HSA-Eligible Health Plans Embrace
Changes to Better Serve Americans
With Chronic Health Conditions
September 2021
2AHIP.ORG
Employer-provided coverage delivers aordable access to care, eective ways to improve health, and nancial
security for more than 183 million Americans every day. Quality health benets for full-time workers are a key part of
the social and economic compact in the United States.
More than 32 million Americans have employer-provided coverage that, when
combined with a health savings account (HSA), provides them with more control over
and value for their health care.
Until recently, HSA-eligible health plans were restricted in covering care that wasn’t
considered preventive before a consumer satised their plan’s deductible. But in
July 2019, the Internal Revenue Service (IRS) issued Notice 2019-45, guidance which
expanded the list of preventive care benets to include many items and services
used to manage chronic health conditions. Now, plans and employers may offer 14
additional items and services pre-deductible, including insulin and other glucose
lowering agents, glucometers, inhalers, statins, and others.
How many health plans are leveraging this new exibility to provide greater value to
patients and consumers?
In May - June 2021 AHIP and the Smarter Health Care Coalition conducted a survey
of health insurance plans to assess changes in the benet design for HSA-eligible
HDHPs. Thirty-six health plans covering every region of the country responded to
the survey. For details on the survey methodology and tabulated survey results see
Appendix A.
Analyzing Health Insurance Provider Adoption
For years, AHIP and the Smarter Health Care Coalition have advocated for the removal of regulatory barriers that prevented HSA-
eligible health plans from more broadly adopting value-based benets to improve value and lower costs. That advocacy included
working with regulatory agencies and Congress to expand the HSA-eligible health plans preventive care safe harbor to ensure access
to high-value services and prescription drugs that could be used to prevent and treat chronic diseases.
Following guidance in 2019 that provided new regulatory exibility to cover certain preventive care services pre-deductible, AHIP and
the Smarter Health Care Coalition wanted to evaluate the effectiveness and uptake of this new exibility. The organizations launched a
survey in May 2021. Nearly 90 health insurance providers were invited to participate. Thirty-six (36) responded to the survey, yielding
a response rate of 40%. The responding health plans cover 109 million Americans (commercial enrollment only; based on the 2020
nancial lings of publicly traded insurance companies, 2019 fully-insured commercial enrollment statistics reported by the NAIC and
the DMHC (CA), and the 2019 national self-insured enrollment estimates by the AHRQ).
Participants included health insurance providers operating within all 50 states, the District of Columbia, and Puerto Rico. They
comprised major medical insurance HSA-eligible health plans, with commercial enrollment of greater than 50,000 according to data
from the AIS Directory of Health Plans: 2020.
The nal survey included 7 questions. Not all participants were asked all questions.
The Qualtrics® online survey tool was used to develop and deploy the web-based survey.
The survey was conducted via email using a key informant approach. Potential survey respondents were identied based on the
internal AHIP databases of health plan staff with expertise in HDHP coverage and management, with such work positions as medical
directors, government affairs specialists, and commercial products directors. AHIP staff contacted potential survey respondents with
knowledge of their health plan HDHP product line and asked them to reply on behalf of their plan or, if not, to pass the invitation to
other plan staff involved in their plan’s HDHP programs.
Key Takeaways
• Most HSA-eligible health plans
are leveraging new regulatory
exibility to cover more chronic
disease prevention services on
a pre-deductible basis.
• Diabetes and heart disease
are the two most commonly
targeted conditions for
reducing or eliminating cost
sharing.
• Reduced or eliminated cost
sharing for chronic disease
prevention drugs and services
is not resulting in a signicant
increase in premiums.
3AHIP.ORG
Insurance Providers Embrace New Flexibilities Across Health Plans
The 36 responding health plans operate in all Census regions, and include large national plans, regional plans, and plans operating in
a single state, or just part of a single state. Given a relatively robust response rate and a wide range of plans submitting the responses,
both geographically and in terms of size, the survey data could be regarded as broadly representative of the national HDHP insurance
industry.
