oll f the unde se re a nr go ell 65 ees , Yet, while employers could incentivize the use of preventive services in non-HSA plans, not all employers have done so. Fi gure 5, Average Spending on Health Care Services per Enrollee With Diagnosis Pertaining to IRS Notice 2019-45, • INR testing. use of health care services were assumed not to increase due to lower cost sharing, and enrollees’ related diagnoses narrow definition of the "safe harbor" has likely caused some plan members to go without needed care, as it is well were in an HSA-eligible health plan. Some were enrolled in a health plan with a health reimbursement arrangement (HRA). Among enrollees with the relevant health conditions, we find the same pattern with respect to the percentage of I w nc ho rew ases ere in c enrolle onsu es m in t er out heir - of he -p aoc lth p ketla cn for osts for the he fulal ye lth ca ar. re W ha e a vls e o be re eq n uir ass e oc tha iatt e an d w indiv ith d idua elelt’e s c rious laim c onseq data ha ue vnc e ful es.l These C The herIne RS wn , ot Mic icha e m el, ayTe m rov esa e B su . cG h e ibson, mploy Kreis rt s t ina ow Ya ur-d I senb changi erg ng , Mic the ha ir epl C lan . Sok desiol, gn to inc Allison B ent . iv Rose ize tn, hea us nd eA of . Ma pre rk v e Fe ntndr ive ick. 2018 .................................................................................................................................................... 10 Finally, use of som EBRI Is e s he uea Bri lth s ef is re erv gic iste es m red ia n y th not e U.S ha . Pavte en tc a ha ndnge Tradd e m bae rk c a Ous ffie ce .m ISa Sny N: 0 e8m 87p –loy 137e Xr/s s 90 0 ubst 887 –it 13 u7tX ed /9 0c $ op .5a 0y +m .50e nts and/or • LDL testing. G wa etrw e ood requir , Jus edt.in, Te We found resa Ba . G 0.87 ibson, perMic cent ha inc el E.F C rease he in p rne re w m , ium Ama s w nda he M. n use Far r of , E he ma ily lt h ca Vogrte m ser ann, a vicend s wAa. sMa ass rk um Fe end d tro ick. Others were in health plans that met the deductible requirement but may have not met other requirements, such as the established that increases in cost sharing for health care have been associated with deleterious consequences. Thus, enrollees filling prescriptions and the number of prescriptions filled. The main difference between the findings for all inf incor lude ma tfin ion o ancn iap l st rersc ess ripti , w on orse drug disa end ase m ce ont nta rol, l heinc altrh se eases rvic in hosp es spending italiza. tions In 2018, , and our exa c se arm ba ptle ion o include f hed alt 2.1 m h disp ill aion rities, 2008. "Effects of Increased Patient Cost Sharing on Socioeconomic Disparities in Health Care." Journal of services for several reasons. First, they may do so because the IRS notice has legitimized it. Second, as health plans coinsurance for © 2 d 0e 23 d,uc Etmp ible lo s. y ee B Fronst enef in a it Resea nd Ferch I ndricns k t(it 20 ute 21 — ) E found ducattio ha n t atnd he Resea percerch Fund. ntage of e All mploy rights ers t reserv hat eed. lim inated cost • Glucometers. restriction on preventive services. increase 20 be14 ca. us "P er of icet he Ela st low icie ty r c aost nd Me shadric ing ation U and e se: mp C loy ost e rSha s did ring notA im cross pose Mul any tiple cost Clin sh 4icaarl C ing. ond If itaions ll 14 se ." Jour rvicna es w l of ere the U.S. Department of Treasury issued guidance 15 years later in 2019 via IRS Notice 2019-45 to further increase the e Finr gur olle e e 6, s a Qua nd nt the ity fin of dMe ings for dical Se those rvicew s Use ith he d, alt Ah condit mong Enr ion olle s is e s Using that theSe sm rva ic lle e, r b sa y m Ty pp lee w oit f He h he alt ah P lth condit lan......................... ions is more 11 p enr art olle icula esr ly in HSA for those -eligib wle it h ch healrtonic h pla m ns e d aic nd al c 11. ond 3 mi ition llion s ae nd nrolle lowe es in r hous othe ehold r he inc alth p omle asns . . PIe n 2021 er-revie , our wed sa litm erpale tur inc e lude has d 1.7 m ake it eG ae si ne err a to l Ioffe nterrn p arl M eve ent dic iv ine e ser 23v ic (8) es on : 1131 a - p11 re36 -de . d du oi:10.1 ctible b 00 asi 7/s s in HSA 11606- 008 plans -06 , it 14 is -0. jus t as easy for employers to sharing for the preventive services identified in the IRS notice ranged from a low of 25 percent to a high of 40 percent • Retinopathy screening. excludedMa from nag p erde -C daerd euc &t ible Spe ccia ov lte yr a Pg ha e rw mit ah no cy 20c ost (11 ). sh aring, use of health care services increased, and the services 2 flexibility of HSA-eligible health plans to cover specific low-cost preventive services on a pre-deductible basis to prevent likely to use health care services (Figure 11), and the quantity used is slightly higher (Figure 12). d m e S ill m eion e eonst http nr rs a:olle t/ed /w e w th s in HSA w a.tirs sele .goc v -te /iv p ligib ub ely/ le irs low - he de ro a ring lt ph p /n-c19 la ost ns -45. sh ap nd ad rfing .6 .8for m ill hi ion e gh-vnr alue olle c ehr s in onic ot he disre he ase altm h ap na lag ns e. mSa ent m p m le e d siic ze ats for ions e ca nn rollees adopt the strategy in other types of health plans. Fi de gp ur ending e 7, P e on rc e tnt hea ser ge v of ice P la en xaE m nr ine olle d. eI s Using n otherMe wor dic ds, b al Se et rw vic ee e, n ne Ama ong rly one Enrolle -half a es Wi nd th twH oe -tahir lth C ds ond subit stion itut s, b ed ya Ty cop pe a yof ment 2 were covered whether or not an enrollee had a related diagnosed condition, premiums increased by 1.5 percent. the exacerbation of chronic conditions (Figure 2). with various health conditions are shown in Figure 3. Health Plan ........................................................................................................................................... 12 from employees, depending on the health care service. Another 4 percent to 19 percent substituted coinsurance for the e e e 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 b b b br r r r 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. i. i. i.o o o 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 r r r rg g g g g g g g g g g g g g g g g g g g g g IIIIIIIIIIIIIIIIIIIIIIs s s s 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 s s s su u u u 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 e e e B B B 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 r r r rief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief A re • • • • • • • • • • • • • • • • • • • • • • s e A A A A A A A A A A A A A A A A A A A A A Aa u u u u u u u u u u u u u u u u u u u u u urg g g g g g g g g g g g g g g g g g g g g g cu u u u u u u u u u u u u u u u u u u u u u hs s s s s s s s s s s s s s s s s s s s s s rtttttttttttttttttttttte 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 p7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 o,,,,,,,,,,,,,,,,,,,,,,r 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 t 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 fr2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 o3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 m • • • • • • • • • • • • • • • • • • • • • • th N N N N N N N N N N N N N N N N N N N N N N eo o o o o o o o o o o o o o o o o o o o o o E ...................... 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