By Phil Kabler, Charleston Gazette-Mail
Public Employees Insurance Agency Finance Board members delivered an early Christmas gift to teachers, school service personnel and public employees, approving a 2019-20 benefits plan featuring no premium increases or cuts in benefits.
However, they did roll back a proposal to eliminate financial penalties for insurees who seek care from out-of-state providers to apply only to counties bordering West Virginia.
That was after West Virginia Hospital Association President Joe Letnaunchyn advised the board that a broader proposal adopted last week by the PEIA Task Force to eliminate penalties for any out-of-state care could cause financial hardship for West Virginia hospitals, which already are at the lowest PEIA reimbursement rates.
“They look at this as just another move to move more patients out of state,” Letnaunchyn said of operators of in-state hospitals.
However, West Virginia Education Association President Dale Lee said it is a fairness issue, and noted one of the biggest concerns raised in both task force and finance board public hearings statewide was from insurees in border counties who complained about delays and difficulties in getting access to in-state providers.
“When it’s your care, or the care of your child, you want the best possible alternative,” he said.
Lee said he doubts if the additional $6 million a year cost of eliminating the out-of-state penalties entirely would do severe harm to in-state providers, whom he agreed should be paid higher reimbursement rates.
As adopted Thursday, the 2019-20 plan will waive penalties originally intended to encourage insurees to seek in-state care, including 10 percent higher coinsurance rates, a $25 per visit copay and a facilities fee that requires the insuree to pay the difference between discounted in-state rates and higher out-of-state and out-of-network rates for a variety of routine procedures such as lab tests, MRIs or colonoscopies.
However, that applies only to counties bordering West Virginia, and the higher rates will remain in place for out-of-state providers beyond the border counties.
The plan, adopted by voice vote in a 12-minute board meeting, also adds an appeals process for insurees who require medications that are on the Tier 3 nonpreferred brand name list, which carries a 75 percent copayment up to the $1,750 annual out-of-pocket maximum for prescription drugs.
Afterward, Lee said that despite disappointment that the out-of-state penalties were not entirely eliminated, the 2019-20 PEIA plan overall is positive.
“This is the first time in several years that a plan by PEIA actually returns money to the plan participants instead of taking more money from their paychecks,” Lee said.
Following the Finance Board meeting, a newly created PEIA Task Force statutory subcommittee considered changes in PEIA law proposed by Perry Bryant, founder of West Virginians for Affordable Health Care.
That includes changing the current 80-20 premium requirement, in which the employer pays 80 percent of PEIA premiums and the employee pays 20 percent, to a more flexible rule, requiring the state to pay at least 80 percent of PEIA costs and specifying that employees will pay no more than 20 percent.
Without that flexibility under current law, if the Legislature appropriates an additional $80 million for PEIA to cover increasing premium costs, employee premiums must increase by $20 million.
Under Bryant’s proposal, limiting the employee share of costs to no more than 20 percent would also take into account costs of deductibles, coinsurance and copays, as well as premiums.
Geoff Christian, a member of both the PEIA Finance Board and task force, said the flexibility makes sense, particularly when health care costs are escalating.
“The way it’s moving so fast, you almost can’t move fast enough to stay ahead of it,” he said.
Bryant also proposed changing the PEIA plan year from a July 1-June 30 fiscal year to a traditional calendar year.
Among other benefits, he said that would allow the PEIA Finance Board to know exactly how much funding the Legislature had appropriated for PEIA in the state budget before beginning work on a new benefits plan.
Currently, the Finance Board adopts the next year’s plan in December based on the governor’s funding recommendations, and on occasion has to come back and make last-minute revisions to those plans based on state budget bills that are voted on the following spring.
Ted Cheatham, PEIA executive director, said he could see pros and cons to a calendar year plan.
On one hand, he said it would eliminate the uncertainty of having to prepare Shoppers’ Guides for the coming plan year before the PEIA budget appropriation passes the Legislature. However, he also noted that the second half of the calendar year plan would fall into a new fiscal year and would be subject to passage of that year’s budget bill.
“In the big, big, big picture, I don’t think it matters,” Cheatham said, noting that PEIA coverage for retirees currently is on a calendar year plan.
The subcommittee did not take any action on the proposals Thursday, but will meet again on Jan. 8, the day before the start of the 2019 regular session, prior to a meeting of the full task force later that day.