Although the number of daily lives lost to COVID-19 has gone down dramatically since January, health officials are still calling on Americans to get vaccinated. At this time, over 50% of Americans have received at least one vaccination. However, to have the most (or best) protection against the virus, the CDC recommends that each person be fully vaccinated.
The spread of viral variants around the world makes getting vaccinated even more significant. Fully vaccinated persons have highly effective protection against the original virus, but also the multiple variants that have been currently identified. As the pace of vaccinations slows, some states are offering valuable rewards (as high as $1 million in Ohio). Colleges are offering educational scholarships with proof of vaccination.
With pandemic safety restrictions being reduced or withdrawn, employees are returning to their workplaces. Employers have concerns about how to assure safety for both vaccinated and unvaccinated employees.
Currently, no federal, state, or municipal government has mandated COVID vaccinations. However, a range of vaccinations have long been required to protect public health for students, health care jobs, and passports, but recognizing exceptions for medical or religious reasons.
As a private employer, the EEOC recently issued guidance for employers if they want to require employees to get vaccinated. This guidance follows the same exceptions for medical reasons or religious beliefs provided employers offer accommodations for employees who cannot get vaccinated. Suggested accommodations for unvaccinated employees include wearing a face mask and social distancing if working in an office environment. Periodic testing could supplement these precautions. Alternatively, employers may allow flexible work hours for employees going to an office, reassignment to a comparable position, or telecommuting.
Some employers have considered offering an incentive program for their employees getting vaccinated. An incentive program may be considered as part of the wellness program. HIPAA has certain requirements for an employer-sponsored wellness program: rewards cannot exceed more than 30% of the total cost of coverage under the group health plan, and they must offer a reasonable alternative for employees who don’t choose to participate in the program.
Numerous legal challenges to individual employer mandates have begun to wind their way through the judicial system.
In June, Houston Methodist Hospital employees challenged the hospital’s mandated COVID vaccine in federal court, although designated vaccinations have long been a condition of employment. In short order, a federal judge dismissed the action stating that the Hospital’s business was to save lives and the vaccine requirement was consistent with that aim.
Many schools and colleges are requiring COVID vaccines prior to the fall term face similar legal challenges. Indiana University announced last spring that all students, faculty, and staff must be fully vaccinated when returning to campus, recognizing the same medical and religious exceptions. On July 19, the court found that the university’s action was in the interest of public health for its students and employees and that the students had not succeeded in showing irreparable harm by the mandate.
Legal challenges, however, face an uphill battle against a 1905 US Supreme Court decision that upheld a required smallpox vaccination as warranted to protect public health. From 1905 to present, courts have uniformly found that vaccine mandates do not unconstitutionally interfere with an individual’s work or education.
Effective January 1, 2022, the federal No Surprises Act of 2021 extends protection to persons who have coverage through employer-sponsored health plans, including self-funded plans, governmental plans, federal or state marketplaces, or individual market health insurers. Group health plans and health insurers must make the Model Notice publicly available to participants and must include on each Explanation of Benefits for plan years beginning on or after January 1, 2022.
“Surprise” bills, also called “balance billing,” is when an out-of-network provider bills for the difference between their billed charge and the health plan’s payment. Because these unexpected amounts exceed the plan’s allowed charge, they do not apply to deductible and out-of-pocket maximums. For the patient, “surprise” understates the negative impact of balance billing.
The No Surprises Act prohibits balance billings for emergency services, air ambulance services from out-of-network providers, and non-emergency care provided by an out-of-network provider at in-network facilities. Out-of-network providers are limited to the plan’s in-network benefit, and they require the costs of these services to count toward in-network deductible and out-of-pocket maximums.
Washington’s Cascade Care public insurance option began offering coverage January 1, 2021. After a competitive bidding process, five private carriers are participating in the program that requires standardized benefits and gold, silver, or bronze levels of coverage. The amount that insurance carriers may pay providers for services are capped.
Colorado is considering creating a state-run insurance plan with mandated lower hospital costs by 2025 unless the private market can significantly reduce insurance costs. In areas where access to health care is already limited, the lack of affordable health insurance compounds the challenges faced by Colorado families.
The Texas Legislature has passed two bills effecting PBM reform. The goal of both pieces of legislation is to establish a level playing field between PBM network and non-network community pharmacies and consequently ensure patient choice. The first prevents a PBM from “clawing back” amounts previously paid to a pharmacy, thereby placing a financial burden on the local pharmacy. The law will require a PBM to pay non-member pharmacies the same as it pays its affiliated pharmacies.
PBMs will not be allowed to direct patients to an affiliated pharmacy to receive a better benefit. Local pharmacies will be allowed to mail or deliver prescriptions to patients if requested.
|ACA Plans – Out-of-Pocket Maximum|
|High Deductible Health Plans (HDHP) – Minimum Deductible|
|High Deductible Health Plans (HDHP) – Out-of-Pocket Maximum|
|Health Savings Accounts – Annual Contribution Limits|