Most respondents offer HSA-eligible health plans for both self-insured and fully insured lines of business: 100% reported offering it in
their fully insured products, and 83%in their self-insured line of business. At least part of this difference may be explained by the fact
that not all responding health insurance providers offer self-insured products.
Most respondents modied their HSA-eligible health plans to cover more chronic disease prevention services on a pre-deductible
basis: 75% covered additional services without applying a deductible in their fully insured products, and 80% in their self-insured
products (see Figure 1).
Figure 1. Most responding health insurance providers leveraged new exibilities to cover new chronic disease prevention
services pre-deductible in HSA-eligible Health Plans.
Fully Insured
Products
Self-Insured
Products
75%
25%
80%
20%
Covered additional services pre-deductible No changes to benefit design
However, expansion in coverage was not uniform across all contracts. While nearly half of survey participants that made changes
reduced or eliminated cost sharing in all their fully insured contracts, only 4% of reporting plans did so in all of their self-insured
contracts, where employers have a much larger control over the specics of their benet design (see Figure 2).
4AHIP.ORG
Figure 2. Health insurance providers leveraged this new exibility more frequently in their fully insured plans than in self-
insured plans.
In some contracts
Plans Reduced or Eliminated Cost Sharing
In most contracts
In all contracts
Fully Insured Products Self-Insured Products
30%
58%
26%
38%
44%
4%
Health insurance providers targeted a variety of chronic health conditions with two conditions targeted by almost all plans: diabetes
(96% of plans in both fully insured and self-insured products), and heart disease (targeted by 73% in fully insured products and 74% in
self-insured products).
Table 1. Chronic Conditions Targeted in Fully Insured Plans.
In some fully insured
products
In most fully insured
products
In all fully insured
products
Not targeted
Asthma 19% 15% 19% 46%
Bleeding disorders 8% 12% 19% 62%
Congestive heart failure 23% 23% 12% 42%
Coronary artery disease 23% 19% 15% 42%
Depression 15% 19% 15% 50%
Diabetes 23% 31% 42% 4%
Heart disease 23% 27% 23% 27%
Hypertension 23% 27% 15% 35%
Liver disease 8% 8% 19% 65%
Osteoporosis 12% 15% 8% 65%
Other (please describe) 12% 4% 12% 73%
5AHIP.ORG
Table 3. Chronic Conditions Targeted in Self-Insured Plans.
In some self-insured
products
In most self-insured
products
In all self-insured
products
Not targeted
Asthma 30% 26% 4% 39%
Bleeding disorders 13% 17% 9% 61%
Congestive heart failure 39% 17% 4% 39%
Coronary artery disease 39% 22% 4% 35%
Depression 39% 9% 9% 43%
Diabetes 57% 30% 9% 4%
Heart disease 39% 26% 9% 26%
Hypertension 39% 22% 4% 35%
Liver disease 13% 17% 9% 61%
Osteoporosis 30% 9% 4% 57%
Other (please describe) 9% 4% 9% 78%
Survey participants that reduced or eliminated cost sharing for chronic disease prevention drugs and services did not report a
signicant increase in premiums as a result of those changes. Most respondents communicated that premiums increased by less than
1% or did not change at all (75% for fully insured products and 54% for self-insured products). Only 4% of plans experienced an
increase in premiums greater than 1% for their fully insured products, and none for self-insured products (see Figure 3).
Figure 3. Reducing or eliminating cost-sharing for chronic disease prevention drugs and services did not result in signicant
premium increases.
Premium
increased >1%
Premium
increased <1%
Premium did
not change
Premium
decreased
Too early to
tell/don’t know
Other
Fully Insured Products Self-Insured Products
4%
0%
0%
0%
46%
19%
15%
29%
7%
17%
8%
56%
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Factors Impacting Adoption
The survey invited respondents to share their experiences in implementing chronic disease coverage changes following the 2019
IRS guidance, lessons learned, or anything else they wanted to share regarding management of chronic health conditions in these
health plans. Respondents provided a breadth of insight on many aspects of chronic disease coverage, with some common themes
emerging. Specically, respondents focused on coding challenges, issues in coverage of prescription drugs, and mental health parity
considerations.
