How Payers Use Chronic Disease Management Flexibilities in HSAs

Pre-deductible coverage for chronic disease management through a health savings account is a widespread practice among health plans which may require policymakers to enact regulatory changes in order to improve member satisfaction and healthcare spending, according to a survey from AHIP and Smarter Health Care Coalition.

Using an online survey tool, AHIP and Smarter Health Care Coalition surveyed 36 health plans, accounting for 109 million covered lives across all 50 states, the District of Columbia, and Puerto Rico.

“Given a relatively robust response rate and a wide range of plans submitting the responses, both geographically and in terms of size, the survey data could be regarded as broadly representative of the national HDHP insurance industry,” the report noted.

Every single respondent reported that they offered health savings accounts to their fully-insured clients and over eight in ten respondents offered health savings accounts to their self-insured clients as well.

Three-quarters of the survey participants stated that they offered chronic disease prevention services outside of the plan’s deductible for their fully-insured products. 

This practice was even more prevalent among self-insured lines of business, with eight out of ten respondents adopting this approach. But only four percent of the survey participants that did this reported reducing cost-sharing for these preventive services across all lines of of their self-insured contracts, compared to 44 percent of fully-insured contracts. 

Most payers did not report significantly higher premiums after lowering or eradicating cost-sharing for chronic disease prevention. Four percent of fully-insured plans saw premiums increase by more than one percent. But nearly six in ten fully-insured plans saw a premium increase of less than one percent, along with 46 percent of self-insured health plans.

Whether or not cost-sharing changed for increased chronic disease management was largely a client’s decision in self-insured plans, survey respondents told AHIP. 

The respondents also noted that the regulatory flexibilities were better suited to reducing prescription drug costs than to lowering medical care costs. Enrollees were particularly positive about insulin benefits.

Nevertheless, payers faced administrative challenges with the complex coding required to apply this flexibility as well as challenges with the mental health parity rules, causing some plans to forego the option altogether.

Diabetes and heart disease were two chronic diseases that received coverage from most of the participants. Nearly all payers reported that they covered diabetes care in their fully-insured and self-insured products. A little under three-quarters of the fully-insured and self-insured products covered heart disease care, the plans said.

The two chronic conditions that received the least attention in fully-insured products were osteoporosis and liver disease, while the two chronic conditions that were not targeted in self-insured plans were liver disease and bleeding disorders.

“Employers and health insurance providers have long sought greater flexibility to address the impact chronic diseases have on the people and communities they serve,” Jeanette Thornton, senior vice president of product, employer, and commercial policy at AHIP, said in the press release.  

“By expanding the list of preventive care benefits, health insurance providers and employers have more tools to help patients get the high-value, low-cost care they need.”

Considering how these approaches impact patient satisfaction—a payer metric that has been improving—81 percent of payers stated that members would appreciate primary care visits becoming eligible for pre-deductible coverage. Meanwhile, 64 percent of the respondents said that making telehealth a pre-deductible service would give patient satisfaction a boost. 

While over half of the health plans stated that making mental and behavioral healthcare eligible to be pre-deductible services would have positive impacts on patient satisfaction, some remained concerned about mental healthcare parity.

“Some responses raised the question of what the purpose of a HDHP is if more services are covered pre-deductible, which raises important policy considerations for future rules governing these plans,” the report added.

The report concluded that policymakers must make regulatory changes in order to improve coverage for chronic disease prevention and management in health savings accounts. The researchers suggested expanding preventive care safe harbor policies or untangling health savings accounts from high deductible health plans.