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New cost-cutting strategy: Employer plans with no outpatient surgery coverage

Unclear how regulators will respond to emerging trend in benefit design

Unlike insurance sold to individuals and small businesses through online marketplaces, large employers are not required to offer a list of "essential health benefits," so some work-based health plans are starting to exclude outpatient surgeries to cut costs, according to an article from Kaiser Health News.

Some insurance companies now offer plans that will pay for inpatient hospital care, office visits and diagnostic imaging, but then provide no coverage for outpatient surgery, which can save employers money but leave workers with extremely high bills, the article said. Yet some experts believe that such plans won't survive the scrutiny that surrounds the outpatient exclusion.

Timothy Jost, a law professor at Washington and Lee University in Virginia and an authority on the health law, told KHN he doesn't know if current egulations allow such plans. "Refusing to cover any outpatient physician surgical services is arguably a violation," he said.

The article also points out that because workers offered minimum-value coverage are presumed to have adequate insurance, they're not eligible for tax credits to buy marketplace policies. So if employers do not provide affordable minimum-value coverage, they face a fine of up to $3,000 per employee.

Minnesota-based benefits company EBSO is one that has implemented 2016 minimum-value plans that cover inpatient hospitalization but not outpatient surgery. President Bruce Flunker told KHN the company's aim is to provide quality, yet more affordable coverage. It's currently unclear, though, how regulators will respond to this new trend in benefit design.

Some insurers in recent years have tried to encourage more patients to seek alternatives to traditional inpatient care in order to trim costs. But the Centers for Medicare & Medicaid Services recently announced plans to cut payments to hospitals for outpatient services and to ambulatory care providers for the 2016 calendar year

To learn more:
- here is the KHN article

Related Articles:
Patients using outpatient services more often
CMS proposes to trim outpatient payments in 2016
OIG: Include more outpatient services in inpatient lump-sum payment