Bright Ideas, Bright Future: Broker Advisory Council Spring Summit Celebrates 2020 Successes, Explores 2021 Opportunities
Ron Wozny, VP, Marketing
In our continuing commitment to partnership and transparency, HealthSmart convened the Broker Advisory Council Spring Summit on March 31, 2021. While the Summit featured a full agenda, the highlight of the meeting, for me, was the opportunity for our broker partners to ask questions and give input, and for us to listen and respond with timely, accurate information.
COVID-19 Update
Pam Coffey, RN, CHCQM, HealthSmart’s EVP and chief clinical officer, kicked off the Summit with a COVID-19 update focused on vaccinations. She reported on the ominous increase in average cases of COVID-19 including a rise in hospitalizations. While some hospitals in the U.S. are closing their COVID units due to a lack of cases, others are experiencing an alarming surge in cases. She also updated the group on the status of vaccination efforts and the rising prevalence of COVID variants, and the threats those might pose to potentially returning to a pre-pandemic “normalized” work environment.
Pam emphasized the importance of fully vaccinated individuals continuing to follow CDC guidelines in terms of wearing a mask, social distancing, limiting social gatherings to no more than six fully vaccinated individuals, and avoiding travel, to help mitigate the spread of the virus and to eventually achieve herd immunity. As always, the emphasis is on sticking to clinically validated approaches.
The Healthcare Price Transparency Rule for Health Plans and TPAs
Bill Kampine, SVP and co-founder of
Healthcare Bluebook, and Scott Geyer, HealthSmart’s SVP of client services, presented an overview of the recently enacted Healthcare Price Transparency Rule and its implications for health plans and TPAs. The rule applies to self-funded group health plans and health insurance issuers in the individual and group markets. While independent TPAs and service providers are not directly subject to the rule, we anticipate that clients will rely on our assistance to achieve compliant implementation.
The rule phases in specific compliance requirements over the next three years:
- Public Rate Files (in-network rates, out-of-network rates, pharmacy medication rates) must be posted by Jan. 1, 2022.
- An Online Consumer Tool must be posted by Jan. 1, 2023. This tool must enable members to search by code, term or provider and receive the provider-specific negotiated price, accumulator balances and estimated cost sharing covering in-network, out-of-network, and pharmacy rates for 500 services.
- An updated version of the Online Consumer Tool that covers all services must be posted by Jan. 1, 2024. It should be noted that, beginning July 2021, issuers may begin to apply shared savings incentives toward their MLR requirement for incentives paid during the 2020 plan year.
Enforcement of the rule uses the same framework as for the ACA market reform requirements. Failure to comply would subject a health plan to monetary penalties of $100 per day per violation per affected member. The rule includes a good faith allowance for data error or omission provided it is corrected, temporary website interruption, and a reliance on third-party information.
Potential changes to requirements and timing include current review of the ACA by the Supreme Court, and a new administration that may impact the implementation. Repeal of the entire ACA is unlikely; however, timelines may move, and the scope of the law may narrow. Health plans should view this as an opportunity to turn compliance into a strategic advantage for their members. The rule also eliminates surprise billing. Because implementation will take some time, health plans should begin working toward complying with the rule.
Looking ahead, Kampine pointed out the rule presents employers with the opportunity to:
- Enhance price and quality data and steer their employees to better value.
- Work with broker and consultant partners to better understand data requirements.
- Develop and test compliant consumer tools.
- Closely monitor policy changes from new administrators and implement guidance from the Departments.
- Evaluate the impact of COVID Relief Extension (HR 133) and new transparency laws (No Surprises Act).
HealthSmartRx Solutions Copay Maximizer and Specialty Case Management
Martino Luu, RPh, EVP of HealthSmartRx Solutions, and Pam Coffey updated the group on
Copay Maximizer and HealthSmart’s
Specialty Case Management programs and how the two work together to benefit members and health plan clients by lowering drug costs and enhancing the quality of care.
HealthSmartRx recognizes that 47 percent of specialty medication spend occurs in the medical benefit. Managing the rising cost of specialty medications requires active management in both medical and PBM channels. The Copay Maximizer program leverages the opportunity available through assistance programs for medical specialty drugs. The program:
- Captures the maximum benefit of manufacturer copay cards
- May reduce or eliminate member copay responsibility
- May save plans up to 10-15 percent off their specialty drug cost
- Integrates with the medical benefit
- Provides flexible options on accumulator integration and administration
- Targets more than 100 high-cost specialty drugs
- Utilizes specialists and dedicated program advocates to identify eligible members, set up their high-cost medications in the system, enroll them in the program, identify and activate medications requiring prior authorization, process prescriptions through manufacturers’ copay assistance and coupon programs, report and invoice client savings on a monthly basis.
HealthSmart case managers can work proactively with the Copay Maximizer staff to effectively manage the care of members and the costs related to that care. The number of members with complex conditions, those whose cost of care exceeds $100,000 annually, have grown by 75 percent over the past five years. Specialty medications, especially injectables, are the fastest growing driver of costs for these members. HealthSmart is one of just a few organizations that has years of experience handling complex and rare conditions as an integrated TPA, PBM and Care Management company. As a result, we are delivering drugs and treatments at a much lower cost while improving the health and satisfaction of members. For more on this program, check out
our recent webinar.
Other Strategic Initiatives
Finally, our HealthSmart executive leaders were pleased to share some important HealthSmart strategic initiatives that are currently in development and will be rolling out soon. The questions and input we got on these initiatives from our broker partners confirmed that together, we’re heading toward a bright future.
As always, thanks to our Broker Advisory Council members for their support, their insight, and their guidance. They are a critical part of our success and we greatly value their time and participation.
This is just one way HealthSmart works hard to stay connected with the broker community to ensure we are delivering the right solutions to meet their needs and the needs of their clients.
If you’re a broker and are interested in joining the HealthSmart Broker Advisory Council, please contact us at
marketing@healthsmart.com.
Ron Wozny – Vice President, Marketing
Ron Wozny joined HealthSmart in 2018, bringing more than 20 years’ experience in healthcare marketing. As Vice President of Marketing, he is responsible for developing and executing strategies to increase brand awareness and drive revenue growth. Ron was previously Vice President of Marketing for Healthx, a leading healthcare IT solution provider for member engagement and provider collaboration. He also served as head of marketing for ZeOmega, a leading population health management software provider, and brings strong marketing and healthcare expertise from similar marketing leadership roles at T-System, Beryl Health, Healthvision and VHA (now Vizient).