Ohio group health plans with 50 or more full-time enrolled employees will have access to new data to help evaluate and assess their plan risk beginning July 1, 2021.
Overview of Senate Bill 9
Earlier this year, Gov. Mike DeWine signed Ohio Senate Bill 9. The law requires health plan issuers (medical insurance carriers) to provide specific health plan data once per calendar year within 30 days of the plan requesting the information. The information request may be for the plan period immediately preceding or the current policy period. The data that must be reported includes:
- The net claims paid or incurred by month;
- Monthly enrollment data by enrollment tier consisting of employee only, employee and spouse, and employee and family;
- Monthly prescription claims information; and,
- Paid claims over $30,000, including claim identifier other than claimant name and the incurred claim date; the amount paid toward each claim, and claimant health condition or diagnosis.
For purposes of counting full-time employees, the law uses the ACA standard of employees working 30 or more hours per week or 130 hours or more per month.
While we expect all issuers subject to the law to comply, we do not expect issuers to exceed the specific requirements. As a result, the timing and nature of the request for your plan information are critical, specifically pertaining to the annual renewal and marketing process.
Given that the regulations specify that information is required to be provided once per calendar year and that it is for the immediately preceding plan period, or the current plan period should be taken into account in determining the data that will be requested and the timing of when that data should be requested. Issuing a request on July 1 may not provide the right data set to meet the review or assessment you are looking to answer.
Additionally, issuers have long held that this data has not been made available because it is not credible due to the number of claimants or that it can be misused by plan sponsors. The carriers are still deciding on how the data will be used for marketing purposes. We may find this data replaces some of the information/process required currently or will be additional information requested as part of the process. All these factors should be taken into consideration.
It is important to understand that the data will provide a snapshot in time of what happened. While that data can be used effectively to review the past and make assumptions about the future, it is important to do so with the support of benefits professionals used to assessing such information. The realization is that a single large claim or diagnosis can vastly change the outlook in a very short period. Further, understanding whether the claims reported are based upon claims paid or claims incurred is also an important consideration that can impact the assessment of the plan data.
It is also important to recognize the sensitivity of the data that will be available. Plans making this data request should understand the obligations it carries. The law itself provides liability protection for the health plan issuers providing this information. We expect that issuers will require some acknowledgement of the type of data being released and assurance of the understanding of how it is to be handled prior to releasing the data. It is important to review your HIPAA privacy and security processes and procedures if receiving this data directly or work with your benefits professional to request and receive the data. Please reach out to your Hylant team to answer any additional questions you may have regarding this legislation or to discuss the best strategy to meet your employee benefits program needs.
The above information does not constitute advice. Always contact your insurance broker or trusted adviser for insurance-related questions.