No Cost Sharing as a Client’s Choice. Several respondents stressed that they offered a choice for pre-deductible chronic disease
prevention drugs and services to their self-insured clients, but the uptake varied and was client-specic.
Coding Challenges. Cumbersome requirements to document eligible diagnoses lead to many services being ineligible for consumers,
with some health insurance providers not doing it at all to avoid increasing the administrative burden for plans and providers. One
plan expressed interest in more coding guidance from the IRS.
Focus on Reducing Rx Cost Sharing. Some respondents communicated that the IRS guidance was structured in such a way that
it made it much easier to implement changes for prescription drugs used to treat chronic conditions, but not for medical services.
However, respondents still experience specic coding challenges for pre-deductible-eligible drugs.
Mental Health Parity considerations. Respondents noted that it is important to remember the mental health parity rules in place
and that updating medical benets may require changes to mental and behavioral health benets, which adds complexity when
complying with the law while adding benets.
Satisfaction with Pre-Deductible Coverage of Insulin. Enrollees report satisfaction with added insulin benets, including the
certainty over the monthly cost-sharing, with at least one plan stating the added benet has “greatly helped members in being
compliant with managing their diabetes.”
Building Upon What Works
We asked survey participants which additional services covered pre-deductible would most likely improve patient satisfaction. The
most mentioned type of service was primary care visits at 81% (see Table 4). One respondent commented that many patients with
chronic disease seek their management with primary care physicians (PCPs) and not specialists. Another respondent added that the
pre-deductible coverage of primary care visits would be benecial for the rst one to three visits but not for all of them.
Another commonly mentioned choice was the permanent ability to offer telehealth services pre-deductible (64%). One respondent
commented that “covering telehealth services (excluding audio-only services) pre-deductible will increase customer satisfaction
without having a signicant increase in premiums”. Another respondent claried the pre-deductible coverage of telehealth would only
be benecial for certain specialties, such as primary care and Mental Health/Substance Abuse.
The last of services selected by the majority of plans as most likely to improve patient satisfaction if covered pre-deductible was
mental and behavior services (53%). Some plans, though, had concerns about how such coverage could be impacted by mental health
parity regulations.
Some responses raised the question of what the purpose of a HDHP is if more services are covered pre-deductible, which raises
important policy considerations for future rules governing these plans.
Finally, respondents said there could be value in decoupling HSAs from the health plan: “Rather than making HDHPs more
complicated in order to offer more benets while still maintaining HSA qualication, it would make more sense to make HSAs eligible
for ALL plan types and preserve the pricing strategies associated with true deductible/coins HDHPs” and “… such changes will
further narrow the gap of premiums. It would be benecial to continue to push for decoupling of HSAs from HDHPs rather than slowly
continue to minimize their value.”
7AHIP.ORG
Next Steps
With more than 32 million Americans enrolled in HSA-eligible health plans, a majority of whom live with at least one chronic health
condition, policy changes are necessary to allow more Americans to save for future health care expenses in tax-advantaged accounts
while ensuring that those living with chronic health conditions have access to the high-value care they need without the burden of a
deductible. These could include expanding the preventive care safe harbor to allow for additional items and services to be covered
pre-deductible or de-coupling HSAs from prescriptive, high-deductible health plans.
Table 4. Pre-Deductible Coverage Of Additional Services To Most Likely Improve Patient Satisfaction.
Services %
Primary care ofce visits 81%
Permanent ability to offer telehealth services pre-deductible 64%
Coverage of mental and behavioral health services 53%
Visits to specialists to manage chronic conditions 44%
Coverage for additional drugs or services used to treat chronic conditions
not included in Notice 2019-45 issued by the IRS in 2019
42%
Permanent ability to offer testing, treatment, or vaccinations
pre-deductible in response to public health emergencies
33%
Visits to on-site medical clinics 22%
Other 25%
