5 ways to reevaluate health benefits design for open enrollment season


Millions of workers are looking for new job options and moving to companies that show they prioritise their employees. Reevaluating health benefits and providing a plan that doesn’t limit employees’ options and enables them to receive the treatments they require are two of the finest ways employers can demonstrate this.

Review employee health plans to make sure that a larger portion of treatment costs is not being passed on to employees as the cost of healthcare rises and the autumn open enrollment period draws near.

Everyone is struggling with excessive healthcare costs, and employers may be tempted to look for ways to control them. However, when creating benefit plans, companies should go beyond limiting the short-term expenses of coverage to ensure that no plan provisions would prevent employees from receiving the necessary medical care.

If executive decision-makers, human resources experts, company health benefits managers, and employees have a better understanding of utilisation management (UM), the cost containment strategies that limit employee access to healthcare services, they can make more informed decisions about healthcare plan design.

Control costs

Plans frequently use step therapy, which forces patients to take less expensive prescriptions before moving on to more expensive ones, and prior authorization to limit costs. Administrative bottlenecks, detrimental delays, crippling stress, expensive out-of-pocket costs, and interference with patient and physician decisions regarding the optimal course of treatment are just a few of the unintended consequences of these tools.

Employers must strike a compromise between the requirement to stick to a budget and offering enough coverage for the healthcare demands of their employees. Many businesses rely on outside parties to assist them in creating their strategy. These professionals, who may be benefits consultants or members of the insurer’s customer team, frequently advise employers to purchase packages that restrict access to prescription pharmaceuticals in order to save money.

However, similar to a seesaw, as you press down on one side, such as prescription medication benefits, the other side, such as medical benefits, rises. Patients are more likely to get ill, stay in the hospital longer, or even become crippled when they can’t get the medications they need. No firm would decide to save costs by hurting its workforce. They might not be aware that the issue is being brought on by their benefit design and utilisation management procedures, though.

Employers can take some actions to create plans that provide reasonable, better, and more affordable coverage for their workers who obtain health insurance through their jobs.

Avoid negative effects

Here are five steps to take to make sure employees aren’t negatively impacted by an organization’s health plans:

Reduce copays and deductibles to prevent employees from accruing medical debt, forgoing necessary treatments, or ceasing them altogether because of out-of-pocket expenses. High deductible health insurance policies have been found to deter both medical care and treatment and preventative services, as well as delay the diagnosis of metastatic cancers.

Pre-authorization, which calls for the insurer to approve specific services, treatments, or prescriptions in advance, should only be utilised for medications that are often misused or incorrectly given.

Step therapy should not be used for serious and persistent diseases. Before a more expensive and frequently more effective medication is approved, a less expensive and frequently less effective one must first be used. Delays in receiving the proper care might result in expensive and bothersome side effects or inefficient and perhaps hazardous treatment brought on by the wrong medication.

Make sure the drug formulary is founded on current clinical recommendations and patient out-of-pocket expenses rather than rebates given to the plan sponsor or PBM. Restrictive drug formularies can make it necessary for workers to switch medications in the middle of a treatment (even if they are stable on the current medication), discourage the use of generic medications, and make necessary treatments so expensive that workers stop taking them and run the risk of getting sicker or incur debt to pay for their prescriptions.

Consider all copays made by a patient or on their behalf when calculating their deductible and out-of-pocket limit. Employees should not be penalised by having to pay their copays and deductibles twice if they depend on pricey specialty medications and may need financial assistance to aid with their copays.

Recognize the effect

When choosing the benefits to offer and how to organise their health insurance plans, business owners should create simple plans that give their employees access to the services they need when they need them. Certain usage management techniques may have unexpected implications that are detrimental to patients as well as to their employers, who depend on a healthy and productive workforce.

Employers may make smarter decisions that help their employees avoid needless delays, time-consuming appeals, and overwhelming out-of-pocket costs by understanding the practical effects of utilisation management methods. This will enhance productivity, job satisfaction, and retention.

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